[Cyclophosphamide during pregnancy: a safe prescription]. / Cyclophosphamide en cours de grossesse: une prescription acceptable.

Cyclophosphamide is an alkylating agent used to treat haematologic malignant diseases and multisystem diseases with progressive glomerulonephritis. It is rarely prescribed during pregnancy. We report a case of Henoch-Schönlein purpura discovered at the end of the first trimester of pregnancy. Despite steroid therapy, glomerulonephritis worsened and 100 mg/day cyclophosphamide per os was administered from 28th week till delivery. The infant, prematurely born, was normal and did not have any haematological disorder. Congenital malformations are often reported (5 out of 19 newborns exposed in utero to cyclophosphamide), but in all those cases, there was another potentially teratogenic agent: either radiotherapy or another antineoplastic drug. Therefore, if mother's life is in jeopardy, cyclophosphamide therapy should be given and not postponed.

[Diagnostic and prognostic elements of non-immunologic feto-placental anasarca. Review of the literature apropos of 7 new cases]. / Eléments diagnostiques et pronostiques de l'anasarque foeto-placentaire non immunologique. Revue de la littérature à propos de 7 nouveaux cas.

Non immunologic hydrops fetalis (NIHF) is relatively more frequent now since prevention and treatment of blood incompatibilities are common. Seven cases of NIHF were observed between November 1984 and April 1987; antenatal diagnosis by ultrasound scanning was possible in six of these seven cases. Fetal prognosis is usually poor. Only one of the seven children survived, four infants died shortly after birth; two women chose an elective termination of pregnancy at 18 and 23 weeks of gestation, respectively. The review of the literature shows that more than 150 etiologies are associated with this condition. An etiology was found in five of our seven cases, these were all different; renal vein thrombosis, cardiac malformation, cystic hygroma, osteogenesis imperfecta and one case of recurrent NIHF (four affected siblings). Two cases remained idiopathic. Diagnosis of NIHF is best oriented by three investigations: obstetrical ultrasound scanning, fetal echocardiography and any kind of amniocentesis, either for karyotype alone, or to evacuate pleural, pericardial of peritoneal effusions. Ultrasound scanning can evaluate the importance of these effusions and help to choose other etiological investigations. Fetal echocardiography is mandatory because out of the 150 etiologies described in association with NIHF, 25% are cardiac (malformation or dysrhythmias). As already mentioned, fetal prognosis in our series was poor, but perhaps more aggressive in utero treatment could have improve it.

[Antenatal diagnosis of holoprosencephaly and its consequences. Apropos of 2 cases]. / Le diagnostic anténatal de l'holoprosencéphalie et ses conséquences. A propos de 2 observations.

Cyclops represents the worst form of a rare malformation of the brain and face: holoprosencephaly. Two cases are reported, including one that was diagnosed at the 23rd week of pregnancy. Now, ultrasonography makes it possible to diagnose early; as soon as the 15th week of gestation. Ultrasound diagnosis is based on hypotelorism and anomalies of the mid-line, with or without facial abnormalities. The outcome is always poor. This malformation is associated with various conditions and a complete assessment, including the karyotype, morphologic studies of the fetus and of his family, and search for related minor facial dysmorphias (median labial or cleft palate with, with a single upper incisor) is mandatory. The condition recurs in 2 to 50% of cases depending on various associated conditions and on the family histories.

[Drug addiction and pregnancy. Principal obstetrical and pediatric complications]. / Toxicomanie et grossesse. Principales conséquences obstétricales et pédiatriques.

The principal obstetrical and paediatric sequelae were studied in 22 heroin addicts who were followed up at Lariboisière Hospital in Paris between 1980 and 1984. The main effects were on the fetus with 45% showing growth retardation below the 10th percentile, 65% fetal distress, 9% prematurity; 33% had infections and 66% had the withdrawal syndrome. Because of this pathology a high number had to be transferred. Considering the period of study, HIV infection could not be evaluated. The most dramatic result seems to be the long-term effect on these children because only a third apparently live with their families and several suffer from abnormalities in psychomotor development.

[Prenatal diagnosis and treatment of auricular flutter. Apropos of a case and review of the literature]. / Diagnostic et traitement anténatal d'un flutter auriculaire. A propos d'un cas, revue de la littérature.

In newborns, atrial flutter is a rare, but severe condition. Late diagnosis was usual and based on fetal ECG. Now, fetal ultrasonography can differentiate in utero atrial flutter and other supra ventricular tachycardias; so it can be treated before development of cardiac failure. Among numerous and various available drugs, digoxin is universally recommended, but the delayed effect and the maternal serum levels to obtain effective fetal concentration of digoxin are not well known. Furthermore, endogenous "digoxin-like" substances have been found in maternal blood in late pregnancy; this finding raises the problem of the validity of monitoring the treatment only by serum digoxin levels. A case of atrial flutter, diagnosed in utero by ultrasonography and treated by digoxin before development of cardiac failure is reported. Neonatal echocardiography showed an aneurysm of the atrial septum, which needed simple monitoring. Its responsibility in the pathogenesis of the arrhythmia is unclear. Numerous cases of aneurysm of the atrial septum have been reported in healthy adults without atrial arrhythmias.

[Echographic diagnosis of cystic hygroma. Apropos of a case]. / Diagnostic échographique d'un hygroma kystique. A propos d'un cas.

A case of nuchal cystic hygroma associated with non immune hydrops fetalis and renal malformation in one of two twins observed at 18th week of gestation is reported. Occurrence of acute polyhydramnios and severity of the anomalies showed by serial ultrasound scans has led to termination of pregnancy induced by prostaglandin E. This rare malformation is related to an abnormality of the lymphatic system and is usually associated with monosomy 45 XO or Turner syndrome. But a review of some 191 reported cases shows that this condition may be connected with various chromosomic or congenital anomalies. This may worsen the prognosis and accurate diagnosis is mandatory to guide the genetic counseling for future pregnancy. Ultrasonography allows precise diagnosis of cystic hygroma as soon as the end of the first trimester. The potentially lethal associated malformations and anomalies of karyotype will condition the management of this malformation. The prognosis usually fatal in utero will often lead to termination of pregnancy.

[The drug combination amoxicillin-clavulanic acid compared to the triple combination ampicillin-gentamicin-metronidazole in the treatment of severe adnexal infections]. / L'association amoxicilline-acide clavulanique comparée à la triple association ampicilline-gentamicine-métronidazole dans le traitement des infections utéro-annexielles sévères.

Forty-four patients with severe pelvic inflammatory disease were randomly divided into two groups. Single drug therapy with the amoxicillin-clavulanic acid was used in 22 patients (group A). The other 22 patients (group B) were given a combination of ampicillin, gentamicin and metronidazole. Clinical results were comparable in both groups with 91% successes and 9% improvements in group A, against 86% successes, 9% failures, and 5% non-interpretable results in group B. The difference between the two groups was not statistically significant (p = 11.6%). 30% of patients in each group had positive serologic tests for Chlamydiae. This had no influence on therapeutic results but led to secondary prescription of a cycline. Because amoxicillin-clavulanic acid is active against aerobic and anaerobic pathogens, including beta-lactamase-producing microorganisms, it is a satisfactory alternative to the ampicillin-gentamicin-metronidazole combination, especially as it is simpler to use, less toxic and less expensive.

[Value of the echography of the maternal kidney during pregnancy]. / Intérêt de l'échographie du rein maternel pendant la grossesse.

Routine ultrasonographic detection of renal tract dilatations in pregnant women is used to define a high risk population for urinary tract infections. In a first group of 96 patients with symptomatic urinary tract infection, 34% of the cases of uncomplicated infection were accompanied by ultrasonographic abnormalities, while 73% of cases of pyelonephritis presented such signs. Antibody coated bacteria were only found in 12% of uncomplicated urinary tract infections and in 30% of cases of pyelonephritis. In a second group of 273 patients, routine ultrasonography revealed abnormalities in 11.5% of cases. 7.5% of patients had dilatations of the upper renal tract, 2% had renal stones and 2% had occult renal malformations. Dilatations of the upper renal tract were associated with asymptomatic urinary tract infections in 30% of cases. Screening for upper renal tract dilatations is recommended between the 17th and 20th weeks of pregnancy. The presence of such lesions constitutes a risk factor for urinary tract infection and appropriate prophylactic treatment should be prescribed.

[Incidence of pulmonary tuberculosis in a population of pregnant women at risk]. / Incidence de la tuberculose pulmonaire dans une population de femmes enceintes à risques.

So long as the diagnosis is made early and treatment is prolonged adequately pulmonary tuberculosis in pregnant women has been shown to have a much better prognosis than formerly. 13 new pregnant women were found to have tuberculosis in 18 months, which gave an incidence of 32 per 10,000 population. This is 5 times more than the mean incidence in France; and makes it worth while screening for the condition, particularly among immigrant.

[Evolution of the indications for cesareans. Comparison of 1971-1976 and 1976-1979 at the Maternity Center of the Louis-Mourier Hospital. Review of the literature]. / Evolution des indications de césariennes. Comparaison entre 1971-1976 et 1976-1979 à la Maternité de l'Hôpital Louis-Mourier. Revue de la littérature.

Changes in the indications for caesarean operations were studied over a period of 9 years from 1971-1979 and two periods from 1971-1975 and 1976-1979 were compared. The principal changes that show up are: an increase in the total number of caesarean sections from 5.3% in 1971 to 15.4% in 1979; modifications in the indications which were mainly due to much greater use of electronic means of monitoring the fetus and an improvement in the methods of resuscitation of the newborn (there were approximately the same number of caesareans for breech presentations, an increase in the number of repeat caesarean operations and of caesarean operations for fetal distress and for dystocia as well as for toxaemia of pregnancy); the improvement in the state of infants at birth seems to be parallelled by the increase in the number of caesarean operations. Though there was 8% neonatal morbidity, only 1% of these at the most could be put down to the caesarean; no maternal death occurred, although caesarean section is accompanied by an increased maternal morbidity of 27%. Reviewing the literature shows that the same tendencies occur in other places. This makes it possible to point out the ways in which action can be taken to limit the number of caesareans in those categories where the indications seem to be most frequent, namely dystocia, repeat caesareans, fetal distress and breech presentation. The optimum level of caesarean sections at 15% with 9% being first caesareans and 6% repeat caesareans should be kept to.