Development of a comprehensive database for research on foetal acidosis.

OBJECTIVE: To develop a research database for mother-and-child clinical and laboratory data and digital foetal heart rate (FHR) recordings. METHODS: The Base Bien Naître (BBN) database was derived from a single-centre health data warehouse. It contains exhaustive data on all parturients with a singleton pregnancy, a vaginal or caesarean delivery in labour with a cephalic presentation after at least 37 weeks of amenorrhea, and a live birth between February 1st, 2011, and December 31st, 2018. On arrival in the delivery room, the FHR was recorded digitally for at least 30 min. A cord blood sample was always taken in order to obtain arterial pH (pHa). More than 6,000 recordings were analyzed visually for the risk of foetal acidosis and classified into five groups (according to the French College of Gynaecologists and Obstetricians (CNGOF) classification) or three groups (according to the International Federation of Gynaecology and Obstetrics (FIGO) classification). RESULTS: Of the 16,089 files in the health data warehouse, 11,026 were complete and met the BBN's inclusion criteria. The FHR digital recordings were of good quality, with low signal loss (median [interquartile range]: 7.0% [4.3;10.9]) and a median recording time of 304 min [190;438]). In 3.7% of the children, the pHa was below 7.10. We selected a subset of 6115 records with good-quality FHR recordings over 120 min and reliable cord blood gas data: 692 (11.3%) had at least a significant risk of acidosis (according to the CNGOF classification), and 1638 (26.8%) were at least suspicious (according to the FIGO classification). CONCLUSION: The BBN database has been designed as a searchable tool with data reuse. It currently contains over 11,000 records with comprehensive data.

Use of automated fetal heart rate analysis to identify risk factors for umbilical cord acidosis at birth.

OBJECTIVE: To identify clinical parameters and intrapartum fetal heart rate parameters associated with a risk of umbilical cord acidosis at birth, using an automated analysis method based on empirical mode decomposition. METHODS: Our single-center study included 381 cases (arterial cord blood pH at birth pHa ≤7.15) and 1860 controls (pHa ≥7.25) extracted from a database comprising 8,383 full datasets for over-18 mothers after vaginal or caesarean non-twin, non-breech deliveries at term (>37 weeks of amenorrhea). The analysis of a 120-min period of the FHR recording (before maternal pushing or the decision to perform a caesarean section during labor) led to the extraction of morphological, frequency-related, and long- and short-term heart rate variability variables. After univariate analyses, sparse partial least square selection and logistic regression were applied. RESULTS: Several clinical factors were predictive of fetal acidosis in a multivariate analysis: nulliparity (odds ratio (OR) 95% confidence interval (CI)]: 1.769 [1.362-2.300]), a male fetus (1.408 [1.097-1.811]), and the term of the pregnancy (1.333 [1.189-1.497]). The risk of acidosis increased with the time interval between the end of the FHR recording and the delivery (OR [95%CI] for a 1-min increment: 1.022 [1.012-1.031]). The risk factors related to the FHR signal were mainly the difference between the mean baseline and the mean FHR (OR [95%CI]: 1.292 [1.174-1.424]), the baseline range (1.027 [1.014-1.040]), fetal bradycardia (1.038 [1.003-1.075]) and the late deceleration area (1.002 [1.000-1.005]). The area under the curve for the multivariate model was 0.79 [0.76; 0.81]. CONCLUSION: In addition to clinical predictors, the automated FHR analysis highlighted other significant predictors, such as the baseline range, the instability of the FHR signal and the late deceleration area. This study further extends the routine application of automated FHR analysis during labor and, ultimately, contributes to the development of predictive scores for fetal acidosis.

Assessment of fetal head engagement with transperineal ultrasound: Searching for the cutoff level.

PURPOSE: Engagement of the fetal head is a determinant element when deciding on operative vaginal delivery. In routine practice, engagement is a clinical diagnosis based on transvaginal digital examination. Transperineal ultrasound might provide complementary information useful for measuring the fetal head-perineum distance (HPD). The purpose of this work was to determine the cutoff HPD distinguishing engagement from non-engagement. MATERIALS AND METHODS: This single-center prospective study approved by the institutional review board was conducted between December 25, 2012 and August 31, 2015 in 411 nulliparous women; 20 did not provide informed consent and were excluded; analysis concerned 391 patients. Clinical diagnosis - engagement or non-engagement depending on results of the transvaginal digital examination (Farabeuf's and Demelin's signs) - was compared with the ultrasound HPD measurement. RESULTS: The clinical diagnosis was non-engagement at complete dilatation in 96 patients (24.6%). The cutoff HPD distinguishing between engagement and non-engagement was 57mm (AUC 83.5% [95%CI 79.3-87.8]), with 75.0% [65.5-82.6] sensitivity, 75.9% [70.7-80.5] specificity, 50.3% [42.2-58.4] positive predictive value, and 90.3% [86.0-93.4] negative predictive value. CONCLUSIONS: In this series, the HPD cutoff distinguishing between engagement and non-engagement was 57mm. Below this cutoff level, the head should be considered engaged, beyond non-engaged. Nevertheless, the pertinence of this cutoff level is hampered by the imprecision of the gold standard used for the clinical diagnosis (transvaginal digital examination). In case of doubt, we recommend, in addition to considering the obstetrical setting, to combine transperineal ultrasound with transvaginal digital examination to avoid deleterious failure of operative vaginal delivery.

Metastasis-free interval in breast cancer patients: Thirty-year trends and time dependency of prognostic factors. A retrospective analysis based on a single institution experience.

INTRODUCTION: Breast cancer remains the leading cause of cancer death in French women in spite of continuously improving management. The objectives of this study were to analyse trends in the metastasis-free interval over the past 30 years and to identify the prognostic factors of survival, while accounting for time dependency. METHODS: A total of 1613 patients diagnosed with invasive non-metastatic breast cancer at Saint Vincent de Paul Hospital, Lille, France between 1977 and 2013, were followed for outcome (metastasis-free interval). Cohort entry time delay, a continuous temporal covariate, was defined to assess improvement of outcome. Data were analysed using the Cox proportional hazards model and presented as hazard ratio (HR). RESULTS: Metastatic disease developed during follow-up in 446 (27.6%) patients. Cohort entry time delay exhibited strong independent prognostic value while accounting for multiple prognostic factors including: tumour size (HR = 1.62, 95 %CI 1.37-1.91); rapid tumour growth (HR = 1.59, 95%CI 1.17-2.16); lymph node ratio (HR = 2.29, 95%CI 1.97-2.66); histological grade (grade 2 was significant only during the first 10 years after diagnosis, grade 3 and progesterone receptor status only during the first 5 years after diagnosis); and oestrogen receptor status (significant only during the first 8 years (HR = 0.75, 95%CI 0.58-0.96)). CONCLUSION: The current study showed an improvement in the prognosis of breast cancer patients over the past 30 years and pointed to the importance of evaluating covariates with time-varying effects.

[Retrorectal cystic hamartoma. Report of one case with vaginal resection and review of the literature]. / L'hamartome kystique rétrorectal (HKRR) : à propos d'un cas réséqué par abord vaginal et revue de la littérature.

Tailgut cyst is a rare congenital presacral lesion. We report a case of a 24-year-old woman presenting a recurrent retrorectal mass with pain. Surgical resection by vaginal way found retrorectal cystic hamartoma. Differential diagnosis include cystic teratoma, epidermal cyst and rectal duplication cysts. The most important complications are recurrence, infection, perineal fistulas and the possibility of malignant transformation. So the complete surgical excision of these lesion is necessary.

[Buttock necrosis after subtotal hysterectomy, bilateral internal iliac arteries ligature and pelvic embolization for control of severe post-partum haemorrhage]. / Un cas de nécrose de fesse survenant après hystérectomie subtotale, ligature bilatérale des artères iliaques internes et embolisation pelvienne pour une hémorragie grave du post-partum.

Post-partum haemorrhage remains a major cause of maternal mortality. Surgical management may be needed in patients with hemodynamic instability. Arterial embolization may be needed in case of persisting haemorrhage despite initial surgical management. We report a case of buttock necrosis occurring after pelvic embolization to control refractory post-partum haemorrhage and failed subtotal hysterectomy with bilateral internal iliac arteries ligation. To the best of our knowledge, this is the first case of buttock necrosis complicating a severe post-partum haemorrhage reported in the literature.

[Antenatal screening for congenital heart disease: a retrospective analysis of 20 years of experience]. / Dépistage anténatal des cardiopathies foetales: une étude rétrospective sur 20 ans.

BACKGROUND: Congenital heart disease is often severe and outcome remains uncertain. In some cases, early intervention at birth can improve the prognosis. Prenatal detection of congenital heart disease by ultrasound may improve outcome for foetuses with congenital heart disease but today, results are not convincing. The purpose of this review was to describe the detection of congenital heart disease in a non selected population. METHODS: A retrospective study was undertaken to evaluate the prenatal detection of congenital heart disease in our department from 1984 to 2003. RESULTS: Incidence of congenital heart disease was 4.9. Sensitivity of detection was 60%, specificity was 99.9%. Most cases were severe heart diseases. In 57 fetuses (40%), congenital heart disease was not detected. Thirty-seven fetuses (65%) presented minor disease; in 20 fetuses (35%), congenital heart disease was found to be severe. Effectiveness of detection of major congenital heart diseases has increased since 2000. CONCLUSION: Large-scale fetal heart screening is necessary for early detection of congenital heart disease and improved outcome.

[Prenatal diagnosis of an intraspinal lipoma. A case report]. / Diagnostic prénatal d'un lipome intra-rachidien. A propos d'un cas.

This report describes a prenatal diagnosis of intraspinal lipoma. This pathology, not well known by obstetricians, forms a part of neural tube defects. Echographic aspect, embryologic origin, differential diagnosis, neurosurgical prognosis and treatment are reviewed and discussed.

[Comparison of three ratios of enzymatic activities measured in amniotic fluid to evaluate fetal lung maturity]. / Comparaisons de 3 rapports d'activités enzymatiques mesurées dans le liquide amniotique pour évaluer la maturité pulmonaire foetale.

Measurement of enzymatic activities in amniotic fluid could be helpful for the evaluation of foetal lung maturity. The ratio TLAP/GGT could be the most informative.

Anti-P30 IgA antibodies as prenatal markers of congenital toxoplasma infection.

This study extends a previous study and confirms that the detection of anti-P30 IgA antibodies is very helpful in the diagnosis of acute acquired or congenital toxoplasmosis. Moreover, we demonstrate that an anti-P30 IgA response can be mounted in the fetuses infected by Toxoplasma gondii during their intra-uterine life as early as week 23 of gestation. A double-sandwich ELISA described in our previous work was used to detect anti-P30 IgA antibodies in 1378 human serum samples collected from 551 patients, including 162 fetuses whose mothers had been infected by T. gondii during pregnancy, 46 congenitally infected and 90 uninfected newborns and 253 women suspected of having been infected during pregnancy, including the mothers of fetuses and newborns previously described. Anti-P30 IgA antibodies were detected in all cases of acute toxoplasmosis but in no case of chronic toxoplasmosis: in the majority of cases, the IgA antibody titre fell below cut-off in 3-9 months. Among the 46 congenitally infected newborns, anti-P30 IgA antibodies were detected in sera of 41 infected newborns (38 at birth, two in the first months of life, one in the seventh month of life), while anti-P30 IgM antibodies were detected in only 30 cases at birth and in one case during the first month of life. Among 162 fetuses, anti-P30 IgA response was observed in five infected fetuses, but was not detected in either 152 uninfected fetuses or in five fetuses considered as infected. The absence or presence of anti-P30 IgA antibodies in the fetus is discussed in relation to the date of maternal infection and collection of the fetal blood. It clearly appears from our study that the combined testing of both IgM and IgA in the fetus and the newborn is essential for a more efficient diagnosis of infection.

[Amniotic infection and neonatal bacterial infection. Search for clinical and bacterial predictive arguments]. / De l'infection amniotique à l'infection bactérienne néonatale. Recherche d'arguments cliniques et bactériologiques prédictifs.

Amniotic fluid infection and its principal sequel bacterial infection of the newborn are major problems in obstetric pathology. The authors hav analysed prospectively 346 obstetrical casenotes over a period of 18 months in order to try to describe and specify the clinical features and to try and work out using bacteriological tests the risk of infecting the neonate by materno-fetal transmission. They compared a control group (27 case histories) and the group at risk (235 cases). 4% of the control group and 18.7% of the "at risk" group were biologically infected (p less than 10(-2)). The following are among the classical clinical criteria to correlate this risk: maternal pyrexia, premature delivery, urinary tract infections and fetal distress; an apparent lessening in active fetal movements is also well correlated to the risk of infection. The bacteriological criteria are: the presence of quantities of altered polymorphonuclear cells in the amniotic fluid--this seems to be more important than others (sensitivity = 70%, specificity = 89%, but positive predictive value = 60% and negative predictive value = 93%). From this study it should be possible to work out antenatally whether the newborn baby will be at high risk of developing an infection in order to consider giving antibiotics to prevent materno-fetal transmission.

[Ultrasonic prenatal diagnosis of lip and palate cleft. Report of 10 cases]. / Diagnostic échographique anténatal des fentes labiales et labio-palatines. A propos de 10 observations.

Hare-lips and cleft palates are the most frequent manifestations of facial malformations (approximately 1 in 1,000 deliveries). The authors point out their technique for ultrasound assessment of the normal and pathological fetal face in the antenatal period. The antenatal examination gives an excellent diagnostic approach of the site and the nature and the extent of the abnormality. The screening for facial defects can be carried out routinely when studying the morphology in the second trimester of pregnancy or when there are other indications for doing this. Although the malformation is usually an isolated one, the management of these cases really depends mainly on any associated malformations than on the normality of the karyotype.

[Evaluation of fetal lung maturity with the measurement of enzymatic activities in amniotic fluid: comparison of three ratios]. / Evaluation de la maturité pulmonaire foetale par la mesure d'activités enzymatiques du liquide amniotique: comparaison de trois rapports.

Measurement, in amniotic fluid, of gamma-glutamyl-transferase (GGT) alkaline phosphatase and of thermostable and thermolabile (TLAP) isoenzyme allows to anticipate the unexpected risk of hyaline membrane disease. ROC method adapted to three ratio of these enzymatic activities shows that TLAP/GGT is the most performant at the level of 0.9 with a sensitivity of 96% and a specificity of 60%.

[Value of amniotic gamma-glutamyl-transpeptidase assay in the diagnosis of fetal digestive stenosis after 24 weeks of amenorrhea]. / Intérêt du dosage de la gamma-glutamyl-transpeptidase amniotique dans le diagnostic des sténoses digestives foetales après 24 semaines d'aménorrhée.

In 18 women compared with 1,181 controls, foetal digestive tract stenoses were discriminated, independently of the gestational age, by a more than 50 IU/l level of gamma-glutamyl transpeptidase in the amniotic fluid. This test had a specificity of 99% and a sensitivity of 85% which was accounted for by the inclusion in the study of distal stenoses and oesophageal atresias, all conditions where the gamma-glutamyl transpeptidase level is normal. In cases with ultrasonically detected abdominal wall abnormalities, this test is also useful in the diagnosis of subjacent digestive tract stenosis.

[HELLP syndrome. Apropos of a series of 9 cases without disseminated intravascular coagulation]. / Le Hellp syndrome. A propos d'une série de 9 observations sans coagulation intravasculaire disséminée.

The Hellp syndrome defined as the association of micro-angiopathic haemolytic anemia, hepatic cytolysis and thrombocytopenia, correspond to a severe form of gravidic toxemia, combined to manifestations of classic-pre-eclampsia. This retrospective study, conducted over 6 years, concerns 9 cases of Hellp syndrome, including 2 occurring during the immediate post-partum. Only cases where this biological triad was obvious and not associated with manifestations of disseminated intravascular coagulation, were considered in this study. In addition to the usual criteria of gravidic toxemia, the early clinical manifestation occur, in this study, between 28 and 38 weeks of amenorrhea and gastrointestinal manifestations are predominant. The physiopathogenic hypotheses of this syndrome remain variable and management varies depending on the authors. Treatment is that of pre-eclampsia. Medical treatments (steroids, heparin, immunosuppressants,...) are discussed, but severe feto-maternal complications require, most of the time, a surgical approach, depending on the number of pregnancies, the obstetrical conditions, the stage of the pregnancy and the severity of the syndrome.

[Children of hyper- and hypothyroid mothers]. / Les enfants des mères hyper et hypothyroïdiennes.

A multicenter study was able to utilize 120 medical files of children born from mothers who presented an abnormal thyroid function, 67 euthyroid goiters, 29 hyperthyroidisms, and 24 hypothyroidisms. In the first case, whether or not an inhibiting treatment was initiated, all children were perfectly normal. In case of maternal hyperthyroidism, the risk of malformations is not increased, deaths in utero and mostly in utero growth delays (1 case in 2) are more frequent. At birth, the child may present a hyperthyroidism due to the effect of SAT with elevated TSH and a goiter, sometimes compressing and impairing breathing, or also a hyperthyroidism due to transplacental crossing of stimulating immunoglobulins with possibility of thyreotoxic crises and heart failure. The diagnosis could be made in utero in the presence of tachycardia or with T4 and TSH assays in the cord. In case of maternal hypothyroidism, usually the children have no problems and the risk of neonatal hypothyroidism is mostly present in premature infants if the maternal balance is poor (2 in 24 cases in our series). Finally, in the reference population, the risk of neonatal hypothyroidism remains 1 in 3600 and justifies systematic screening on the 5th day of life.

[Dysthyroidism and fertility]. / Dysthyroïdies et fertilité.

The role of the thyroid gland in sterility is not well known; hyperthyroidism may have an effect upon estrogen secretion by decreasing the level of the free forms of estradiol, resulting in a lowering or disappearance of the LH ovulatory peak. Clinically, severe hypothyroidism would cause a retarded sexual development but simple hypothyroidism and hyperthyroidism do not seem to have a major effect upon sexual maturity. During the period of genital activity, hyperthyroidism may result in amenorrhea and dysovulation phenomena reminding of ovarian dystrophy; hypothyroidism results in the same phenomena, with decreased libido, but with a better screening process and a better adjusted substitute treatment, these disorders are rare. Finally, systematic evaluation of the thyroid function in unexplained sterilities, appears unnecessary most of the time.

[Computerized obstetrical record of the North Pas-de-Calais region]. / Dossier obstétrical informatisé de la région Nord - Pas-de-Calais.

The computerized obstetrical record of the North-Pas-de-Calais region proceeds from the desire of a number of people from the Regional Health Observatory, to dispose of a prospective epidemiologic tool in the field of perinatology. The objective is a better knowledge of the cause of perinatal death, analyzing the modalities of prenatal monitoring, delivery conditions, transfer of the newborns, as well as socio-economical conditions. The program manages the computerization of a usual obstetrical file, in the region, including approximately 200 items and allowing every possible comparison with the well-known CCIM record. The program permits local treatment of the data (statistical calculations) in each maternity hospital: rapid transmission of information between maternity and correspondents (computerized personalized mail), a base of agreement between the different protagonists: midwives, pediatricians, specialists, an easier collaboration with the protection agencies and, especially, the Regional Direction of Sanitary and Social Affairs, with automatic response to hundreds of questions of the yearly questionnaire, which saves a great deal of time and an extreme reliability of the information. This program is compatible with any IBM PC microcomputer and includes a hard disk of 10 or 20 mega-octets. The current price (microcomputer with hard disk, monitor, keyboard, letter-quality printer, management program) make all these performances available at a relatively low expense, under 25,000 francs (not including the tax).

[Heterotopic twin pregnancies. Review of the literature after a case where the 2 children survived]. / Les grossesses gémellaires hétérotopiques. Revue de la littérature à partir d'une observation où les 2 enfants ont survécu.

A combination of an extra-uterine and an intra-uterine pregnancy is defined as heterotopic twin pregnancy. A case is reported where the 2 infants were born alive and have had a normal psychomotor development at 3 years of age. It is a case where the first observation taken by ultrasound made the diagnosis possible at 27 weeks of the pregnancy and therefore gave rise to the crucial problem of how to manage the case. Because of this case history we have discussed the frequency (one in every 30,000 pregnancies), the aetiological factors, the clinical factors, the prognostic factors and what is to be done. The discussion takes note of the modern ways of diagnosing it (ultrasound), of monitoring it and of handling in a specialised unit this exceptional kind of "high risk" pregnancy.

[Communicating uteri. Study and review of the literature. Apropos of 11 cases]. / Les utérus communicants. Etude et revue de la littérature. A propos de 11 cas.

The authors are reporting 11 communicating uteri's cases. This class of uterine malformation present 1 a 2% of the malformation. They report Musset's classification and Toaff too. The Musset's type 2 is more frequent. After a summary of diagnostic, the authors describe the treatment during and outside the pregnancy.