RESUMEN
We report a rare case of Tessier no. 4 craniofacial cleft diagnosed by ultrasound imaging at 10 weeks' gestation. Tessier no. 4 craniofacial cleft is a very rare and complex congenital abnormality, characterized by an oblique orbitomaxillary facial cleft. Prenatal diagnosis of orofacial clefting is usually done at midtrimester of pregnancy, based on careful sonographic examination of the fetal face. However conventional 2D ultrasound is limited in screening isolated cleft palate and defects of the secondary palate. Thus, 3D ultrasound shows a greater sensitivity in a referred population and antenatal evaluation of facial clefs.
Asunto(s)
Coloboma/diagnóstico por imagen , Anomalías Craneofaciales/diagnóstico por imagen , Órbita/anomalías , Ultrasonografía Prenatal , Coloboma/complicaciones , Anomalías Craneofaciales/complicaciones , Cara , Femenino , Humanos , Imagenología Tridimensional/estadística & datos numéricos , Labio/anomalías , Órbita/diagnóstico por imagen , Embarazo , Primer Trimestre del Embarazo/fisiología , Adulto JovenRESUMEN
OBJECTIVES: To determine ultrasonographic markers that can help to predict prognosis in twins acardiac pathology in order to manage it. PATIENTS AND METHODS: A retrospective multicentric study has been led between 1997 and 2006. The following data were collected: frequency of monitoring, ultrasonographic markers studied according to the outcome of each pregnancy, associated with a review of the literature. RESULTS: Six twin pregnancies with this condition were identified. The main studied criteria are: foetal growth of the pump twin, congestive heart failure, resistance index of the umbilical arteries, ductus venosus Doppler and middle cerebral artery peak velocity. There was no consensus concerning the method of ultrasonographic monitoring. DISCUSSION AND CONCLUSION: According to our study and the literature, our management must take into account the ratio of (or the difference in) resistance indices between the twins, the middle cerebral artery peak velocity, the tricuspid regurgitation and the ratio of abdominal circumferences of the two twins.
Asunto(s)
Transfusión Feto-Fetal/diagnóstico por imagen , Cardiopatías Congénitas/diagnóstico por imagen , Embarazo Gemelar , Ultrasonografía Prenatal , Femenino , Humanos , Embarazo , Pronóstico , Estudios RetrospectivosRESUMEN
Obstetric litigation is a growing problem in developed countries and its escalating cost together with increasing medical insurance premiums is a major concern for maternity service providers, leading to obstetric practice cessation by many practitioners. Fifty-four to 74 % of claims are based on cardiotocographic (CTG) abnormalities and their interpretation followed by inappropriate or delayed reactions. A critical analysis is performed about the nine criteria identified by the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics in their task force on Neonatal Encephalopathy and Cerebral Palsy: four essential criteria defining neonatal asphyxia and five other suggesting an acute intrapartum event sufficient to cause cerebral palsy in term newborns. The importance of placental histologic examination is emphasized in order to confirm sudden catastrophic events occurring before or during labor or to detect occult thrombotic processes affecting the fetal circulation, patterns of decreased placenta reserve and adaptative responses to chronic hypoxia. It may also exclude intrapartum hypoxia by revealing some histologic patterns typical of acute chorioamnionitis and fetal inflammatory response or compatible with metabolic diseases. Magnetic resonance imaging (MRI) of the infant's damaged brain is very contributive to elucidate the mechanism and timing of asphyxia in conjunction with the clinical picture, by locating cerebral injuries predominantly in white or grey matter. Intrapartum asphyxia is sometimes preventable by delivering weak fetuses by cesarean sections before birth, by avoiding some "sentinel" events, and essentially by responding appropriately to CTG anomalies and performing an efficient neonatal resuscitation. During litigation procedures, it is necessary to have access to a readable CTG, a well-documented partogram, a complete analysis of umbilical cord gases, a placental pathology and an extensive clinical work-up of the newborn infant including cerebral MRI. Malpractice litigation in obstetric care can be reduced by permanent CTG education, respect of national CTG guidelines, use of adjuncts such as fetal blood sampling for pH or lactates, regular review of adverse events in Clinical Risk Management (CRM) groups and periodic audits about low arterial cord pH in newborns, admission to neonatal unit, the need for assisted ventilation and the decision-to-delivery interval for emergency operative deliveries. Considering the fast occurrence of fetal cerebral hypoxic injuries, and thus despite an adequate management, many intrapartum asphyxias will not be preventable. Conversely, well-documented hypoxic-ischemic brain insults during the antenatal period do not automatically exclude intrapartum suboptimal obstetric care.
Asunto(s)
Asfixia Neonatal/complicaciones , Parálisis Cerebral/etiología , Parálisis Cerebral/prevención & control , Responsabilidad Legal , Obstetricia/legislación & jurisprudencia , Asfixia Neonatal/diagnóstico , Cardiotocografía , Femenino , Humanos , Recién Nacido , Imagen por Resonancia Magnética , EmbarazoRESUMEN
Cerebral palsy (CP) is a group of disorders of the development of movement and posture, causing activity limitations, that are attributed to nonprogressing disturbances that occurred in the developing fetal or infant brain. The motor abnormalies are often accompanied by disturbances of sensation, perception, cognition, behavior and/or by a seizure disorder. The prevalence of CP has not decreased in developed countries over the past 30 years, despite the widespread use of electronic fetal heart rate monitoring and a 5- to 6-fold increase in the cesarean delivery rate. In the term newborn, CP may be attributed to perinatal asphyxia in case of metabolic acidosis in the cord blood (pH<7,00 and base deficit>12 mmol/L), followed by a moderate or severe neonatal encephalopathy within 24 hours and a further neurological impairement characterized by spastic quadriplegia and dyskinesia/dystonia. Dating the time of fetal asphyxia during delivery is possible when there are acute catastrophic complications during labor and unexpected acute or progressive fetal heart rate anomalies after a normal admission test, when there is a need for intensive neonatal resuscitation, a multi-organ failure within 72 hours of birth and visualization of acute non focal cerebral abnormalities, mainly by early magnetic resonance imaging (MRI). MRI sequences show either a brain-damaged pattern of the central basal ganglia, thalami and posterior limbs of internal capsules with relative cortical sparing, in acute, near-total asphyxial insults manifested by a continuous bradycardia or a pattern of cortical injury in the watershed zones and relative sparing of the central grey matter, in prolonged partial asphyxia, manifested by late or atypical variable decelerations with progressive fetal tachycardia, loss of reactivity and absent fluctuation. Prolongation of either type of asphyxial insult results in more global brain damage. In order to differentiate a CP occurring after perinatal asphyxia from other neurological sequelae in relation with infection, hemorrhage, stroke, malformations, genetic or metabolic diseases, it is essential that a definitive information from the brain by MRI and an extensive histological examination of the placenta are at disposal.
Asunto(s)
Asfixia Neonatal/diagnóstico , Parálisis Cerebral/diagnóstico , Acidosis/diagnóstico , Adulto , Enfermedades de los Ganglios Basales/diagnóstico , Cerebro/lesiones , Femenino , Hipoxia Fetal/complicaciones , Hipoxia Fetal/diagnóstico , Humanos , Hipoxia Encefálica/diagnóstico , Recién Nacido , Imagen por Resonancia Magnética , Masculino , Edad Materna , Insuficiencia Multiorgánica/complicaciones , Insuficiencia Multiorgánica/diagnóstico , Embarazo , Factores de Riesgo , Enfermedades Talámicas/diagnósticoRESUMEN
OBJECTIVES: To revalue the interest of X-ray pelvimetry and analyse our current management of patients with a previous caesarean delivery. PATIENTS AND METHODS: Case-control retrospective study reviewing 418 case records of women with a scarred uterus: a study group of 206 parturients who delivered in 2002, when X-ray pelvimetry was the rule, compared with a control group of 212 parturients who delivered in 2007, without any X-ray pelvimetry. Outcomes of labour, influence of X-ray pelvimetry, indications of caesarean sections, rates of uterine rupture and neonatal well-being have been analysed. RESULTS: There was no significant difference between both groups concerning the outcomes of labour. The transverse pelvic diameter is positively correlated with an eutocic delivery and inversely correlated with the rate of caesarean section performed during labour because of obstructed labour. Measurements of the pelvis were unrelated neither to the risk of uterine rupture nor to the neonatal outcome. The risk of uterine rupture is significantly higher when an emergency caesarean section is required. CONCLUSION: Our study brings to light a complementary point of view about X-ray pelvimetry. Indeed, our results show that it could be useful in the following of a caesarean section for obstructed labour.
Asunto(s)
Cicatriz/diagnóstico por imagen , Rotura Uterina/diagnóstico por imagen , Útero/patología , Adulto , Estudios de Casos y Controles , Cesárea , Femenino , Francia , Humanos , Histerosalpingografía/métodos , Complicaciones del Trabajo de Parto/diagnóstico por imagen , Pelvimetría/métodos , Embarazo , Resultado del Embarazo , Estudios Retrospectivos , Rotura Uterina/patologíaRESUMEN
The authors describe two cases of idiopathic intracranial hypertension (IIH) during pregnancy. The first case was discovered in a 21-year-old primigravida at 15 weeks gestation and thereafter six evacuation lumbar punctures were necessary, and a treatment by acetazolamide, 1000mg/day, was prescribed until parturition. Labor was induced at 37 weeks for intrauterine growth retardation associated with oligohydramnios. The second patient, a 38-year-old tertigravida primipara presented clinical signs of IIH at 28 weeks gestation in the context of preterm labour after a suicide attempt by massive ingestion of venlafaxine. She was given an evacuation lumbar puncture and went into labour at 29 weeks, after tocolysis failure. The diagnosis of IIH is to be done only by exclusion, in front of a normal biological composition of the spinal fluid at lumbar puncture with increased opening pressure, and after a brain imaging excluding any expansive intracranial process or hydrocephaly. Obstetrical prognosis is usually favourable. The main complication of this pathology resides in the ocular impact. Outside pregnancy the risk factors of IIH which have been evoked are polycystic ovary syndromes and blood coagulation anomalies as thrombophilia or hypofibrinolysis. Treatment of this pathology should be medical in the first instance and surgical only in the case of resistance or for severe ocular involvement.
Asunto(s)
Hipertensión Intracraneal/diagnóstico , Complicaciones del Embarazo/diagnóstico , Acetazolamida/uso terapéutico , Adulto , Encéfalo/irrigación sanguínea , Encéfalo/patología , Ciclohexanoles/efectos adversos , Sobredosis de Droga , Oftalmopatías/etiología , Oftalmopatías/prevención & control , Femenino , Retardo del Crecimiento Fetal , Edad Gestacional , Humanos , Hipertensión Intracraneal/complicaciones , Hipertensión Intracraneal/terapia , Trabajo de Parto Inducido , Angiografía por Resonancia Magnética , Oligohidramnios , Embarazo , Punción Espinal , Intento de Suicidio , Clorhidrato de VenlafaxinaRESUMEN
We report the case of a dichorionic-diamniotic pregnancy in which a discordance in the size of the fetuses was observed as early as the first trimester. This discordance in size was maintained over time and the two fetuses continued their respective growths. We suggest the very rare phenomenon of superfetation as a diagnosis because less than 10 cases are described in the literature. Even though a formal proof of the diagnosis is difficult to obtain, the elements described in this article rally in favor of this hypothesis. Superfetation is defined by the fertilization and the implantation of a second oocyte in a uterus already containing the product of a previous conception. After a description of the case, a review of the literature enables us to describe the frequency, the possible risk factors and the existing case reports on the subject. The rarity of this case justifies its publication for the information of clinicians.
Asunto(s)
Edad Gestacional , Superfetación/fisiología , Gemelos Dicigóticos , Adulto , Femenino , Humanos , Recién Nacido , Recien Nacido Prematuro , Embarazo , Resultado del Embarazo , Primer Trimestre del Embarazo , Factores de Riesgo , Ultrasonografía PrenatalRESUMEN
OBJECTIVE: Premature preterm rupture of membranes (PPROM) accounts for a significant part of overall perinatal mortality and morbidity. This study aims to define potential prognostic factors for neonatal outcome. PATIENTS AND METHODS: One hundred and thirty-one pregnancies complicated with PPROM at between 26 and 32 weeks were retrospectively reviewed over a three-year period. The influence of chorioamnionitis on perinatal morbidity and mortality was assessed using a composite outcome. RESULTS: On admission, gestational age (GA) at diagnosis, fetal heart rate anomalies and increasing severity of clinical features of chorioamnionitis were significantly related with an adverse outcome. Significant factors associated with a favourable outcome were an administration of steroids for lung maturation, prophylactic antibiotics and tocolytic therapies. Stratifying according to GA at PPROM, the survival rates were 43 and 52% at before 22 weeks and between 22 and 26 weeks respectively. The prognosis dramatically improved after 26 weeks with an 84.6% rate of survival without impairment. Although this rate reached 97.5% after 30 weeks, there was no statistical evidence supporting any benefit to prolong pregnancies beyond this point. The complete expression of chorioamnionitis independently increased the mortality rate by 41% (OR=1.41; 95% CI [0.99-2.01]. Overall, the most relevant factor was GA at delivery, levelling the prognostic value of GA at diagnosis. DISCUSSION AND CONCLUSION: If no consensus rules PPROM at the moment, the most efficient prognosis factor before 34 weeks is mostly determined by GA at delivery.
Asunto(s)
Aberraciones Cromosómicas/estadística & datos numéricos , Rotura Prematura de Membranas Fetales/terapia , Adolescente , Adulto , Femenino , Muerte Fetal , Rotura Prematura de Membranas Fetales/mortalidad , Edad Gestacional , Humanos , Recién Nacido , Embarazo , Resultado del Embarazo , Tercer Trimestre del Embarazo , Pronóstico , Estudios Retrospectivos , Resultado del TratamientoAsunto(s)
Enfermedades Uretrales/diagnóstico , Adulto , Femenino , Humanos , Imagen por Resonancia Magnética , Masculino , Embarazo , Resultado del Embarazo , Diagnóstico Prenatal/métodos , Factores de Tiempo , Ultrasonografía , Enfermedades Uretrales/diagnóstico por imagen , Enfermedades Uretrales/embriologíaRESUMEN
INTRODUCTION: The outcome of total knee arthroplasty (TKA) is traditionally rated by objective criteria such as the knee society clinical rating system (KSCRS). Subjective criteria, such as satisfaction, will be of more importance, because health-care is shifting towards a market model. The aim of this study was to investigate the agreement on satisfaction after TKA between two orthopaedics surgeons, when one of the surgeons reviews his own results. PATIENTS AND METHODS: We investigated a group of 57 patients (63 TKAs) using a visual analogue scale (VAS) for satisfaction. There were 53 TKAs available and were separately seen by the two orthopaedic surgeons for clinical follow-up. RESULTS: After we split the satisfaction rate as excellent-good and fair-poor (VAS smaller or equal to 20 was excellent-good), we found a substantial agreement (kappa = 0.77) between the orthopaedic surgeons. However, we found that the surgeon who viewed his own results (B) scored a significantly lower satisfaction than surgeon A when analysing the complete group. CONCLUSIONS: The interobserver agreement of satisfaction, using a VAS, was high between the two orthopaedic surgeons. The satisfaction VAS is a simple tool to quantify satisfaction of surgeons and patients after TKA and could be used to evaluate quality. Comparison between studies could be more efficient and reliable using the satisfaction VAS method.
Asunto(s)
Evaluación de Resultado en la Atención de Salud/métodos , Dimensión del Dolor , Anciano , Artroplastia de Reemplazo de Rodilla , Femenino , Indicadores de Salud , Humanos , Masculino , Persona de Mediana EdadAsunto(s)
Placenta/patología , Femenino , Humanos , Embarazo , Complicaciones del Embarazo/patologíaRESUMEN
Three cases of intermittent absent end-diastolic and reversed end-diastolic flow velocity (A/REDV) are reported in the proximal umbilical artery of the growth-retarded twin in monochorionic twin pregnancies. This typical doppler velocimetric pattern has been related to arterio-arterial anastomoses in two cases of intra-uterine growth retardation and in one case of twin-twin transfusion syndrome. According to the literature, superficial arterio-arterial anastomoses may be detected by doppler colour velocimetry in 75 to 85% of cases, while identification of arteriovenous connections is more difficult to be documented in vivo (50% of cases in experienced hands). The role of superficial vascular anastomoses, either arterio-arterial or venovenous, and that of deep arteriovenous communications is now well documented in the main complications of monochorionic pregnancies, particularly for twin-twin transfusion syndrome, intrauterine growth retardation, intrauterine fetal death and acardiac twins.
Asunto(s)
Enfermedades en Gemelos/diagnóstico por imagen , Complicaciones del Embarazo/diagnóstico por imagen , Gemelos Monocigóticos , Ultrasonografía Doppler en Color , Ultrasonografía Prenatal , Arterias Umbilicales/diagnóstico por imagen , Adulto , Femenino , Retardo del Crecimiento Fetal/diagnóstico por imagen , Transfusión Feto-Fetal/diagnóstico por imagen , Humanos , Recién Nacido , Masculino , Embarazo , Resultado del Embarazo , Segundo Trimestre del Embarazo , Tercer Trimestre del Embarazo , Embarazo MúltipleAsunto(s)
Extracción Obstétrica/instrumentación , Extracción Obstétrica/métodos , Parto Obstétrico/instrumentación , Parto Obstétrico/legislación & jurisprudencia , Parto Obstétrico/métodos , Extracción Obstétrica/efectos adversos , Extracción Obstétrica/legislación & jurisprudencia , Femenino , Humanos , Embarazo , SeguridadRESUMEN
OBJECTIVE: The objective of this study is to evaluate current means of monitoring of pregnant women victims of abdominal trauma and to determine whether systematic hospitalization is warranted. MATERIAL: and methods. This was a retrospective study of pregnant women who consulted the Nantes hospital during a three-year period for abdominal trauma during pregnancy. Four principal means of monitoring (examination, fetal heart rate or ERCF, ulstrasonography, Kleihauer test) were evaluated according to the fetal outcomes. RESULTS: Ninety-five patients were including in the study. The abdominal trauma resulted from a traffic accident for 49 patients (51%), a fall for 39 patients (41%) and high-energy trauma for 7 patients (8%). Three patients (3%) presented fetal complications: one fetal death, one fetal porencephaly, one premature birth at 34 weeks gestation for premature rupture of the membranes and abruptio placentae. These three women were traffic accident victims who also suffered extra-abdominal trauma. Ultrasonographic signs (npv=99%) and anomalies foetal monitoring (npv=98%) were also observed in two cases (fetal death and premature birth). The porencephaly was fortuitously discovered 3 weeks after trauma at a routine ultrasound. The Kleihauer test remained negative in all patients. The other traumas did not give lead to fetal complications. The incidence of premature births did not increase after trauma. Fetal outcome was good when monitoring parameters were normal at admission. CONCLUSION: Ultrasonography and fetal heart rate monitoring enable proper assessment of fetal well-being but only have predictive value if they are negative. A negative Kleihauer test, useful for Rh negative patients to determine the amount of anti-D antibody to inject, does not provide any information about fetal outcome when it is negative. The complications observed were related only to traffic accidents. Hospitalization is probably not very useful when monitoring elements are normal at admission and when the women has suffered mild trauma.
Asunto(s)
Traumatismos Abdominales/complicaciones , Complicaciones del Embarazo/etiología , Traumatismos Abdominales/diagnóstico , Traumatismos Abdominales/terapia , Adolescente , Adulto , Femenino , Hospitalización , Humanos , Vigilancia de la Población , Embarazo , Complicaciones del Embarazo/prevención & control , Estudios RetrospectivosAsunto(s)
Movimiento Fetal , Edad Gestacional , Femenino , Muerte Fetal , Humanos , Embarazo , Factores de RiesgoRESUMEN
We report the cases of two patients who had a favorable outcome with aspirin and corticosteroid therapy during pregnancy for chronic villitis of unknown etiology complicated by labor asphyxia and further intrauterine fetal demise in one gravida 3 patient and for chronic intervillositis of unknown etiology diagnosed after three perinatal deaths in another patient (gravida 4). Chronic villitis of unknown etiology (CVUE) is detected in 7 to 33% of placentas, mainly after intrauterine growth retardation (IUGR), unexplained prematurity, preeclampsia, perinatal asphyxia and intrauterine fetal death (IUFD). The less frequent chronic intervillositis of unknown etiology (CIUE) (0.6 to 0.9/1.000) has been implicated in recurrent severe pregnancy complications, such as spontaneous abortions, IUGR and IUFD. Histopathology and immunohistology are in favor of an immune response against the foreign fetal allograft. The favorable results obtained with corticosteroids and aspirin remain to be confirmed by larger series.
Asunto(s)
Corticoesteroides/uso terapéutico , Antiinflamatorios no Esteroideos/uso terapéutico , Aspirina/uso terapéutico , Vellosidades Coriónicas , Enfermedades Placentarias/tratamiento farmacológico , Complicaciones del Embarazo/tratamiento farmacológico , Adulto , Vellosidades Coriónicas/inmunología , Vellosidades Coriónicas/patología , Quimioterapia Combinada , Femenino , Retardo del Crecimiento Fetal/etiología , Humanos , Inmunohistoquímica , Recién Nacido , Inflamación/complicaciones , Inflamación/inmunología , Inflamación/prevención & control , Masculino , Enfermedades Placentarias/inmunología , Enfermedades Placentarias/prevención & control , Embarazo , Complicaciones del Embarazo/inmunología , Complicaciones del Embarazo/prevención & control , Resultado del Embarazo , Prevención SecundariaRESUMEN
We report two cases of Ballantyne's syndrome which was first described in association with foeto-placental hydrops caused by rhesus isoimmunization. Our two cases occurred in association with materno-fetal parvovirus infection. Although the pathogenic mechanism remains to be fully elucidated, fluid retention and hyperplacentation are the main features. Together with these two case reports, a literature review confirmed the diverse nonimmunological etiologies associated with Ballantyne's syndrome. Clinicians should be aware of this particular presentation of hydrops fetalis resulting from a mechanism different from hypotrophic placentation because specific etiological treatment can avoid unnecessary pregnancy termination. Pre-conception counselling is also different.
Asunto(s)
Hidropesía Fetal/etiología , Infecciones por Parvoviridae/complicaciones , Preeclampsia , Isoinmunización Rh/complicaciones , Adulto , Femenino , Humanos , Hidropesía Fetal/diagnóstico , Hidropesía Fetal/terapia , Recién Nacido , Embarazo , Resultado del Embarazo , Pronóstico , SíndromeAsunto(s)
Nifedipino/uso terapéutico , Trabajo de Parto Prematuro/tratamiento farmacológico , Tocólisis/métodos , Tocolíticos/uso terapéutico , Adulto , Medicina Basada en la Evidencia , Femenino , Humanos , Nifedipino/efectos adversos , Trabajo de Parto Prematuro/prevención & control , Selección de Paciente , Embarazo , Resultado del TratamientoRESUMEN
OBJECTIVES: The main object of this study was to evaluate the effect of delayed pushing on the second phase of delivery and the second one was to analyze the maternal and fetal consequences. MATERIAL AND METHOD: This was a meta-analysis of randomized prospective studies. The inclusion criteria were nulliparous women with epidural analgesia, singleton cephalic presentation at term and a spontaneous or induced labor. RESULTS: There was a significant increase in the number of spontaneous deliveries when pushing was delayed (p=0,019). On the other hand, no significant difference could be found in the incidence of perineal trauma (p=0,64). Post-partum hemorrhage and maternal fever could not be accurately evaluated because of insufficient data in the selected publications. Concerning the neonatal outcomes, the criteria for evaluation were too heterogeneous for analysis. CONCLUSION: In nulliparous parturients under epidural analgesia the fetal descent must be respected, so long as the fetal heart rate is unremarkable, in order to increase the probability of a spontaneous delivery, without apparent adverse consequences for the mother or the neonate.