Doppler analysis of the umbilical artery: why we must prefer the free loop of the cord.

AIM: The main objective was to confirm with modern tools the former assertion that there is a vascular resistance gradient along the umbilical cord. METHODS: We performed a prospective observational study in a population of women with third trimester monofetal and uncomplicated pregnancies during two months. Pulsatility Index and Resistance Index were calculated on three sites: placental end, free loop and fetal end of the cord. RESULTS: Sixty-five pregnant women were included in the study. Mean gestational age was 32 weeks and 3 days. We confirmed the presence of a resistance gradient with a significant increase of both Resistance and Pulsatility Indices from the placental toward the fetal end of the cord (Resistance Index = 0.61±0.07 at placental end and 0.66±0.11 at fetal end [P<0.001]. Pulsatility Index = 0.97±0.17 at placental end, and 1.06±0.25 at fetal end [P<0.001]). CONCLUSION: Resistances seem higher when doppler waveform analysis of the umibilical artery are performed at the fetal end of the cord. We recommend the free loop insonation site to obtain a better sensitivity. International guidelines strongly need to be well diffused in order to standardize practices.

Late post-partum dyspareunia: does delivery play a role?

OBJECTIVE: To study whether post-partum dyspareunia one year after a delivery is associated with characteristics of delivery: perineal trauma, obstetric interventions and women's experience. METHODS: A self-administered questionnaire on post-partum sexual function was mailed in May 2002 to all consecutive women who gave birth to a live-born term infant in a maternity unit, between January 2001 and June 2001. Obstetric data were abstracted from the hospital computerized medical database. Late dyspareunia was defined as pain during intercourse, one year after delivery. Multiple logistic regression modeling was used to select independent predictors of late post-partum dyspareunia. RESULTS: Seventy (27.6%) of the 254 women studied experienced late dyspareunia. There was no relation between late post-partum dyspareunia and neither the mode of delivery nor state of the perineum, including perineal laceration or episiotomy. Multiple logistic regression analysis showed that late post-partum dyspareunia was associated with dyspareunia before pregnancy, low satisfaction with delivery, and employment status. CONCLUSIONS: Late post-partum dyspareunia seemed to be linked more with the mother's experience of childbirth than with perineal trauma. This hypothesis should be investigated further.

Cervical assessment at 22 and 27 weeks for the prediction of spontaneous birth before 34 weeks in twin pregnancies: is transvaginal sonography more accurate than digital examination?

OBJECTIVES: This study compared the accuracy of ultrasound cervical assessment (cervical length and cervical index) and digital examination (Bishop score and cervical score) in the prediction of spontaneous birth before 34 weeks in twin pregnancies. METHODS: In a prospective multicenter study, digital examination and transvaginal sonography were performed consecutively in twin pregnancies attending for routine sonography at either 22 weeks (175 women) or 27 weeks (153 women). The digital examination took place first, and the Bishop score and cervical score (cervical length minus cervical dilatation) were calculated. Ultrasound measurements were then made of cervical length and funnel length to yield the cervical index (1 + funnel length/cervical length). The association between each variable and delivery before 34 weeks was tested by the Mann-Whitney U-test. The receiver-operating characteristics (ROC) curves of the ultrasound and digital indicators were determined for both gestational age periods, and the areas under the ROC curves compared. The best cut-off values for each indicator were used to determine predictive values for delivery before 34 weeks. RESULTS: The median gestational age at delivery among the women included in the 22-week examination period was 36.0 (range, 21-40) weeks; 10.9% (19) gave birth spontaneously before 34 weeks. The median cervical length was 40 (range, 6-65) mm. All four parameters were predictors of delivery before 34 weeks. The areas under the ROC curves for cervical index, cervical length, Bishop score and cervical score did not differ significantly. The median gestational age at delivery among the women in the 27-week examination period was 36.0 (range, 27-40) weeks; 9.2% (14) gave birth spontaneously before 34 weeks. The median cervical length was 35 (range, 1-57) mm. All parameters except the Bishop score were predictors of delivery before 34 weeks. The likelihood ratio of the positive and negative tests for cervical length < or = 25 mm was 5.4 (range, 3.2-9.0) and 0.3 (range, 0.1-0.7), respectively, compared with 2.3 (range, 1.3-4.2) and 0.6 (range, 0.3-1.1), respectively, for cervical score < or = 1. The area under the curve for the cervical index was significantly larger than that for the Bishop score (P = 0.008) or cervical score (P = 0.02). CONCLUSION: Transvaginal sonography predicted spontaneous delivery before 34 weeks better than digital examination at the 27-week but not the 22-week examination.

[Risk of very preterm delivery: can we refrain from in utero transfer and manage these patients in level I and II maternity wards?]. / Menace d'accouchement prématuré sévère précoce: est-il licite de ne pas transférer in utero et comment gérer une naissance en centre de niveau I et II?

The frequency of premature delivery is estimated at 0.5% of births (approximately 2000 per year in France). The rate of in utero transfers before 28 weeks, although difficult to evaluate, is well above this percentage, raising the risk of overloading level III maternity wards. Who should or should not be transferred? What tests are most pertinent? What are the criteria for diagnosing premature labor? Which treatment should be offered? How should the decision to transfer be established? What information should be furnished to the parents? How should an unexpected delivery be managed? How should the transfer network be optimally organized?

Down's syndrome screening with nuchal translucency at 12(+0)-14(+0) weeks and maternal serum markers at 14(+1)-17(+0) weeks: a prospective study.

BACKGROUND: Sonographic and biochemical methods for Down's syndrome screening have developed simultaneously, but independently. As a consequence, the rate of invasive procedures for fetal karyotyping has dramatically increased and become an important public health issue which needs to be controlled. One approach is to combine sonographic and biochemical results into a single risk assessment. METHODS: In a multicentre interventional study, nuchal translucency (NT) was measured between 12(+0) and 14(+0) weeks of gestation. Maternal serum markers (MSM) were measured between 14(+1) and 17(+0) weeks of gestation. Karyotyping was advised when: (i) NT was > or =3 mm; or (ii) the MSM-related risk was > or =1 in 250 at term. Karyotyping was delayed until after a maternal blood sample had been taken. NT and MSM were expressed as multiples of the medians (MoMs), and risks were calculated and tailored to the study population. A combined risk for NT and MSM was estimated retrospectively. Costs per case diagnosed, and the cost per case averted were calculated for the three screening strategies. RESULTS: A total of 9444 women was screened. Twenty-one fetuses (0.22%) had Down's syndrome, whilst 326 women (3.4%) were lost to follow-up. Among 9118 women followed up, 5506 had both NT and MSM, 821 had only NT, and 2791 had only MSM. Median maternal age was 30.5 years. False-positive rates for NT, MSM and NT combined with MSM were 3.0, 5.8 and 0.23% respectively. The false-positive rate generated by a sequential two-stage screening was 8.6%. Detection rates of Down's syndrome were 62 and 55% for NT and MSM respectively. Seven cases with Down's syndrome (35%) had raised NT and MSM, and 17 (81%) had either raised NT, MSM, or both. For a 5% false-positive rate, detection rates were 55 and 80% for NT alone and for combined NT and MSM respectively. Ultrasound alone appears to be more cost-effective ( pound50 per case diagnosed) than both tests ( pound61 per case diagnosed). CONCLUSIONS: The study results suggest a 25% increase in the detection rate of Down's syndrome using a combination of NT measurement at 12(+0)-14(+0) weeks and MSM at 14(+1)-17(+0) weeks for a 5% false-positive rate, with modest increase in cost.

[Sarcoidosis and pregnancy. A retrospective study of 11 cases]. / Sarcoïdose et grossess. Etude retrospective de 11 cas.

PURPOSE: To analyze the evolutive profile of sarcoidosis together with reciprocal interactions between pregnancy and sarcoidosis. METHODS: All events that occurred during pregnancy in 11 women presenting with sarcoidosis were analyzed. Histological confirmation was obtained for the 11 cases. For all pregnancies were analyzed the course of both sarcoidosis and pregnancy, and the influence of pregnancy on the disease evolution. RESULTS: Among 33 pregnancies, 23 led to the birth of healthy fetuses (five spontaneous abortions, four voluntary abortions, and one therapeutic abortion). The major event was fetal hypotrophy in six cases. Three of them occurred during pregnancy in prednisone-treated patients with active sarcoidosis. No relapse of cured sarcoidosis or further evolution of sarcoidosis that was inactivated as of the beginning of pregnancy were observed. The course of active sarcoidosis varied, as improvement (one case), worsening (two cases) and stabilization (two cases) were observed. During the first year of follow-up after delivery, four relapses and, in two cases, preliminary signs of the disease were observed. CONCLUSION: Apart from the hypothetical but not definite risk of hypotrophy, no negative interaction between sarcoidosis and pregnancy could be established. Pregnancy does not seem to interfere with the course of sarcoidosis. Considering the risk of relapse after delivery, pregnant women presenting with sarcoidosis should benefit from clinical and radiological follow-up.

[Effect of smoking on the fetus and the child during pregnancy]. / Retentissement, sur le foetus et l'enfant, du tabagisme pendant la grossesse.

Cigarette smoking remains a frequent problem during pregnancy. Nicotine has deleterious effects on the foetus. The most common problem remains "small for date" babies. However, this is a minor problem compared with two major toxic consequences: intellectual impairment and increased rate of infantile cancer. Many studies have shown diminished intellectual capacity, behavioural problems and an increase of sudden infant death syndrome. The cancerigenic and genotoxic effects of smoking are well documented with recent studies showing the genotoxicity of amniotic fluid in smoking pregnant women and lymphocyte chromosome mutation in newborns. The frequency of cancers, particularly leukaemia, lymphoma and cerebral tumours are increased in children born to women who smoke during pregnancy. It is therefore excessively important to help pregnant women and their doctors become aware of the toxic effects of active or passive smoking in pregnancy and encourage the patients and their friends and relations to stop smoking as soon as pregnancy is diagnosed or if it's possible before the pregnancy.

[Diabetic pregnancy. Evaluation and prospects from the study of 212 diabetic pregnancies followed-up between 1985 and 1992]. / Grossesse diabétique. Bilan et perspective à partir de l'étude de 212 grossesses diabétiques suivies entre 1985 et 1992.

A total of 212 diabetic pregnancies were studied prospectively over the period 1985 to 1986, included: 76 insulinodependent diabetics (IDD), 34 non insulinodependent diabetics (NIDD), and 102 gestational diabetes. The perinatal mortality rate for all diabetic pregnancies was 1.4% (n = 3); 3 congenital malformations were recorded (a therapeutic abortion was performed in 2 cases). These results are comparable with those of the non diabetic population. However, it is to be noticed that maternal as well as neonatal morbidity was important (hypoglycaemic comas: 18 in 9 IDD, preeclampsia: 7 IDD, 2 NIDD, 1 DG; caesarean delivery: 50% IDD, 50% NIDD, 25% DG; neonatal morbidity 20% of the new born. The main objectives must be targeted on the prevention of severe hypoglycaemia in IDD, the early diagnosis of DG and the development of pregnancy care in NIDD.

Systemic polyarteritis nodosa diagnosed at hysterectomy.

A 61-year-woman was referred because of declining general health. A diagnosis of uterine malignancy was suspected on the basis of uterine enlargement and an elevated erythrocyte sedimentation rate. Hysterectomy was performed, and histologic examination revealed necrotizing vasculitis affecting the ovaries, fallopian tube, and uterus. Muscle biopsy showed typical periarteritis nodosa lesions. Despite the scarcity of such cases, the incidental finding of necrotizing arteritis in a surgical uterine specimen warrants further investigation to determine if the vasculitic process is localized.

[Fentanyl in peridural obstetrical analgesia. Evaluation after 4 years' use]. / Le fentanyl dans l'analgésie obstétricale par voie péridurale. Bilan après quatre ans d'utilisation.

7,500 deliveries occurred from the date of opening of the Maternity Hospital Jean-Rostand. 3,500 of these were conducted under epidural anaesthesia. At different stages prospective studies were carried out to recall the effect of adding fentanyl to bupivacaine when the epidural injection was made. A pharmacokinetic study. This shows that the levels in the mother and the fetus begin to coincide more with the number of doses that are given and pass from 0.3 after 50 micrograms have been administered to 0.5 after 100 micrograms have been administered and 0.7 after 150 micrograms have been administered. The fetal levels are far lower than those required to depress respiration. The half life of distribution through the circulation has been worked out at 4 minutes and the half for elimination of the drug at 460 minutes. The maternal levels show great fluctuations and late alterations. Analgesia is earlier, more complete and more prolonged when fentanyl is added. Fentanyl also masks irregularities. Undesirable effects such as tiredness, pruritus, nausea, vomiting and urinary retention occur infrequently and last only for short periods of time. No mother had respiratory depression. The doses of bupivacaine that had to be given were as a whole less when fentanyl was added. In 40% of cases it only required one injection to achieve analgesia throughout the whole labour. The length of labour and the number of caesarean operations carried out did not change.(ABSTRACT TRUNCATED AT 250 WORDS)