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Fetuses and infants of women with anti-SSA/Ro and anti-SSB/La antibodies are at risk of neonatal lupus syndrome, featuring skin lesions, hematological and hepatic disorders, and congenital heart block (CHB) in the absence of severe cardiac malformation. The prevalence of CHB in newborns of anti-SSA/Ro positive women with known connective tissue disease is 1 to 2% and the risk of recurrence ranges from 10 to 17%. CHB is definitive and is associated with significant morbidity (pacemaker must be implanted in 2/3 of cases) and mortality (16 to 19%). Myocardial involvement may either be associated or appear subsequently. Other manifestations are discussed. For anti-SSA/Ro positive pregnant women, echocardiograms should be performed every 2 weeks from 16 to 24 weeks of gestation, and every week in case of past history of CHB. Electrocardiogram should be performed in the first days of life for all children to detect incomplete CHB. Therapy for CHB detected in utero is based on fluorinated steroids, especially betamethasone. Its efficiency is variable.

Materno-fetal platelet allo-immunization causes fetal or neonatal thrombocytopenia and sometimes severe intracerebral bleeding. The HPA-1s antigen is most generally implicated. This accident can occur during the first pregnancy with a major risk of severe recurrence during the next pregnancy. These women require specific care in a specialized center although no consensus has been reached on management of second pregnancies. Proposed treatments include immunoglobulins and/or corticosteroids, fetal blood puncture and unique or iterative platelet transfusions.

Objectives: Use of serum markers alone for trisomy 21 screening programs leads to a high rate of amniocentesis. Adding a second parameter (ultrasonography during the second trimester) might reduce this rate yet retain satisfactory sensitivity. This work was conducted to evaluate the pertinence of associating serum hCG level between 16 and 17 weeks gestation and morphological ultrasonography between 18 ans 20 weeks gestation., Method: A prospective study was conducted in 5,163 pregnant women aged over 38 years. A morphological ultrasonography was performed in all patients whose hCG level > 1/150 indicated a risk. An amniocentesis was proposed if an anomaly was detected at ultrasonography., Results: Serum hCG was above the risk threshold retained in 11.9% of the patients and among these patients at least one anomaly was detected at ultrasonography in 12%. An amniocentesis was performed in 1.4% of all patients. The positive predictive value of the screening test was 20%., Conclusion: Combining a serum marker and ultrasonography during the second trimester allows a reduction in the rate of amniocentesis compared with screening with serum markers alone. Sensitivity for detecting trisomy 21 remains satisfactory.

We present a case of maternal and fetal virilization caused by an androgen-secreting ovarian tumor. Biopsy at caesarean section was required to determine the etiology (Krukenberg tumor) and orient diagnosis to a primary cancer (gastric adenocarcinoma).

The psychological effect of reducing the number of embryons was studied prospectively in two Paris hospitals. All women who had multifetal pregnancy reduction (n = 18) were contacted for interviews just after the operation, during pregnancy, and four months after delivery. The decision to reduce the number of embryons was painful and led to a guilty feeling. After operation, nearly one-half of the women suffered psychologically. To justify their decision, and contain their emotions, the women spoke of the problems related to having triplets and, most importantly, the medical arguements explained by the physician. Medical counselling is thus essential to help this couples at the time of the operation. The pregnancy period is almost always a period of calm for these women. Nevertheless, four months after delivery, 5 women expressed a psychological malaise related to the reduction, and 2 women refused to continue the study because they did not want to revive their suffering. This study shows that psychological problems are of major importance after multifetal pregnancy reduction and can occur several months after delivery. These negative conclusions should however be examined in light of the consequences if reduction had not been performed.

Having carried out four cases of vaginal caesarean section the authors describe the technique they used. The advantages of the operation are: it is simple and can be carried out quickly, future obstetric behaviour is not compromised. It is important to avoid two complications of the operation: haemorrhage and injury to the bladder. These are reduced if the vertical incision in the cervix is made in the midline and long enough. The ideal indications for the operation are absence of cervical dilatation, or the occurrence of severe maternal haemorrhage during the operation to terminate a pregnancy, or while the uterine contents are being expelled towards the end of the second trimester. It is disputable whether there is a place for vaginal caesarean operation when the fetus is alive, in view of the recent studies on fetal prognosis.

The place of laparoscopic surgery continues to increase in the field of surgery in our specialty. Although the advantages would seem to be obvious, it seemed to us interesting to quantify, if possible, the parameters of operative stress and compare laparoscopic surgery with conventional surgery. Markers studied are Prolactin, Cortisol, Adrenaline, Nor-Adrenaline, Dopamine and the Beta-Endorphins. The only marker that shows any difference in the two procedures in our study is Beta-Endorphin which is significantly less raised in laparoscopic surgery directly after the operation (p less than 0.01). This was very specific for pain, which is one of the benefits of this technique and shown in this parameter which confirms the clinical impression. The curves of the changes in the different markers have been analysed and discussed.

A retrospective study of 70 fat women and 70 women of normal weight was carried out to compare their obstetric performance. The patients were assessed before pregnancy for corpulence by estimating the body mass index (IMC). Obesity was defined by having an index of 30 or above. The mean weight of the obese patients at delivery was 142 kgs and of the controls 65.4 kgs. The main risk in obese patients is a raised blood pressure (34%); and in spite of this no child showed intrauterine growth retardation. The mean weight of the newborn infants was 3.7 kgs against a mean weight of 3.2 kgs in the control group. Eighteen infants born to obese mothers were very heavy (25%). The increase in fetal weight explains why the caesarean section rate was three times as high in the obese patients as in the control due to disproportion (25%). These differences are statistically significant. Neonatal morbidity was similar in the two groups. It is debatable whether a slimming diet was worthwhile. All the same calorie intake reduced slightly to about 1.800 calories a day together with vitamin supplements is advisable. It does not have any ill effect on the fetus.

The authors used epidural anaesthesia to carry out laparoscopy in 220 patients. The chief indications for the laparoscopies were GIFT (intratubal transfer of gametes) and tubal sterilization. The technique used was slightly different according to the indications for the use but they had to be sure of anaesthetising up to T4. In 90% of cases the patients tolerated the procedure well. No change in ventilation or in metabolic measurements. As far as fertilization was concerned studies carried out in various parameters failed to show any untoward side effects due to the use of local anaesthetics. Finally so long as the anaesthesia is only used for a short length of time this technique seems to be suitable for day cases.

Renal transplantation has changed completely the fertility of women who had been dialysed. Our study is on 10 pregnancies which we followed up in 7 women who had had renal transplants in the University Hospital of Pitié Salpêtrière (Professor Y. Darbois) between 1979 and 1985. All patients were treated by the same technique and the same methods of prevention of rejection of the transplant. The mean interval between the transplant and pregnancy was 53 months. In 3 cases there was hypertension and raised creatinine levels (more than 150 in 3 cases). In 2 cases the two conditions were associated. The prognosis is bad when a raised blood pressure or a change in renal function occurs before pregnancy starts, leading to a real deterioration in renal function during the pregnancy when such function was abnormal before the pregnancy started. As far as the infants were concerned, the most common complication was IUGR (intrauterine growth retardation) which was found in half of all cases. Blood flow studies in these fetuses are particularity interesting. There were two cases of intra-uterine fetal death. The reasons for these were not necessarily connected with the deterioration in renal function. All the deliveries were by caesarean section, for medical reasons in 7 out of 10 cases. The average duration of the pregnancy was 35 weeks of amenorrhoea. As far as the mothers were concerned, they did not have more infections than other women in spite of being immuno-suppressed (this was excluding urinary tract infections).(ABSTRACT TRUNCATED AT 250 WORDS)

This is a retrospective study of IVF cycles with failure of cleavage at the PMA centre of the University Hospital, Pitie-Salpetriere occurring between May 1985 and December 1988. Failures of cleavage occurred in 23% of the cycles where at least one oocyte was recovered (170 out of 729 cycles). There were three groups of conditions which were analysed: 1. The male factor which was known about before the attempt at IVF (38 cycles - 23% of failures of cleavage). 2. No previously known male factors (126 cycles-74% of failures of cleavage). 3. IVF with frozen donor sperm (6 cycles-3% of failures of cleavage). These couples had a total of 340 cycles with 25 pregnancies. The prognosis differs according to the category mentioned above. If there is a male factor, one attempt at IVF with this partner's sperm seems absolutely justified before proceeding to IVF with donor sperm or to AID. If there is no male factor the oestradiol curve does not make it possible to foresee a failure of cleavage and it is necessary to carry out a second IVF cycle to handle these couples.

Thirty-three cases of obstetrical paralysis of the brachial plexus have been seen in 15 years in the gynaecological and obstetrical department of the University Hospital Pitié Salpêtrière. The authors, from studying these cases, work out the factors that tend to bring about this pathological condition. They are: multiparity, excessive weight gain in pregnancy, fetal excessive growth, prolonged second stage of labour, instrumental delivery and shoulder dystocia in cephalic presentations. In breech presentations it is mainly faulty performance of the manoeuvres that are needed to deliver the shoulders. These lesions involve, in most cases, the roots of C5 and C6. Spontaneous regression occurs very often. The authors have found 25% of sequellae. It is difficult to prevent shoulder dystocia. It consists in realising well the size of the fetus and using instruments really sensibly when the presenting part is high in a primiparous woman. In a multiparous woman one has to be on the look-out for increasing macrosomia of the fetus and it is important to teach the manoeuvres that are necessary to deal with shoulder dystocia. As far as breech delivery is concerned the major risk is the delivery itself without there being any need for fetal or maternal criteria to alter matters. Therefore prevention in this presentation has to be the presence of a competent obstetrician at each delivery always.

The accuracy and the low radiation dosage administered when tomodensitometry is carried out for pelvimetry has led us to specify the use of this technique in every day practice. We propose to make is still more reliable and to simplify it. We have correlated the measurements obtained on the ultrasound screen with those that have been obtained by measuring the dried pelvis and have sought ways of measuring directly the three fundamental diameters of the pelvis. We have achieved exact measurements within one millimeter. This very precise correlation has been reproduced when we examined skeletons using the tomodensitometer. Then, when we checked again the accuracy of these measurements, we used the method on pregnant women. We have taken two views and two slices: an AP view to study the contents of the uterus and the morphology of the upper strait; a profile view to measure the diameter between the promontory of the sacrum and posterior surface of the symphysis, and we have programmed the two following slices: a perpendicular slice at the level of the upper strait measuring directly the transverse median diameter; another slice at the level of the sciatic spines to measure directly the diameter between these spines. We present this method because it is very simple and absolutely precise and gives all the information that is necessary. The patient does not have to stay still for long and only has a small dose of irradiation. This procedure does not need the use of conversion tables, nor parallel rulers nor standardisation.

Gn RH analogues seemed to us to be very useful in in-vitro fertilisation. They make it easier to programme oocyte recovery. They avoid an endogenous surge of LH, and they particularly seemed to increase significantly the percentage of pregnancies that continue after embryo transfer.

413 menstrual cycles were monitored in the first two years of the work of the In-Vitro Fertilization Unit in La Pitié-Salpêtrière. On-going pregnancies were achieved from the very first months of activity, with a level which stayed relatively constant in the first year. Technical changes were introduced and in particular a higher recovery rate of oocytes when ultrasound was used and above all when LH-RH analogues were used in the process of stimulation. It is this last point that seems to be the most interesting. In fact, when the results are examined there is a definite rise in the number of on-going pregnancies of which the level went up by 2.3 times as compared with using a classical protocol of Clomithene citrate and HMG. In the 153 cycles when D-Trp6 LH-RH was used, the percentage of on-going pregnancies was 13.7% for each cycle and 20% for embryo implants. Furthermore, it became possible to work out the dates for the patients and this appears to us essential as the numbers of couples attending increase.