[The use of intrauterine device in nulliparous over 18 years: a Belgian consensus]. / La contraception intra-utérine chez la nultlipare de plus de 18 ans: vers un consensus belge.

Under the presidency of prof. H. Depypere (UZ Ghent) and Prof. P. Simon (ULB Erasme) a Belgian panel of thirteen experts (gynecologists, representatives of universities and scientific associations for gynecology-obstetrics) reached a consensus on the use of intrauterine systems, both copper IUDs as hormone IUDs, in nultiparous women.

Spontaneous hepatic rupture in a normotensive monoamniotic twin pregnancy: case report and review of the literature.

BACKGROUND: Spontaneous liver rupture during pregnancy is extremely rare, and often associated with hypertensive disorders. Maternal outcomes are poor and morbidity is high. CASE: A 27-year-old women (G1P0), pregnant with monochorionic-monoamniotic twins, developed extensive abdominal pain while she was electively admitted at 32 weeks for fetal pulmonary maturation. Diagnosed with preterm labor, a caesarean section was performed. Postoperatively, our patient deteriorated and a second laparotomy revealed an extensive liver rupture. There was no evidence of hypertensive disorders or hepatic tumors. After perihepatic packing and embolization, our patient required long-term treatment in our intensive care unit. She survived, and both mother and children are healthy after 6 months. CONCLUSION: Despite being rare, spontaneous liver rupture in absence of hypertensive disorders during pregnancy is associated with high maternal morbidity and mortality. Adequate treatment requires a multidisciplinary approach.

[Increased nuchal translucency at 11-14 weeks of gestation in congenital heart disease, genetic syndromes and adverse pregnancy outcome].

Nuchal translucency (NT) measurement between 11-14 weeks of gestation is an'effective method of ultrasound screening for chromosomal fetal anomalies, congenital heart disease, some other structural abnormalities, rare genetic syndromes, skeletal dysplasia and adverse pregnancy outcome (spontaneous abortion and intrauterine fetal demise). The aim of the present study is to assess the prognostic value of increased first trimester NT in fetuses with normal karyotype in relation to pregnancy outcome.

[First trimester ultrasound screening for structural and chromosomal anomalies in multiple pregnancy]. / Ultrazvukov skrining za strukturni i khromozomni anomalii pri mnogoplodna bremennost v purvi trimectur.

AIM OF THE STUDY: To assess the feasibility of first trimester ultrasound screening for structural and chromosomal fetal anomalies in multiple gestations. METHODS: An observational prospective follow up study was carried out in 32 cases of multiple pregnancies. Two scans were scheduled in each case--the first, between 6-9 weeks of gestation (w.g.) and the second, between 11-14 w.g. The aim was assessment of fetal number, viability, chorionicity/amnionicity and fetal biometry. In addition, nuchal translucency [NT] measurement, assessment of risk for chromosomal anomalies and fetal anatomy survey were always performed. Increased NT > or = 95 percentile and/or detection of structural anomaly were considered indications for invasive prenatal diagnosis and fetal karyotyping. Selective fetocide was considered in cases of chromosomal or structural anomalies and in high-order multiple gestations (> or = 3 fetuses). Pregnancy outcome was ascertained by the physical examination of the fetuses, placentas and membranes postpartum, the hospital records, the referring physicians or the parents. RESULTS: From 32 cases of multiple pregnancies included in the study, 28 were twins, and 4--triplets. 68% (19/28) of the twin pregnancies were bichorionic-biamniotic [Bi-Bi], 25% (7/28)--monochorionic-biamniotic [Mo-Bi] and 7% (2/28)--monochorionic-monoamniotic [Mo-Mo]. 4 cases of increased NT in one of the twins (1--associated with trisomy 21) were observed, as well as 2 cases of structural fetal anomalies (1--discordant for exencephaly, and 1--with conjoint twins), 2 cases of feto-fetal transfusion syndrome that developed in the second trimester (1--associated with increased NT between 11-14 w.g.), 1 case of TRAP syndrome [twin-reversed arterial perfusion] and 1 case of cord entanglement in monoamniotic twins. In addition, there were 4 cases of a vanishing twin in the first trimester, and in 2 other cases spontaneous miscarriage of both twins occurred before 24 w.g. In two of the triplet pregnancies selective fetocide was performed, one was successfully delivered at 33 w.g. and in the last case the parents chose to terminate the pregnancy. CONCLUSIONS: First trimester ultrasound is a method of choice for detection of major structural fetal anomalies in multiple gestations. Increased NT between 11-14 w.g. in multiple pregnancies is a useful screening tool for detection of chromosomal fetal anomalies, while in monochorionic twins its presence might predict the development of fetofetal transfusion syndrome. First trimester selective fetocide in high-order multiple gestations or in affected twins is one of the options in pregnancy management.

[Ultrasound screening and diagnosis of fetal structural abnormalities between 11-14 gestational weeks]. / Ultrazvukov skrining i diagnostika na strukturnite anomalii na ploda mezhdu 11-14 g.s.

AIM OF THE STUDY: To assess the feasibility of ultrasound screening and diagnosis of structural fetal anomalies at the 11-14 week scan. METHODS: An observational prospective follow up study from March 2000 till May 2003 was performed at three referral centers by seven experienced sonographers with high-resolution ultrasound equipment. 1135 singleton pregnancies between 11+0 and 14+6 weeks gestation (w.g.) participated in the study. The first trimester scan included assessment of fetal number, viability and biometry, nuchal translucency [NT] measurement and fetal anatomy survey performed according to standardized published protocols. Increased NT > or = 95th centile and/or diagnosis of structural fetal anomaly was considered as indication for invasive prenatal diagnosis, early fetal echocardiogram and follow-up scans, including a detailed fetal anomaly scan at 18-22 w.g. and a third scan at 28-32 w.g. Pregnancy outcome was ascertained from hospital records, referring physicians or the patients themselves. RESULTS: The overall prevalence of structural fetal anomalies in the present study was 4.6% (53/1135). 22% (12/53) of the structural anomalies were detected between 11-14 w.g. 9 of those had normal karyotype, and 3 were associated with chromosomal anomalies. Furthermore, 10 cases of increased NT, with or without non-immune hydrops fetalis, were associated with congenital heart disease, rare genetic syndromes and adverse pregnancy outcome later in gestation. The ultrasound detection rate of structural fetal anomalies in the present study increased from 22% (12/53), to 69% (37/53) and 79% (42/53) for the first trimester scan, the first and second trimester scans, and the combination of all three scans, respectively. 21% (11/53) of all structural fetal anomalies were missed by prenatal ultrasound. CONCLUSIONS: The first trimester scan is a method of choice for the diagnosis of major structural fetal anomalies. NT measurement is a useful screening test for chromosomal anomalies. In cases with increased NT subsequent development of congenital heart disease, rare genetic syndromes or adverse pregnancy outcome should be ruled out. At present, the second trimester scan constitutes an indispensable tool for the detection of most structural abnormalities. Even in advanced gestation the prenatal diagnosis of certain anomalies is difficult and often unfeasible.

Limb-body wall complex: 4 new cases illustrating the importance of examining placenta and umbilical cord.

Limb-body wall complex (LBWC) is a rare, sporadic, congenital defect defined as a combination of at least two of three characteristics: 1. limb defects, 2. anterior body wall defects, and 3. exencephaly or encephalocoele with/without facial clefts. Three pathogenic mechanisms have been proposed: early amnion rupture, vascular disruption and embryonic dysgenesis. In this study we carried out the pathological evaluation of four fetuses with LBWC and their placentas. None of the cases had craniofacial defects. Three fetuses showed an abdominal wall defect with eventration of abdominal organs, cloacal exstrophy, absent external genitalia, abnormal internal genitalia, scoliosis and lower limb defects. One fetus showed failure of closure of both thoracic and abdominal walls with ectopia cordis, evisceration of left lung and abdominal organs, severe reduction defect of left arm, but normal colon, anus, bladder, genitalia and lower limbs. All cases had a short, malformed umbilical cord, incompletely covered by amnion. The umbilical vessels were embedded in an amniotic sheet which connected the skin margin of the anterior body wall defect to the placenta. These anomalies suggest an abnormal body stalk development as a pathogenic mechanism for LBWC. Prenatally, the abnormal fetoplacental attachment can be detected ultrasonographically by the end of the first gestational trimester. Postnatally, the examination of placenta, umbilical cord and membranes is crucial in confirming the diagnosis of LBWC.

CD34++ CD38- and CD34+ CD38+ human hematopoietic progenitors from fetal liver, cord blood, and adult bone marrow respond differently to hematopoietic cytokines depending on the ontogenic source.

CD34++ CD38- and CD34+ CD38+ hematopoietic progenitor cells (HPCs) from human fetal liver (FL), cord blood (CB), and adult bone marrow (ABM) were isolated and investigated for their growth characteristics, cytokine requirements and response to two modulators of early hematopoiesis, interferon (IFN)-gamma and macrophage inflammatory protein (MIP)-1alpha. We observed first that a significantly lower percentage of CD34++ cells were CD38- in ABM than in FL and CB. Second, the functional differences between CD34++ CD38- and CD34+ CD38+ cells were less pronounced in FL and CB than in their ABM counterparts. Third, an inverse correlation was found between growth factor response and the ontogenic age of HPCs, and a direct correlation was noted between cytokine requirements and the ontogenic age of HPCs. Fourth, spontaneous colony formation in a classic semisolid culture system was reproducibly obtained only in the ontogenically earliest cells, that is, in FL but not in CB and ABM, in which no such spontaneous colony formation was observed. Fifth, the modulatory effects of IFN-gamma and MIP-1alpha were qualitatively different depending on the ontogenic age of the progenitor source: whereas IFN-gamma was only a selective inhibitor of primitive CD34++ CD38- ABM progenitor cells, it inhibited both CD34++ CD38- and CD34+ CD38+ FL and CB cells to the same extent. In contrast to the effects of MIP-1alpha on ABM, we could not find any consistently stimulatory or inhibitory effects on FL and CB progenitors. In conclusion, important functional and biologic differences exist between FL, CB, and ABM progenitor cells, and these differences could have major implications for the use of these cell populations in preparative protocols of ex vivo expansion, transplantation strategies, or gene transfer experiments.

Longitudinal evaluation of uteroplacental and umbilical blood flow changes in normal early pregnancy.

The hemodynamic changes in the uteroplacental circulation and the umbilical artery were evaluated in normal pregnancy from 8 to 14 weeks' gestation. A 6-9-MHz broad-band transvaginal sonographic transducer combined with pulsed color Doppler was used to scan 37 healthy volunteer pregnant women at weekly intervals. Vascular impedance to blood flow in all examined vessels decreased significantly throughout the first gestational trimester. Resistance to flow was highest in the main uterine artery and decreased towards the spiral artery. When the flow velocity waveform patterns of the arteries under investigation were analyzed, specific changes were observed. The diastolic notch was present in the spiral artery flow velocity waveform in all cases until 10 weeks' gestation. From then, the diastolic notch disappeared progressively and was absent in 100% of cases at 13 weeks. The diastolic notch in the arcuate artery disappeared within 2 weeks of its disappearance in the spiral artery. We could not detect intervillous blood flow during the first 12 weeks. From then on, intervillous flow was observed in most pregnancies, reaching 100% at 14 weeks' gestation. These changes reflect the growth and development of the uteroplacental circulation. The absence of detectable intervillous flow during most of the first trimester confirms the concept that, during the first 3 months of gestation, blood flow to the intervillous space is inhibited by trophoblastic plugs.

Successful triplet pregnancy in a patient with a unicornuate uterus with a cavitary communicating rudimentary horn.

In a patient with primary infertility, ovulation was induced by monitored stimulation with human menopausal gonadotrophins (HMG) because of polycystic ovarian disease. Infertility work-up had shown a unicornuate uterus with a cavitary communicating rudimentary horn. The husband showed a varicocele-related moderate oligo-asthenoteratozoospermia. A triplet pregnancy occurred in a third HMG ovulation induction cycle combined with intra-uterine insemination of the husband's washed semen. The pregnancy was carefully monitored, and measures to prevent premature delivery were taken. Because of the patient's obvious discomfort in the presence of premature labour, Caesarean section was performed at 33 weeks gestation and three healthy infants were delivered. This is the first report of a successful triplet pregnancy in a women with a unicornuate uterus. The reproductive and obstetric outcome of this condition in general, and in the case of multiple pregnancy, is discussed.

The influence of angiotensin II-induced vasoconstriction on common carotid artery blood flow and velocity-time profiles in normal women.

Non-invasive methods of measuring blood velocity, especially Doppler velocimetry, are being increasingly used in obstetrics to provide observational information. We report a preliminary study of their usefulness in experimental studies. Doppler velocimetry was used to assess blood flow and velocity-time profiles in the common carotid artery of seven women of reproductive age before and during the incremental administration of angiotensin II. Angiotensin II infusion evoked the expected increments in systolic and diastolic arterial pressure and fall in heart rate. Angiotensin II was associated with a dose-dependent fall in maximum blood velocity, which, at an average rise in systolic blood pressure of 23 mmHg, had fallen from 91 +/- 16 to 52 +/- 4 (mean +/- SD, p < 0.01). Absolute maximum blood velocity was strongly correlated with systolic and diastolic blood pressures (p < 0.001 for both). The minimum velocity was unaltered throughout, and the calculated flow did not change significantly (490 +/- 100 cf. 380 +/- 50 ml/min). Overall, these findings are in agreement with those previously reported using invasive methods of monitoring flow during angiotensin II infusion, and further support the usefulness of Doppler velocimetry as an investigative tool in human physiology and pharmacology.However, the pulsatility index, resistance index and systolic/diastolic velocity ratio all fell significantly during angiotensin II infusion (p < 0.01 for all). The conventional interpretation of a fall in these indices, i.e. reduced downstream resistance, is clearly erroneous under these circumstances, since angiotensin II induces arteriolar vasoconstriction. This illustrates the importance of interpretation of Doppler velocity envelopes in the light of pharmacological mechanisms likely to be evoked by the experimental procedure.

Influence of raising maternal blood pressure with angiotensin II on utero-placental and feto-placental blood velocity indices in the human.

1. The effect of doubling doses of angiotensin II on maternal systemic blood pressure and arcuate and fetal umbilical artery Doppler velocity profiles has been investigated in 10 women in first- and 10 in second-trimester pregnancy. Ten non-pregnant women were also studied. 2. A progressive decrease in the pressor response to angiotensin II in early pregnancy as previously described was confirmed. 3. Angiotensin II induced a significant dose-dependent increase in the pulsatility index (a measure of downstream resistance) in the umbilical artery in both first- and second-trimester patients. There was an apparent increase in the threshold response of the pulsatility index to angiotensin II in the umbilical artery as pregnancy progressed. There was also a significant correlation between changes in maternal systolic or diastolic pressure and change in umbilical artery pulsatility index, but this did not differ between the two trimesters. This suggests that the increase in pulsatility index is related to blood pressure rather than angiotensin II. This is consistent with reports that angiotensin II does not cross the haemomonochorial placenta. 4. Basal pulsatility index in the arcuate artery fell with increasing gestation. There was a significant inverse association between the evoked change in maternal systemic blood pressure and the change in arcuate artery pulsatility index, suggesting local vasodilatation. 5. We conclude that acutely increasing maternal blood pressure leads to increased vascular resistance on the fetal side of the circulation.

[The calibrating drainage of the common bile duct (C.B.D.). Value of "axial exit" drainage (author's transl)]. / Le drainage calibrant de la voie biliaire principale pédiculaire. Place du drainage à "sortie axiale".

The authors believe that utilisation of calibrating drainage is justified in case of difficult restauration of the C.B.D. of normal caliber, either throughout its length or in one segment. They underline that "axial exit" has not the disadvantages of the "lateral exit" of T-tubes. They recall the various modalities of "axial exit" (transcystic, transpapillary, transhepatic, "en seton") and their own contribution to the improvement of the transpapillary drainage by the association of a systematic sphincterotomy. Abstract of their clinical series, technics, postoperative mortality and morbidity, calibrating drainage duration and results (in connection with etiology) are reported. Main advantages of the "axial exit" are the absence of any risk of stenosis on a non dilated C.B.D. (as for the "lateral exit") and the facility for long time calibration up to several years. No hemorrhage, no bile leakage have been observed. The one only risk of this sort of drainage is the premature fall of transcystic or transpapillary drains ; but this disadvantage does not exist for "en seton" drainage. Shortly : "axial exit" calibrating drainage is recommandable when a very long time calibration after restauration of non dilated C.B.D. is necessary.