[Prenatal diagnosis of partial trisomy 9p]. / Diagnostic anténatal d'une trisomie 9p partielle.

The prenatal diagnosis of trisomy for the distal half of the short arm of n(o) 9 chromosome (partial trisomy 9p) has been realized from a morphologic ultrasound. A genetic investigation has permitted to establish that this trisomy was due to a bad segregation of a stable translocation present in the patient's mother. To our knowledge, the ultrasound prenatal diagnosis of partial trisomy 9p has never been reported in the literature. The prognosis of this syndrome remains very pejorative and the termination of pregnancy is the most often proposed solution.

Varicella and pregnancy.

OBJECTIVE: To appreciate the risk of embryo-foetopathy in case of maternal varicella occurring before 20 weeks of gestation, as well as the maternal complication risk (notably pulmonary) in case of maternal varicella occurring the third trimester of pregnancy. METHOD: Over the period from January 1987 to February 1995, 20 patients were managed for maternal varicella confirmed during the pregnancy. From these observations, the authors, by studying the literature, attempt to better specify the real fetal and/or maternal complication risk in case of maternal varicella. RESULTS: In their personal series of 20 cases, including 17 before 20 weeks of gestation, the authors have noted no embryo-foetopathy. Similarly, no maternal complication (notably pulmonary complication), has been found. Careful study of the literature allows to specify some points. In case of varicella before 20 weeks, one observes an identical frequency of spontaneous abortions, as compared to the general population and a moderated increase of the frequency of premature delivery. The risk of congenital varicella syndrome reaches about 1.3%. Finally the risk of neonatal varicella consists in a maternal infection which occurs during the perinatal period and which is source of a high perinatal morbidity. The prenatal diagnosis is based essentially and currently, on the amniocentesis with viral research by polymerase chain reaction (PCR) in the amniotic fluid, completed by a ultrasound supervision. CONCLUSION: The occurrence of maternal varicella during the pregnancy is rare (0.7/1000) because more than 90% of women are immunized. The risk of congenital varicella syndrome is limited to the 20 first weeks and seems very weak, authorizing therapists to reassure patients presenting a varicella during their pregnancy. Nevertheless, the risk of pulmonary complications for the mother, in case of varicella during the third trimester, does exist and requires appropriated treatment.

Monoamniotic twin pregnancies. Review of the literature, and a case report with vaginal delivery.

OBJECTIVE: To specify the process of the sometimes difficult diagnosis of monoamniotic twin pregnancies, as well as the best practise for delivery of this type of pregnancy. METHOD: Using their personal observation (a patient with a monoamniotic twin pregnancy, which presented a vaginal delivery at 35 weeks of gestation, two girls, in cephalic presentation, without particular problem, despite an entanglement of the cord and the existence of a knot), the authors established a review of the literature on this subject. RESULTS: Monoamniotic twin pregnancies represent a rare possibility. The prognosis is traditionally somber: 40-60% mortality, mainly due to pathologies of the cord. The review of the recent literature shows that most authors remain in favour of weekly ultrasound supervision from the 23rd week and of caesarean section in principle at 34 weeks (or from fetal pulmonary maturation). CONCLUSION: In the absence of funicular compression signs by colour-doppler, and under the cover of flawless obstetrical conditions, vaginal delivery can only be authorized for cases when both presentations are cephalic.

Anti-TJa alloimmunization (anti-PP1Pk): two consecutive pregnancies of an anti-TJa-carrying patient.

Anti-TJa alloimmunization is an extremely rare condition which can cause miscarriages during the first and second terms of pregnancy. At 20-year-old female patient, an anti-TJa carrier, was given plasma transfusions in the course of her first two pregnancies. The cordocentesis, which was the main follow-up test during the first pregnancy, could not be carried out during the second pregnancy due to the presence of a huge subchorionic hematoma. Both pregnancies were characterized by fetal growth retardation, which was particularly considerable in one. Due to chronic fetal distress, both infants were delivered prematurely by cesarean section. The immunohematological data concerning anti-TJa alloimmunization and the different palliative treatments available to date are reviewed.

[Appendicitis and pregnancy. Seven case reports]. / Appendicite et grossesse. A propos de 7 observations.

OBJECTIVES: Determiner optimal diagnosis and therapeutic management of pregnant women with suspected appendicitis. METHOD: Among over 9,000 patients who delivered in our obstetrics ward over a 4-year period, 7 (1/1, 285) underwent appendectomy during their pregnancy. Based on these observations and a review of the literature, an attempt was made to determine the best diagnostic approach in this rare situation. RESULTS: The frequency observed here was in agreement with data reported in the literature (1/1,000 to 1/2,000). Premature delivery occurred eight days after appendectomy at 29 months gestation in one woman. There was no complication in the 6 other pregnancies. Positive diagnosis, difficult during pregnancy, was based on clinical, biological and echographic findings. Laparoscopy improved not only diagnosis but also treatment and prognosis before 20 weeks gestation. CONCLUSION: Clinical presentation of appendicitis is modified during pregnancy rendering diagnosis difficult. The gravity of the appendicitis as well early diagnosis and management influence the maternal and fetal prognosis more than its association with pregnancy.

[Intestinal obstruction and pregnancy]. / Occlusion et grossesse.

Occlusion, a rare condition during pregnancy, occurred at 38 weeks gestation in a 26-year-old patient due to volvulous of the sigmoid on a dolichomegacolon. The diagnosis was made on the basis of the clinical manifestations and coloscopy evidence. Prognosis depends more on severity to the occlusion than on its association with pregnancy.

[Anomalies of umbilical vein in the fetus. A case report and review of the literature]. / Les anomalies de la veine ombilicale intra-abdominale chez le foetus. A propos d'un cas et rèvue de la littérature.

Abnormal connexion of the umbilical vein in the inferior vena cava was diagnosed in a fetus at 18 weeks' gestation. Associated anomalies included nuchal and axillary lymphangiectasia, hypertrophic cardiomyopathy and hepatomegaly. Neonatal death occurred after spontaneous vaginal delivery at 25 weeks. A review of the literature summarizes the diagnostic criteria and associated anomalies.

[In utero fetal death in multiple pregnancies during the second and third trimesters. A series of 21 cases]. / Mort foetale in utero dans les grossesses multiples au cours des deuxième et troisième trimestres. A propos de 21 cas.

OBJECTIVE: Recall the maternal and fetal risks in multiple pregnancies with in utero death during the second and third trimester. METHODS: From january 1, 1984 through December 31, 1994 21 cases of in utero death occurred among 405 multiple pregnancies followed in our unit. The frequency and circumstances of maternal and fetal complications were established according to type of placenta implantation, etiology, term at death of the twin and delay from death to delivery. RESULTS: The rate of in utero death was 5.2%. Various etiologies were observed, but the main cause was intra-uterine growth retardation. Maternal complications were marked by moderate asymptomatic disorders in hemostasis which resolved rapidly. Fetal complications included premature delivery (20/25 infants) and multicystic encephalopathy in one surviving twin. In monochorial pregnancies there is either tromboplastin release or hypotension-hypoxia phenomena which lead to neurological lesions. CONCLUSION: Fetal prognosis depends essentially on the type of placenta implantation. The most severe fetal complications are caused by neurological damage occurring in monochorial pregnancies. Screening for this anomaly is difficult, limiting the antenatal evaluation to the prognosis of the surviving twin. In bichorial pregnancies, and even more so in monochorial pregnancies. It is important to prevent premature delivery and maintain regular obstetrical care. The ultrasound-Doppler examination is the key to follow-up in pregnancy.

[Internal version and breech extraction of the second twin. A series of 35 cases]. / Version par manoeuvres internes et grande extraction de siège chez le deuxième jumeau. A propos de 35 observations.

OBJECTIVES: Identify indications and assess results of internal version followed by breech extraction. Evaluate fetal and maternal prognosis. METHODS: A retrospective study of 35 cases of ionternal versions followed by primary breech extraction of the second twin performed between 1 January 1986 and 31 December 1994, were analysed and compared with data in the literature. RESULTS: There were 2 failures requiring cesarean extraction of the second twin. There were no maternal complications other than minor bleeding at deliver in 3 who did not require transfusion. Obstetrical trauma was observed in 3 cases with no sequelae. Five infants were referred to the prematurity unit and 9 to the infant intensive care unit due to consequences of prematurity. In six cases nitroglycerin used as a uterine relaxing agent was associated with spinal analgesia thus avoiding general anesthesia. CONCLUSION: Internal version is the only alternative (together with external version) to cesarean, allowing rapid delivery of the second twin in breech position. Maternal prognosis is excellent and fetal prognosis is good if contraindications are avoided.

[Infarction and pregnancy. Review of the literature. A case report]. / Infarctus et grossesse. Revue de la littérature, à propos d'une observation.

UNLABELLED: BUT: Assess risk factors and pathogenesis of myocardial infarction in young women and evaluate cardiologic and obstetrical management of myocardial infarction during pregnancy as well as assess the prognosis of pregnancy in patients with a prior myocardial infarction. METHODS: Fra a personal observation of pregnancy after myocardial infarction, we reviewed the literature on two distinct themes: myocardial infarction during pregnancy and pregnancy after myocardial infarction. RESULTS: Pregnancy was deliberately authorized in a 21-year-old who had myocardial infarction 3 years earlier. The pregnancy was uneventful and cesarean section with epirual analgesia at 37 weeks gestation delivered a healthy 2,350 g boy. Unfortunately the patient died at her home 18 month later. Acardiac cause was retained although death due to ventricular rhythm disorder or recurrent myocardial infarction could not be confirmed due to lack of an autopsy. The prognosis of pregnancies after myocardial infarction would not appear to be catastrophic although this case raises some doubts as to whether pregnancy should be authorized in these patients. The major difference in mortality according to whether the infarction occurs before or during pregnancy would suggest that risk might be reduced by a haling period after the infarction. CONCLUSION: It appears that pregnancy in women with a prior myocardial infarction would be possible if sufficient precautions are taken. All situations increasing cardiac work should be avoided. Stress and pain must be avoided during delivery and the post-partum period. Intensive cardiological and obstetrical supervision supervision are required for correct management of the pregnancy.

[Myasthenia and pregnancy. Two case reports]. / Myasthénie et grossesse. A propos de 2 observations.

OBJECTIVE: Assess obstetrical care in rare cases of pregnant women with myasthenia. METHOD: Two personal cases led to a brief recall of the disease process and the literature and an assessment of proposed optimal care. RESULTS: Both pregnancies were carried to term without aggravation of the myasthenia. According to the data in the literature, pregnancy has a variable effect on myasthenia (1/3 stability, 1/3 improvement, 1/3 aggravation). The risk of decompensation during expulsion is great and the patient's efforts should be limited, although cesarian section is not required (excepting classical surgical indications). Peridural anaesthesia is not required (excepting classical surgical indications). Peridural anaesthesia is recommended because it reduces patient fatigue and facilitates instrumental extraction. Nursing is authorized except in case of severe episodes with a major rise in antibody levels. Pre-eclampsia was reported in only 5 cases: both maternal and fetal risk is high in such cases requiring intensive care. Fetal risks include rare neuro-muscular disease in which prognosis is poor and in 15 to 20% of the cases, neonatal myasthenia. CONCLUSION: Myasthenia is an autoimmune disease rarely occurring in young women of childbearing age. Care for pregnant women with myasthenia requires close collaboration between the different specialists.

[May-Heggelin anomaly and pregnancy. A case report, review of the literature]. / Anomalie de May-Hegglin et grossesse. A propos d'une observation, revue de la littérature.

The May-Hegglin anomaly is a rare autosomal dominant platelet disorder characterized by thrombocytopenia, giant platelets and existence of crescent-shaped inclusions within the cytoplasm of granulocytes, eosinophils and monocytes (Döhle body). We report a case of May-Hegglin anomaly associated with a pregnancy. The pregnancy and delivery were uneventful. The child is not a carrier of this hematologic anomaly. Nine cases of complicated pregnancies with this anomaly have been reported in the literature. The risks of maternal hemorrhagic accident during pregnancy and during delivery are weak due to the fact that platelets functions are preserved. The same applies to the fetus. Nevertheless, as in the case of maternal autoimmune thrombocytopenic purpura, most reports advice performing a fetal platelet count on fetal blood sampling before birth to decide upon the mode of delivery. The risk of the cordonal approach to perform fetal blood sampling must be balanced against the small fetal hemorrhagic risk and most authors propose to allow normal delivery whilst avoiding all traumatic instrumental extraction, especially the use of vacuum extractor.

[Cord prolapse. Review of the literature. A series of 50 cases]. / Procidence du cordon. Revue de la littérature, à propos de 50 observations.

OBJECTIVES: Identify the role of cord prolapse in modern obstetrics by estimating the frequency of this obstetrical accident, its conditions, prognosis and treatment and by analyzing factors favoring development of cord prolapse. METHOD: From a retrospective study of 50 observations of cord prolapse occurring in the department of obstetrics from January 1985 to June 1994. Results were compared with those reported in the literature. RESULTS: The frequency of cord prolapse was 0.21% over the 10-year period. Cesarean section was required in 72% of the cases, and obstetrical manoeuvers were used in some of the vaginal deliveries (28%). Neonatal mortality was 20/1000. Predisposing factors were breech presentation, prematurity, twin pregnancy and multiparity. CONCLUSION: Despite much progress in obstetrics, the frequency of cord prolapse has not changed over time. The consequences are not as lethal as in the past, because of progress in diagnosis and neonatal resuscitation. Fetal prognosis remains however severe.

[Are there still indications for cerclage in 1995?]. / Y a-t-il encore des indications de cerclage en 1995?

AIM: In order to assess their undertook a retrospective study in their department over a 4 year period: from January 1991 to December 1994. METHOD: the study concerned 129 patients who were treated by cerclage. This procedure was performed prophylactically in the great majority of them (97), while it was carried out as an emergency in 32 (25%). RESULTS: the authors drew a distinction between two groups (prophylactic and emergency suture) when analyzing the various results: complications due to suture, mean age of pregnancy at delivery, threatened premature labor, mean length of prolongation obtained. These personal data formed the basis of a review of the literature, in order to specify the indications for suture adopted by various authors at the present time. CONCLUSION: the authors found themselves to be in agreement with data from the literature, considering a history of at least two obstetric accidents (late abortions) and/or the existence of a severe uterine malformation to be the principal indication for prophylactic suture. "Emergency" suture should be performed whenever there is a serious threat of early premature labor in the presence of cervical changes such that suture offers the only chance of prolonging the pregnancy.

[Uterine rupture after twenty-two weeks of amenorrhea due to placenta praevia percreta. A case report]. / Rupture utérine à vingt-deux semaines d'aménorrhée par placenta praevia percreta. A propos d'une observation.

The authors report a case of rupture of the uterus 22 weeks after the LMP, due to placenta praevia percreta and requiring emergency hysterectomy to arrest bleeding, followed by urinary complications. With the predisposing factors of the scars of 4 previous cesarean sections and the low anterior insertion of the placenta, this exceptional case--in terms of its rarity and gravity--led the authors to undertake a review of the literature seeking other cases of this greatly feared obstetric complication. They review the clinical, ultrasonographic (notably the use of color Doppler) and paraclinical (MRI, cystoscopy) diagnostic approach necessary to make an accurate diagnosis of placenta percreta (if possible before any hemorrhagic complications). This situation virtually invariably requires hysterectomy to arrest bleeding, under very difficult conditions because of the massive hemorrhage involved. Mortality remains high and morbidity principally concerns the urinary complications frequently encountered.

[Physiopathology of pre-eclampsia: the role of immunology]. / Physiopathologie de la pré-éclampsie: place de l'immunologie.

Preeclampsia complicating 3% of all births is an important cause of maternal death and is associated with an increased risks of neonatal morbidity and mortality. Among the numerous theories proposed to explain this syndrome, the concept of placental ischaemia resulting in a generalized disturbance of endothelial physiology is receiving increasing support. Maternal immunological systems is often solicited during normal pregnancy. Most likely the immunological system is implicated in preeclampsia. Its responsibility is protean. Trophoblastic antigens may not be properly recognized by maternal immunologic system, resulting in a defect of trophoblastic invasion of the myometrial segment of the spiral arteries. Preeclampsia does not seem to be accompanied with trophoblast immunological rejection by the mother. Some cases of preeclampsia are associated with autoimmune phenomena. The autoantibodies could be directed against phospholipids or/and trophoblastic membrane components. Activated neutrophils release a variety of substances, capable of mediating vascular damage. An imbalance between the protective antioxidant activity and aggressive oxidant mechanisms could initiate the endothelial lesions. Preeclampsia could be one presentation of immunodystrophism with local excess of harmful cytokines. The immunologic system is probably not the initiator of preeclampsia, but its role is ambiguous: either the protective immunologic mechanisms usually operating during pregnancy can be surpassed, or immunologic responses are inadequate and directly aggressive. A better understanding of the underlying immunologic anomalies will improve the nosologic classification of preeclampsia syndrome.

[Diabetes insipidus and postpartum anterior hypophyseal insufficiency]. / Diabète insipide et insuffisance antéhypophysaire du post-partum.

There have only been thirty cases of total post-partum hypopituitarism published in the literature and these have nearly all been secondary to Sheehan's syndrome. The authors report a case of partial anterior hypopituitarism associated with diabetes insipidus which arose after an uneventful Caesarean operation and the origin of which seems to lie in auto-immune hypophysitis. The authors first describe the morphological and endocrine changes that the hypophysis undergoes during pregnancy and then point out that auto-immune hypophysitis seems to have been only recently recognised. This can be used to explain some cases of post-partum hypophyseal insufficiency occurring almost silently without any history of third haemorrhage. Research has been made systematically for anti-hypophyseal antibodies and for specific antibodies of the organ, but has not always been positive. So the diagnosis of auto-immune hypophysitis is often made only after eliminating other reasons for it. A brief review of the physiopathological mechanisms of diabetes insipidus makes it possible to suggest that vasopressinase coming from the placenta together with prostaglandins could play a role.