Grossesse et psoriasis : le point de vue du gynécologue-obstétricien.

Psoriasis is a common chronic inflammatory disorder which worries a lot of women of childbearing age. The questions are abundant about heredity of psoriasis, its effects on the pregnancy and the future child and the risks of the used treatments. The best way to reassure them is to work closely together with the dermatologists. A préconceptionnel consultation by an expert in pathologic pregnancies obstetrician gynaecologist is strongly recommended for a first contact to explain the following pregnancy. Psoriasis is not dangerous for the pregnancy but some treatments will be prohibited. This will justify advices as soon as the patient has a desire to have a baby. The first trimester is the highest- risk period and the obstetrical complications seem increasing when the psoriasis is severe.

Relationship between Plasma D-Dimer Concentration and Three-Dimensional Ultrasound Placental Volume in Women at Risk for Placental Vascular Diseases: A Monocentric Prospective Study.

INTRODUCTION: The aim of this study was to correlate placental volumes deduced from three-dimensional ultrasound and virtual organ computer-aided analysis (VOCAL) software with systemic concentrations of D-dimer and soluble endothelial protein C receptor (sEPCR). METHODS: This was a monocentric experimental prospective study conducted from October 2008 to July 2009. Forty consecutive patients at risk of placental vascular pathology (PVP) recurrence or occurrence were included. Placental volumes were systematically measured three times (11-14, 16-18 and 20-22 weeks of gestation (WG)) by two independent sonographers. D-dimers and sEPCR plasma concentrations were measured using ELISA kits (Enzyme Linked ImmunoSorbent Assay). RESULTS: Eleven patients had a PVP. The plasma D-dimer level was positively correlated with placental volume (r = 0.45, p < 0.001). A smaller placental volume and placental quotient was evidenced in women who developed a PVP at the three gestational ages, and the difference was more pronounced during the third exam (20 WG). No obvious correlation could be demonstrated between the development of a PVP and the levels of D-dimer and sEPCR. There was no significant difference in the values of placental volumes measured by the two sonographers. CONCLUSION: The placenta growth could be a major determinant of the elevation of D-dimer during pregnancy. Consideration of placental volume could allow for modulation of the D-dimer concentrations for restoring their clinical interest.

Accuracy of antenatal ultrasound signs in predicting the risk for bowel atresia in patients with gastroschisis.

OBJECTIVE: Evaluate accuracy of prenatal ultrasound findings in predicting the risk of bowel atresia in patients with gastroschisis. METHODS: A retrospective study was conducted on 18 fetuses with a prenatal diagnostic of gastroschisis treated at University hospital of Saint Etienne France between 2002 and 2012. Ultrasound abnormalities were used to classify them into three groups: no ultrasound abnormality (n=4), oligohydramnios (n=9), intra-abdominal bowel dilatation ≥20.5mm (n=5). Postnatal outcomes were compared between groups. The threshold value of 20.5mm for the prediction of atresia was determined through the receiver operator characteristics curve. RESULTS: In the group with oligohydramnios, intra uterine growth restriction were significantly more frequent (p=0.015) and three newborns had serositis including two with secondary complications after the initial surgery. In the group with major intra-abdominal bowel dilatation, all had a narrow defect <10mm significantly more than other fetuses (p=0.002). Intra-abdominal bowel dilatation reaching 20.5mm started at a mean gestational age significantly lower than that of the other fetuses (23.3 versus 29.7 weeks p=0.02). On the five fetuses presented intra-abdominal bowel dilatation ≥20.5mm, four showed atresia and no other newborn has this complication (p=0.0016). The threshold value of 20.5mm has a sensitivity of 100% and a specificity of 92.9%. The area under the curve was equal to 96.4%. CONCLUSION: Intra-abdominal bowel dilatation ≥20.5mm seems to be associated with the risk of postnatal atresia. MRI could help to clarify a complicated or uncertain ultrasound aspect.

Three-dimensional sonographic diagnosis of abdominal wall endometriosis: a useful tool?

OBJECTIVE: To report the usefulness of three-dimensional (3D) ultrasonography for the assessment of parietal endometriosis. DESIGN: Case report. SETTING: Academic research hospital. PATIENT(S): A 35-year-old woman with a noncyclic, painful abdominal nodule near a caesarean delivery scar. INTERVENTION(S): 3D ultrasonography and wide surgical resection with healthy margins. MAIN OUTCOME MEASURE(S): 3D ultrasonographic assessment of the endometriotic nodule. RESULT(S): We found that 3D ultrasonography offered a more specific description of parietal endometriosis with irregular and spiculated margins and depth infiltration as well as provided preoperative evaluation of volume measurements. CONCLUSION(S): Three-dimensional ultrasonography is a useful, noninvasive tool in extrapelvic endometriosis.

[Hyperemesis gravidarum: a rare but potentially severe complication of the first trimester of pregnancy]. / Hyperemesis gravidarum: une complication rare mais potentiellement grave du premier trimestre de la grossesse.

Although nausea and vomiting are common symptoms in early pregnancy, hyperemesis gravidarum (HG) is a rare complication of the first trimester of pregnancy. This condition is defined as intractable vomiting occurring before 20 weeks of gestation, with fluid and electrolyte disturbance, significant weight loss, and ketonuria, leading to hospitalization in the absence of other cause than pregnancy. Some biological disturbances found in HG, such as hyperthyroidism and hepatic cytolysis, which are correlated with the importance of vomiting, are without severe clinical consequences, but may represent diagnostic pitfalls. The aetiology is unknown, but human chorionic gonadotropin hormones likely play the first role. Psychological disturbance is currently seen as the result of the burden and stress of HG rather than a causal factor. Maternal outcome may be severe in the absence of treatment, but pregnancy outcome seems good, as far as the condition has been adequately controlled. The management of HG includes IV rehydration, thiamine supplementation, antiemetic drugs (doxylamine, metoclopramide and chlorpromazine being the first-line choices), and in severe cases, nasogastric or parenteral nutrition. A psychological support is often necessary.

Lipoprotein (a), birth weight and neonatal stroke.

BACKGROUND: Elevated lipoprotein (Lp) (a) is the most common genetically determined risk factor found in babies with perinatal ischemic stroke. The influence of maternal Lp(a) has not been studied extensively to date. OBJECTIVES: To investigate the role of Lp(a) in our population of neonates with stroke. METHODS: In a prospective uncontrolled cohort of term-born children with neonatal arterial ischemic stroke, Lp(a) levels were investigated in 69 mothers and 69 children. Paternal Lp(a) was not explored. RESULTS: An increased Lp(a) level was found in 26 mothers [38%; 95% confidence interval (CI) 28-50%] and in 15 children (22%; 95% CI 13-33%). Both rates were higher than the reference range reported in the general Caucasian population (10% in adults and 5% in children). Additionally, there was a correlation between maternal and infantile Lp(a) levels (p < 0.0001) and between elevated maternal Lp(a) level and lower birth weight (p = 0.027). CONCLUSIONS: Elevated maternal Lp(a) is apparently a risk factor for neonatal arterial ischemic stroke. We speculate that the pathological mechanism of this relation may be mediated through a dysfunction of the placental vascularization.

Use of the Delphi method to facilitate antithrombotics prescription during pregnancy.

INTRODUCTION: Management of pregnant women at risk for venous thromboembolism (VTE) remains complex. Guidelines do not definitively fix optimal strategies due to limited trial data. Our objective was to build an easy-to-use tool allowing individualised, risk-adapted prophylaxis. MATERIALS AND METHODS: A Delphi exercise was conducted to collect 19 French experts' opinions on pregnancy-related VTE. RESULTS: Experts with an active interest in clinical research and care of VTE and placental vascular complications were selected. The risk score was classified by an anonymous computer vote. A scoring system for VTE risk in pregnant women was developed, each score being associated with a specific treatment: graduated elastic compression stockings, aspirin, prophylactic Low Molecular Weight Heparin (LMWH: variable durations), or adjusted-dose of LMWH through pregnancy and postpartum. CONCLUSIONS: Our simple consensual scoring system offers an individual estimation of thrombosis risk during pregnancy together with its related therapeutic strategy, in accordance with most of the new international recommendations. The accuracy of our individual risk score-based therapeutic guidance is currently being prospectively evaluated in a multicenter trial.

Obstetrical and neonatal characteristics vary with birthweight in a cohort of 100 term newborns with symptomatic arterial ischemic stroke.

OBJECTIVES: Many questions remain regarding the mechanism of perinatal stroke. METHODS: In a series of 100 prospectively enrolled term neonates with symptomatic arterial ischemic stroke, we explored family antecedents, pregnancy and delivery conditions and clinical presenting features and distinguished features of the 50 larger infants with the remainder. Cardiac and cervical arterial imaging were performed in 70 and 51 cases. RESULTS: Previous fetal loss, first pregnancy, primiparity, twin-gestation, cesarean and traumatic delivery, neonatal distress, male sex and premature rupture of membranes were statistically more common than in the general population. Normal pregnancy proportion and mean birthweight were in the normal range, arguing against a vasculo-placental origin in the majority. Furthermore, there was an excess of large babies. The larger infants were more subject to suffer from acute perinatal events, with a trend for an excess of neonatal distress (p=0.065) and for more severe presenting features (p=0.027), while the lighter were more likely to have experienced longstanding obstetrical risk factors such as complicated pregnancy (p=0.047) and tobacco exposure (p=0.028). Cervical MR angiography showed an internal carotid occlusion in two babies, whereas echo-Doppler was always normal; in one case the two methods were discordant. Echocardiography was non-informative. INTERPRETATION: The data from this prospective cohort of neonates with stroke confirm that many obstetrical and perinatal factors are risk determinants. They also suggest that birthweight and gender may be biomarkers of two populations of neonates with different pathological mechanisms. MR angiography appears more sensitive than echo-Doppler for the exploration of the neonatal cervical vasculature.

Feasibility of an easy-to-use risk score in the prevention of venous thromboembolism and placental vascular complications in pregnant women: a prospective cohort of 2736 women.

INTRODUCTION: Management of pregnant women at increased risk of venous thromboembolism (VTE) remains complex in the absence of an easy-to-use tool allowing individualised, risk-adapted prophylaxis. Our objective was to assess whether treatment based on risk score is feasible in these women. MATERIALS AND METHODS: A scoring system for VTE risk in pregnant women was developed, each score being associated with a specific treatment. This system was implemented in a prospective cohort of 2736 consecutive women delivered in our teaching hospital from July 2002 to June 2003. Thromboembolic and obstetrical outcomes during pregnancy and the early post-partum period were recorded. RESULTS: Treatment based on risk score was implemented in 2685 of the 2736 women included (98.1%). The scoring system identified 2431 women with no risk factor and 305 women (11%) with at least one risk factor. Eight women not at risk (0.3%, [95% CI: 0.1-0.5]) and one at risk (0.4%, [95% CI: 0-1.1]) experienced a VTE. This low event rate precluded estimation of the discriminatory power of the score. However, the benefit of the scoring system was evaluated indirectly by assessing VTE incidence in the 46 women at risk in whom it was not used (15.2%, [95% CI: 4.8-25.6]). CONCLUSIONS: Our simple scoring system offers an easily implemented procedure for risk-based VTE prophylaxis of pregnant women and the proposed therapeutic strategy appears to be effective and safe in reducing VTE. The discriminatory power of the score is currently being evaluated in a randomized, controlled trial.

Prenatal discovery of an omphalocele associated with an inner umbilical cord Meckel's diverticulum.

The antenatal discovery of Meckel's diverticulum is a rare occurrence; the localization of both Meckel's diverticulum and omphalocele in the umbilical cord has never been described. We present herein a prenatal case of an omphalocele associated with inner umbilical cord dilated Meckel's diverticulum. An umbilical cord cyst was suspected with the cystic image seen during the first trimester exam, and sonography was repeated every month. Several possible diagnoses were discussed including umbilical cord cyst, omphalocele and umbilical cord hernia due to the changing sonographic images during pregnancy. Childbirth had to be arranged at a specialized center. After birth, clamping of the umbilical cord away from the base prevented iatrogenic atresia of the ileum. Surgical treatment had to be arranged during the first days of life.

Reliability of immunoglobulin G antitoxoplasma avidity test and effects of treatment on avidity indexes of infants and pregnant women.

The immunoglobulin G antitoxoplasma avidity test (Vidas; BioMérieux) is an immunoenzymatic test useful for excluding acute infection after the onset of pregnancy. The avidity index (AI) is the ratio of the signal in a test sample washed with urea, which disrupts low-avidity complexes, to that washed without urea. An AI of >0.3 is taken to mean that infection had occurred more than 4 months ago. The increase of the AI with time and the influence of the different treatments given to pregnant women and their newborns were evaluated. A total of 59 pregnant women (271 sera) and their 60 neonates (199 sera) were tested from 1998 to 2002. There were five groups of women based on the type and duration of treatment given. Thirteen pregnant women (group 1) did not receive any treatment, 15 (group 2), 11 (group 3), and 17 (group 4) women received treatment with spiramycin (9 MIU/day) for 0.5 to 2, 2.5 to 5, and 5.5 to 8 months, respectively, and the last 3 women (group 5) received tritherapy (pyrimethamine-sulfonamide and spiramycin alternatively) for 1.5 to 2.5 months. All of the maternal sera collected in the first 6 months had an AI of <0.30, with a mean of 0.07 (range, 0.01 to 0.21). The increase was slow (0.02/month), and there was no significant difference when comparisons were made between the treatment groups. Neonates with proven maternofetal transmission had an increasing AI, unlike those without transmission. However, long-term therapy with pyrimethamine-sulfonamide, as opposed to treatment with spiramycin alone, was found to slow down the progression of the AI. An AI of >0.2 is sufficient to exclude acute infection in pregnant women. In neonates, it is not of major use to diagnose congenital infection; however, it could be a good indicator of compliance and efficacy of treatment of infected infants.

Congenital diaphragmatic hernia. Two cases with early prenatal diagnosis and increased nuchal translucency.

The early ultrasound prenatal diagnosis of congenital diaphragmatic hernia is uncommon and suggests a poor outcome. We report 2 cases diagnosed at 10 and 12 weeks' gestation, with increased fetal nuchal translucency thickness (4 and 11 mm) and associated abnormalities (complex heart defect in one and many malformations in the other, including duodenal atresia and asplenia). In 1 case, the baby was delivered vaginally at 36 weeks, but neonatal death occurred; the pregnancy was terminated at 15 weeks in the second case.