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Objectives The aim of this study was to define the prenatal ultrasound semiology of cleft palate without cleft lip using 3D visualization of the fetal palate. Methods A prospective longitudinal study was performed in our University Hospital Center from 2011 to 2018. The fetal secondary palate was studied in 3D, starting with 2D axial transverse ultrasound view. We defined a cleft palate as a disruption of the horizontal plate of the palatine bone of the secondary palate. Prenatal findings were correlated to anatomic postnatal examinations performed by a paediatric plastic surgeon. Results Forty-three cases of cleft palate without cleft lip were prenatally diagnosed, of whom 34 were associated with malformations. We defined four types of disruptive appearances: isolated nonvisualization of the posterior nasal spine; partial-disruption or cleft velum; complete disappearance or V-shaped cleft palate; and complete disappearance or U-shaped cleft palate. The adjusted kappa coefficient, between prenatal and postnatal evaluation, was 0.88 (95% CI: 0.79-0.97), corresponding to an excellent agreement. Conclusions Using a strictly axial transverse ultrasound view, visualization of the secondary fetal palate enables to diagnose a cleft palate without cleft lip. This method offers a prenatal anatomic classification of cleft palate with a high level of concordance to postnatal findings.

Background Management of pregnancy and risk stratification in women with congenital heart diseases (CHD) are challenging, especially due to physiological haemodynamic modifications that inevitably occur during pregnancy. Aims To compare the accuracy of the existing pregnancy cardiovascular risk scores in prediction of maternal complications during pregnancy in CHD patients. Method and results From 2007 to 2018, all pregnant women with a CHD who delivered birth after 20 weeks of gestation were identified. The discriminating power and the accuracy of the five existing pregnancy cardiovascular risk scores [CARPREG, CARPREG II, HARRIS, ZAHARA risk scores, and modified WHO (mWHO)] were evaluated. Out of 104 pregnancies in 65 CHD patients, 29% experienced cardiovascular complications during pregnancy or post-partum. For the five scores, the observed rate of cardiovascular events was higher than the expected risk. The values of area under the ROC curve were 0.75 (0.62–0.88) for mWHO, 0.65 (0.53–0.77) for CARPREG II, 0.60 (0.40–0.80) for HARRIS, 0.59 (0.47–0.72) for ZAHARA, and 0.58 (0.43–0.73) for CARPREG. Conclusion The modified WHO classification appeared to better predict cardiovascular outcome in pregnant women with CHD than the four other existing risk scores. Clinical Trial Registration: Clinicaltrials.gov: NCT04221048.

Les acteurs de santé en période périnatale sont désormais confrontés à la nécessité d’intégrer les multiples registres en jeu dans le développement de l’enfant à venir en fonction des connaissances récentes sur la plasticité cérébrale. Le cerveau présente une réceptivité maximale à des compétences spécifiques au cours des « périodes sensibles » des deux premières années de vie : passée cette période, il devient difficile, voire impossible, pour la structure cérébrale considérée, de reprendre un développement normal. Un manque ou un dysfonctionnement dans l’ajustement environnemental sur cette période est fort préjudiciable. Les objectifs de l’étude sont d’optimiser les conditions d’accueil du nouveau-né et de croiser les regards sur le développement précoce dans l’espoir de réduire les troubles ultérieurs de l’enfant. La collaboration croissante et rigoureuse avec l’ensemble des équipes concernées, et particulièrement des pédiatres depuis une dizaine d’années, a permis de développer des stratégies innovantes visant à améliorer la continuité sensorielle et émotionnelle des parents et de l’enfant, de la vie foetale aux toutes premières étapes de son développement. La méthode expérimentale de « posturage » du nouveau-né a été conçue dans ce climat de collaboration étroite : simple et reproductible, s’appuyant sur le bon sens, elle permet au bébé de ressentir un sentiment de continuité dans le temps de la naissance et d’exprimer de nombreuses compétences interrelationnelles. Dans les situations de vulnérabilité psychique maternelle majeure, les pères se sont mobilisés en grand nombre pour venir dès la consultation pédopsychiatrique anténatale échanger sur cette thématique. Ils ont fait l’effort d’être présents en post-partum et dans le suivi pluridisciplinaire des trois premiers mois, ce qui laisse présager de l’efficacité de cette démarche. Une telle perspective ouvre de sérieux espoirs sur une recherche permettant de valider ces pistes de réflexion au regard de l’avancée fulgurante des neurosciences. Poursuivre l’effort de repérage par la diffusion de l’entretien prénatal précoce et prendre soin des nouveau-nés à terme avec la même rigueur que dans les soins de développement pour les grands prématurés sont autant de défis à relever ensemble avec des parents devenus coacteurs du développement de leur enfant.

Early gestational diabetes mellitus (eGDM) is diagnosed when fasting plasma glucose before 24 weeks of gestation (WG) is ≥ 5.1 mmol/L, whilst standard GDM is diagnosed between 24 and 28 WG by oral glucose tolerance test (OGTT). eGDM seems to have worse obstetric outcomes than standard GDM. We compared the rates of postpartum glucose metabolism disorders between women with early versus standard GDM in this prospective study on women with GDM from three university hospitals between 2014 and 2016. Patients were included if they were Trial registration: NCT01839448, ClinicalTrials.gov on 22/04/2013.

Background Management of pregnancy and risk stratification in women with congenital heart diseases (CHD) are challenging especially due to physiological haemodynamic modifications that inevitably occur during pregnancy. Objective To compare the accuracy of the main published scores including CARPREG II score in prediction of maternal complications during pregnancy in CHD patients. Method We included all pregnant women with CHD who delivered their babies after the 20th gestational week in our institution between 2007 and 2018 until 6 months postpartum. Pregnancy scores (CARPREG, CARPREG II, Harris, ZAHARA risk scores and modified WHO (mWHO) risk classification) were applied retrospectively. Results Of 121 pregnancies in 65 CHD patients, 30% had cardiovascular complications. The c-statistic was 0.577 (95% confidence interval (CI): 0.428, 0.727; P = 0.19) for CAPREG score, 0.593 (95% CI: 0.469, 0.717; P = 0.11) for the ZAHARA score, 0.601 (95% CI: 0.402, 0.799; P = 0.15) for Harris score, 0.646 (95% CI: 0.525, 0.767; P Fig. 1 ). Conclusion Even if the new CARPREG II score seems to be better than most of the previously used scores as predictor of adverse maternal cardiovascular events mWHO appears to be more accurate in CHD patients.

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Resume But Realiser un etat des lieux de la prise en charge des femmes conductrices d’hemophilie dans un CHRU francais et evaluer les differents problemes rencontres chez ces patientes. Patientes et methodes Etude retrospective concernant les conductrices d’hemophilie ayant consulte au CHRU de Montpellier entre 1995 et 2011. Le recueil des donnees a ete effectue a partir des dossiers medicaux et d’un questionnaire envoye aux conductrices. Les informations recueillies concernaient les caracteristiques biologiques, l’histoire hemorragique et la prise en charge des grossesses. Resultats Soixante-quatre conductrices d’hemophilie A ou B ont ete incluses. Leur taux de FVIII ou FIX median est de 52 % (15–137 %). Trente et un pour cent des conductrices ont des regles d’une duree superieure a 7 jours. Cent quarante-deux grossesses ont ete debutees par 54 conductrices qui ont donne naissance a 101 enfants, dont 26 garcons hemophiles. Soixante-deux diagnostics prenatals ont ete realises, 15 ont conduit a une interruption medicale de grossesse en raison d’un fœtus de sexe masculin hemophile. Soixante-seize pour cent des accouchements se sont deroules par voie basse et 49 % ont eu lieu dans une maternite de niveau III. L’accouchement a ete complique par une hemorragie du post-partum primaire dans 10,8 % des cas et secondaire dans 8,5 % des cas. Conclusion Le risque hemorragique chez les conductrices est associe a leur taux de facteur antihemophilique. Pour ameliorer la prise en charge de ces patientes, un dossier pluridisciplinaire et standardise, avec un questionnaire specifique pour evaluer les saignements pourrait etre envisage. Un registre regional repertoriant toutes les conductrices, quel que soit leur taux de facteur, serait egalement utile.

Objective The aim of this study was to evaluate the contribution of prenatal magnetic resonance imaging (MRI) to ultrasound (US) in the prenatal diagnosis of intra-abdominal cystic masses, correlated with the postnatal diagnosis. Methods In this retrospective, observational study, prenatal MRI and US diagnoses were compared with postnatal diagnoses. MRI was performed in 56 fetuses with intra-abdominal cyst diagnosed by US between 2004 and 2013. Final diagnosis, revealed by postnatal evaluation, was obtained for 49 of them and was taken as the reference. MRI was evaluated as superior, equal, or inferior to US. Results An accurate diagnosis was provided by US in 25 cases (51%) and by MRI in 36 out of the 49 cases (73.4%). MRI corrected the US diagnosis in 13 cases (26.5%) by providing a more precise localization or additional etiologic information. In two cases (4%), MRI wrongly changed the diagnosis correctly made by US. Conclusion Prenatal MRI better characterized the nature of abdominal cystic lesions previously diagnosed by US in 13 cases. This enhanced postnatal therapeutic planning and so improved parental counseling and pregnancy management. © 2015 John Wiley & Sons, Ltd.

Objectives The objective of this article is to describe and assess prenatal imaging findings, fetal and postnatal outcomes of thrombosis of torcular herophili, and to determine diagnostic features, pathophysiology, prognosis, and optimal management. Methods Over a decade, we compiled the largest single-center retrospective study of outcomes. Fetal magnetic resonance imaging (MRI) was used to confirm the sonographic suspicion and monitor thrombosis of torcular herophili. We noted prenatal and postnatal imaging specifications, pregnancy outcomes, and clinical and radiological pediatric monitoring. Analysis of findings and review of the literature allowed us to define prognostic factors. Results In eight cases of prenatal diagnosis of thrombosis of torcular herophili, MRI outcomes were specific. There were five deliveries at full term, two terminations of pregnancy, and one fetal demise in utero. Neonates had a good clinical and radiological outcome. Factors of poor prognosis were deep venous sinus thrombosis, enduring mass effect, brain parenchymal injury, and heart failure related to dural arteriovenous shunt. Conclusion Among dural sinus malformations, thrombosis of torcular herophili with or without extension at the posterior segment of the longitudinal sinus frequently has a good prognosis. It is urgent to wait because the prognosis can only be ascertained over time by means of ultrasound scan and MRI monitoring. © 2014 John Wiley & Sons, Ltd.

Objective To compare the prognostic value of fetal serum α1-microglobulin with that of β2-microglobulin and cystatin C for postnatal renal function. Method Retrospective study of α1-microglobulin, β2-microglobulin, and cystatin C in fetal serum from 126 fetuses with congenital abnormalities of the kidney and urinary tract (73 and 53, respectively). Two groups were defined: group with normal renal function and group with renal failure. For live born infants, renal function was assessed on the basis of serum creatinine (cutoff 50 µmol/L) or glomerular filtration rate (cutoff 75 mL/min/1.73 m2) or both. In case of infant or fetal death, histological kidney lesions were considered. Results Significant differences (p

Resume Objectif Etablir si la realisation des manœuvres a membranes rompues sur deuxieme jumeau (J2) est un facteur de risque de cesarienne. Patientes et methodes Deux cent cinquante-neuf accouchements gemellaires par voie basse apres 33 semaines d’amenorrhee de 1997 a 2009 au sein d’une maternite de niveau III. Etude cas–temoins retrospective, comparant un groupe constitue de cesariennes sur J2 et un groupe temoin constitue des cinq accouchements par voie basse des grossesses gemellaires suivant le cas. Une prise en charge active de J2 etait effectuee avec un intervalle libre court entre les deux naissances. Resultats Onze cesariennes sur J2 (4,2 %) ont ete pratiquees. L’indication la plus frequente etait l’echec de la version par manœuvre interne. Le risque de cesarienne sur J2 etait plus eleve quand les membranes etaient rompues immediatement avant ou pendant la version par manœuvre interne (VMI) (OR : 25,4 IC 95 % [2,35–275,7] p Discussion et conclusion Dans notre experience, la rupture des membranes avant ou pendant la VMI est significativement associee a un risque d’echec de la manœuvre et de cesarienne sur J2. Par consequent, nous preconisons d’effectuer la VMI a membranes intactes conformement a l’accord professionnel des recommandations francaises de 2009.

Objective To investigate the accuracy of prenatal axial three-dimensional (3D) ultrasound in predicting the absence or presence of cleft palate in the presence of cleft lip. Methods Between March 2005 and January 2009, there were 81 cases with a prenatal two-dimensional (2D) ultrasound screening diagnosis of unilateral or bilateral cleft lip at 22–25 weeks of gestation referred to our tertiary care center. Of these, 79 fetuses were included in this prospective study and two were excluded. Axial 3D ultrasound imaging of the fetal palate was performed and the diagnoses were compared with clinical findings at delivery. The frequencies of intact and cleft palate, the degree of association between the prenatal predictions and postnatal findings and the probability of detection of cleft lip and palate were determined. Results Of 79 prenatal predictions, 77 (97%) were correct and the association between the prenatal predictions and postnatal findings was strong. The sensitivity for detection of cleft lip and palate within this high-risk population was 100% and the specificity was 90%. In one of the excluded cases, the palate could not be visualized due to a fetal prone position. There were chromosomal anomalies in 4% of cases and associated structural or growth anomalies in 23%, termination of pregnancy was carried out in 4% and intrauterine fetal demise occurred in 3%. Conclusion Axial 3D ultrasound of the fetal palate has high accuracy in identifying prenatal cleft palate when cleft lip is diagnosed at mid-trimester 2D ultrasound screening. Copyright © 2011 ISUOG. Published by John Wiley & Sons, Ltd.

Objectives To evaluate the results and risks of a protocol for second- and third-trimester termination of pregnancy after prior caesarean section. Study design This is a retrospective study, conducted in a level 3 (university hospital) maternity unit between January 2001 and September 2008. 67 women with a history of caesarean section underwent second- and third-trimester termination of pregnancy. The protocol was administration of 600 mg mifepristone the first day and application of laminaria tents the second day. One the third day, 48 h after mifepristone, two 200 μg tablets of misoprostol were given orally every 3 h until delivery. Epidural analgesia was performed routinely. Complications analysed were uterine rupture, labour lasting over 12 h, and bleeding requiring blood transfusion. Results Delivery was vaginal in 64 cases (95.5%), a median 4 h 20 min (P25: 3 h 5 min, P75: 7 h 7 min) after administration of misoprostol (median number of tablets 2; P25: 2, P75: 4). The median number of tablets of misoprostol was significantly higher for termination of pregnancy than for fetal death in utero (4 vs. 2; p = 0.002). The rate of uterine rupture was 4.8% [95% CI: 1.2–14.2]. Bleeding during delivery requiring a transfusion occurred in 2 cases (3.0%; 95% CI: 0.5–11.3). Conclusion A high rate of vaginal delivery was achieved at low doses of misoprostol, with a short median induction-to-delivery interval, and a rate of uterine rupture higher than that observed during attempted vaginal delivery at term in a caesarean scar pregnancy. The rate of severe bleeding during delivery was low.

We report the only case of recurrent bilateral adnexal torsion during pregnancy with normal ovaries. This rare situation raises diagnostic as well as therapeutic management difficulties.

Background: Early postpartum discharge is a recent practice in France, but the influence of a shortened hospital stay on subsequent breastfeeding is unknown. The objective of the present study was to compare the breastfeeding mode after early discharge (ED) and conventional discharge (CD) from a hospital maternity unit. Methods: An observational study was conducted in a French university hospital among 135 breastfeeding mothers, who delivered between 1 January and 31 July 2006. Forty-five ED mothers were matched with 90 CD mothers on 13 criteria. A structured questionnaire was used to collect data regarding feeding practices at 10 weeks postpartum, the period corresponding to paid maternity leave. Results: Exclusive breast-, mixed, and bottle feedings were reported by, respectively, 35 (77.8%), three (6.7%) and seven (15.5%) ED mothers and 64 (71.1%), 12 (13.3%) and 14 (15.6%) CD mothers (no significant differences). Satisfaction with support for breastfeeding and reasons for switching to mixed or bottle feeding were comparable in the two groups. Multivariate analysis indicated that only the planned duration of breastfeeding and the mother's dissatisfaction with help significantly influenced breastfeeding prevalence. Conclusions: Early postpartum hospital discharge organized by skilled professionals is compatible with a satisfactory rate of exclusive breastfeeding up to the return to work. Formalized programs of instruction for perinatal professionals would help to reduce early abandonment.

SummaryInherited disorders of fibrinogen are rare and affect either the quantity (hypofibrinogenaemia and afibrinogenaemia) or the quality of the circulating fibrinogen (dysfibrinogenaemia) or both (hypodysfibrinogenaemia). Extensive allelic heterogeneity has been found for all these disorders: in congenital afibrinogenaemia for example more than 40 mutations, the majority in FGA, have been identified in homozygosity or in compound heterozygosity. Numerous mutations have also been identified in patients with hypofibrinogenaemia, many of these patients are in fact heterozygous carriers of afibrinogenaemia mutations. Despite the number of genetic analyses performed, the study of additional patients still allows the identification of novel mutations. Here we describe the characterization of a novel FGA intron 2 donor splice-site mutation (Fibrinogen Montpellier II) identified in three siblings with hypodysfibrinogenaemia. Functional analysis of RNA produced by the mutant minigene in COS-7 cells revealed that the mutation led to the in-frame skipping of exon 2. Western blot analysis of COS-7 cells expressing an exon 2 deleted FGA cDNA revealed that an alpha-chain lacking exon 2, which codes in particular for fibrinopeptide A and polymerisation knob ‘A’, has the potential to be assembled into a hexamer and secreted. Analysis of precipitated fibrinogen from patient plasma showed that the defect leads to the presence in the circulation of alpha-chains lacking knob ‘A’ which is essential for the early stages of fibrin polymerisation. Fibrin made from purified patient fibrinogen clotted with thrombin displayed thinner fibers with frequent ends and large pores.

Rapidly involuting congenital hemangiomas are rare tumors, usually localized in the dermal-hypodermic tissue. They are fully developed at birth and present as solitary masses that do not proliferate postnatally. We report on a fetus that presented with hydramnios and left hydrothorax. Postnatal ultrasounds and computed tomography imaging showed a congenital hemangioma invading the left diaphragmatic dome and extending to the abdominal wall, pericardium, and liver. The mass was well tolerated, showing regular involution on serial ultrasounds and complete involution by the end of the second year of life. Rapidly involuting congenital hemangiomas can exceptionally affect the diaphragmatic region in the perinatal period. This observation demonstrates the relevance of current radiologic techniques, which are minimally invasive, for the diagnosis and follow-up of this particularly rare and potentially life-threatening lesion.

Resume Objectif Le cerclage isthmique par voie abdominale est indique dans les echecs de cerclage par voie vaginale, les pertes fœtales recurrentes du second trimestre et les conisations etendues ou delabrements cervicaux. L’approche cœlioscopique plus recemment decrite doit demontrer, outre sa faisabilite technique, son interet en termes de prevention des accidents obstetricaux. Patientes et methodes Il s’agit d’une evaluation retrospective monocentrique sur 14 cas de cerclage isthmique cœlioscopique selon la technique de Benson, realises hors grossesse entre mai 2005 et novembre 2007. Nous avons analyse les antecedents obstetricaux, les etiologies de beances cervico-isthmiques, les therapeutiques deja mises en œuvre pour leur prise en charge et le devenir de ces patientes apres cerclage. Resultats L’âge moyen des patientes est 33,5 ans. Quatre-vingt-treize pour cent d’entres elles avaient au moins un antecedent d’avortement tardif ou d’accouchement premature et 42,9 % avaient deja eu un echec de cerclage par la technique de Mac Donald. Les indications de cerclage par voie haute ont ete portees dans six cas pour antecedent d’echec de cerclage par voie vaginale et dans huit cas pour impossibilite anatomique du cerclage par voie vaginale. La duree operatoire des cerclages a ete de 45 minutes (35–60 minutes) et la duree d’hospitalisation d’un jour. Aucune complication n’est, a ce jour, survenue en per- ou postoperatoire. Sur les 14 cerclages realises, six ont abouti a une grossesse. Cinq grossesses ont ete menees a terme avec naissance d’enfants vivants. Une grossesse s’est terminee par un avortement spontane du premier trimestre. Discussion et conclusion Le cerclage isthmique par voie cœlioscopique est techniquement realisable et apporte aux patientes les avantages de la cœlioscopie. L’indication doit etre correctement posee et doit repondre aux memes criteres que le cerclage par laparotomie. L’evolution des grossesses cerclees par cette technique semble etre favorable.

As the prevalence of obesity grows in western countries, maternal obesity is becoming an increasingly frequent high-risk obstetrical situation. Obese women have a higher incidence of pregnancy complications (gestational diabetes, hypertension, toxaemia, etc.) and of adverse fetal outcomes (macrosomia, neural tube defects, perinatal mortality). Cesarean section is more frequent in obese women, resulting in a higher risk of anaesthetic and post-operative complications. Maternofetal complications are proportional to the degree of obesity, and even moderate overweight amplifies the risk. Long-term complications include worsening of maternal obesity, maternal type 2 diabetes, and childhood obesity and metabolic disorders. Before conception, these patients should receive tailored weight-loss advice and be screened for obesity complications. Food intake during pregnancy should be tailored to achieve the minimum maternal weight gain required for normal fetal growth. Long-term follow-up is required to prevent worsening of maternal obesity after delivery, and the child's growth curve should be closely watched

The obesity epidemic is of some concern in women of reproductive age. Maternal obesity is associated with many pregnancy complications, especially gestational diabetes and hypertensive disorders of pregnancy. Delivery in obese women is characterized by a high caesarean-section rate and an increased risk of anaesthetic and postoperative complications. Weight retention after birth may increase the risk of type 2 diabetes in the long term. Foetal risks include macrosomia, malformations and increased perinatal mortality, with the long-term infant health marked by a higher risk of obesity and metabolic disorders. Optimal management includes preconception counselling, pregravid weight-loss programmes, monitoring of gestational weight gain, repeated screening for pregnancy complications and long-term follow-up to minimize the social and economic consequences of pregnancy in overweight women.

Objectives To describe a three-dimensional (3D) ultrasound technique for assessing the fetal soft palate. Methods A prospective study conducted from April to December 2006 included 87 fetuses in a low-risk population. Fetal ultrasound scans were performed between 21 and 25 weeks of gestation to determine the normal 3D ultrasound view of the fetal soft tissues of the palate. The sonographers used a 30°-inclined axial 3D view of the fetal palate. Ultrasound images obtained in this view were compared with fetopathological specimens of the same gestational age by two observers, both pediatric surgeons. Each observer indicated whether they thought that the uvula or the velum could be detected, and the differences in responses between the observers were assessed. Results The frequencies of detection of the uvula and velum of each observer varied between 80% and 90%. The observers showed a significant difference in judging the visualization of the uvula, but not in judging the velum. Conclusions A 30°-inclined axial 3D ultrasound view seems to be effective in assessing the integrity of the fetal soft palate. Copyright © 2008 ISUOG. Published by John Wiley & Sons, Ltd.

The objective of this case report is to evaluate the faculty of a recently described original three-dimensional ultrasound technique to detect pathological processes of the fetal palate. The palate of the fetus of a patient with a personal history of isolated incomplete cleft palate is evaluated by three-dimensional ultrasound at 34 weeks of gestation. The postnatal findings are compared to the prenatal investigation. The used three-dimensional ultrasound technique provides selective visualization of the total hard palate which permits the prenatal diagnosis and multidisciplinary approach of an incomplete cleft palate. These prenatal findings might encourage further studies to confirm the value of this recently described innovative technique in the diagnosis and surgical prenatal counselling of fetal cleft palate.

Summary Purpose Drug abuse during pregnancy is an important public health problem. Montpellier University Hospital established a center for addiction and pregnancy in 1997 to provide multidisciplinary prenatal care aimed at reducing maternal and fetal risks during pregnancy and afterwards. This study assesses the trends in drug-taking behavior and pregnancy outcome among women receiving this prenatal care. Methods This exploratory prospective study examined participants in this program during its first 5 years (1997-2002). Women were included if they had been: pregnant, addicted to opiates, enrolled in the program for at least 15 days, and if their delivery took place at Montpellier Hospital. We recorded how often they came to prenatal care, drug-taking behavior, social and economic level, and obstetrical and neonatal outcomes. Results The study included 114 women. Those receiving drug substitution at the onset of pregnancy mainly saw general practitioners (64/89 at the beginning of pregnancy), who most often prescribed buprenorphine (70/105 at the end of pregnancy). More than two thirds of patients (n=78) abused several substances. Heroine abuse decreased (p Conclusion Multidisciplinary prenatal care with medical, social, and psychological support can decrease opiate abusers' risks during pregnancy even when the drug treatment program is essentially unsupervised.

OBJECTIVE: To report a child born with renal impairment following severe anhydramnios due to maternal exposure to an angiotensin II receptor type 1 (AT1) antagonist, valsartan, and hydrochlorothiazide during the first 28 weeks of pregnancy. CASE SUMMARY: A hypertensive woman treated with valsartan 80 mg/day, hydrochlorothiazide 12.5 mg/day, prazosin 10 mg/day, lysine acetylsalicylate 100 mg/day, and levothyroxine 250 μg/day became pregnant. At 28 weeks' gestational age, severe anhydramnios associated with high β2-microglobulin levels in the fetal blood cord was observed. Upon discontinuation of valsartan, fetal renal prognosis improved. In this case, using the Naranjo probability scale, the renal insufficiency of the child was probably related to valsartan. At the age of 2.5 years, the child presented with only mild chronic renal insufficiency. Growth parameters were within the normal range, and there was no evidence of developmental delay. DISCUSSION: Exposure to AT1 antagonists during the second part of pregnancy can lead to abnormalities similar to those observed after exposure to angiotensin-converting enzyme inhibitors, that is, reduced fetal kidney perfusion that may result in oligoamnios and neonatal renal insufficiency. Fourteen previous reports of maternal exposure to AT1 antagonists during this period have been published. In 6 cases, fetal or neonatal death occurred; in 2 cases, pregnancy was terminated because of complete anhydramnios or fetal abnormalities; in 1 case, renal insufficiency persisted at 8 months of age; in 2 cases, kidney function was fairly normal at birth; and in 4 cases, including the one described here, neonatal renal failure improved in the first year of life. CONCLUSIONS: AT1 antagonists should be avoided throughout pregnancy. If these agents are prescribed accidentally to a pregnant woman, monitoring of amniotic fluid volume and β2-microglobulin fetal blood levels after discontinuation of the AT1 antagonist can provide critical data for advising parents on pregnancy and fetal outcome.

Objectives Megacystis-microcolon-intestinal hypoperistalsis syndrome (MMIHS) is a usually lethal disease during the first year of life. There is no specific ultrasound prenatal diagnosis and no identified genetic locus. The value of amniotic fluid digestive enzyme assay and fetal urine biochemistry in the prediction of MMIHS was analysed. Methods Retrospective study of 14 MMIHS cases. Amniotic fluid digestive enzymes and fetal urine biochemistry were compared in MMIHS and megabladder (63 and 264 cases respectively). Results Abnormal amniotic fluid digestive enzyme profile (vomiting of bile or digestive secretion leakage) was observed in 8/10 MMIHS cases. These profiles were observed in 7/63 controls; 80% sensitivity (95%CI = 55%–100%); 89% specificity (95%CI = 81%–96%). Fetal urinalysis was normal in 12/12 MMIHS cases except high calcium (>0.6 mmol/l). This profile was observed in 33/264 megabladder control cases; 100% sensitivity; 98.7% specificity (95%CI = 83.5%–91.5%). Conclusion For the first time, we propose a prenatal diagnosis of MMIHS based on amniotic fluid digestive enzyme assay and on fetal urinalysis. Copyright © 2005 John Wiley & Sons, Ltd.

OBJECTIVE—To evaluate perinatal outcome in pregnancies in women with type 1 and type 2 diabetes and the influence of preconception care 10 years after the St. Vincent’s declaration.RESEARCH DESIGN AND METHODS—A cross-sectional study was conducted in 12 perinatal centers in France in 2000-2001. The main investigated outcomes were perinatal mortality, major congenital malformations, and preterm delivery.RESULTS—Among 435 single pregnancies, 289 (66.4%) were from women with type 1 and 146 (33.6%) from women with type 2 diabetes. Perinatal mortality rate was 4.4% (0.7% national rate), severe congenital malformations rate was 4.1% (2.2% national rate), and preterm delivery rate was 38.2% (4.7% national rate). Preconception care was provided in 48.5% women with type 1 diabetes and in 24.0% women with type 2 diabetes. Women whose first trimester HbA1c was >8% had higher rates of perinatal mortality (9.2 vs. 2.5%; odds ratio 3.9; 95% CI 1.5–9.7; P < 0.005), major congenital malformations (8.3 vs. 2.5%; 3.5; 1.3–8.9; P < 0.01), and preterm delivery (57.6 vs. 24.8%; 1.4; 1.1–1.7; P < 0.005) than those with first trimester HbA1c CONCLUSIONS—Pregnancies in women with diabetes are still poorly planned and complicated by higher rates of perinatal mortality and major congenital malformations. Despite knowledge of the importance of intensified glycemic control before pregnancy, reaching the St. Vincent’s target needs further implementation in France.

The objective of this article is to describe and assess prenatal imaging findings, fetal and postnatal outcomes of thrombosis of torcular herophili, and to determine diagnostic features, pathophysiology, prognosis, and optimal management.Over a decade, we compiled the largest single-center retrospective study of outcomes. Fetal magnetic resonance imaging (MRI) was used to confirm the sonographic suspicion and monitor thrombosis of torcular herophili. We noted prenatal and postnatal imaging specifications, pregnancy outcomes, and clinical and radiological pediatric monitoring. Analysis of findings and review of the literature allowed us to define prognostic factors.In eight cases of prenatal diagnosis of thrombosis of torcular herophili, MRI outcomes were specific. There were five deliveries at full term, two terminations of pregnancy, and one fetal demise in utero. Neonates had a good clinical and radiological outcome. Factors of poor prognosis were deep venous sinus thrombosis, enduring mass effect, brain parenchymal injury, and heart failure related to dural arteriovenous shunt.Among dural sinus malformations, thrombosis of torcular herophili with or without extension at the posterior segment of the longitudinal sinus frequently has a good prognosis. It is urgent to wait because the prognosis can only be ascertained over time by means of ultrasound scan and MRI monitoring.

Objective : To compare the incidences of tachysystole, hypertonia and fetal heart rate (FHR) abnormalities in women treated by mifepristone plus prostaglandins (PGs), mifepristone alone or PGs alone for an unfavourable cervix. Study Design : In this retrospective study, all women between 37 and 42 weeks were eligible for the study if they had undergone cervical ripening prior to labour induction. In group 1, the women were treated with mifepristone plus PGs ( n =103). Group 2 women were treated with mifepristone alone ( n =96) and group 3 women with PGs alone ( n =100). Incidences of tachysystole, hypertonia and FHR abnormalities were compared. Results : During induction of labour, tachysystole and hypertonia occurred more frequently in women treated with mifepristone. Severe bradycardia and recurrent late decelerations were more frequent after the initiation of oxytocin in groups 1 and 2 than in group 3. Conclusions : In this study, mifepristone increased the incidences of tachysystole, hypertonia and FHR abnormality.

Objective To determine whether early placental drainage plus cord traction reduces the incidences of manual removal and blood loss, and to determine the risk factors associated with blood loss after delivery. Design Prospective randomised study. Setting University teaching hospital, Montpellier, France. Methods A randomised study compared 239 women who had placental cord drainage plus cord traction with 238 women with expectant delivery. The need for manual removal of the placenta and the drop in haemoglobin after delivery were assessed. The duration of the third stage of labour and the time between birth and the beginning of perineal suturing were measured. Statistical analysis used the paired t test for continuous variables, the Kruskal-Wallis test for nonparametric data and χ2 test for categoric variables. Stepwise logistic regression analyses were performed with a drop in haemoglobin as the outcome variable. Results No significant difference was found in the two groups with regard to the incidence of manual removal of retained complete or incomplete placenta or postpartum haemorrhage. The median values of the duration of the third stage of labour, birth-to-perineal suture time and drop in haemoglobin were significantly lower in the cord drainage group than in the control group. After controlling for confounding variables, parity proved to be the only significant predictor of drop in haemoglobin. Conclusion Cord drainage decreases the duration of the third stage of labour and reduces blood loss but not the incidence of manual removal of the placenta.

Prenatal diagnosis is presently performed following invasive procedures with variable risks of fetal loss; non-invasive procedures using fetal cells in maternal blood would be welcome for the early detection of fetal sex or aneuploidy. We describe a simple and rapid protocol to detect fetal cells and thus to assess fetal sex. In a first step, nucleated blood cells were separated into mononuclear and polynuclear cells using a double density gradient centrifugation. In a second step primed in situ (PRINS) labelling technique was performed to label Y-chromosomes. 15 samples were studied and correct gender assignment was made in 13/15. The number of labelled nuclei was higher in polynuclear cell phases than in mononuclear cell phases. Moreover, the polylobular aspect of labelled nuclei from polynuclear cell phases strongly suggested that they could belong to fetal polynuclear cells. The PRINS technique combines some advantages of FISH, such as visual assessment of in situ chromosome labelling and the powerful specificity and sensitivity of PCR. In association with a simple enrichment procedure it constitutes a rapid protocol for fetal cell detection, non-invasive early prenatal sex assessment, and could further be applied to detect the main viable aneuploidies.

Objective: The aim of the study was to characterize n-3 and n-6 fatty acid Δ5- and Δ6-desaturase activities and their time course variations in human fetal liver between the 17th and 36th gestational week. Study Design: Twenty-one biologic samples were obtained after legally approved medical abortion, according to French law. The desaturase activities were measured in the 21 liver samples by a radiochemical method by means of reverse-phase high-performance liquid chromatography. The fatty acid composition (percentage by weight) of liver phospholipids was assessed in 16 samples by gas-liquid chromatographic analysis. Results: Both Δ5- and Δ6-desaturase activities were significantly expressed between the 17th and 36th gestational weeks. During the second trimester n-6 fatty acid Δ5- and Δ6-desaturase activities showed opposite patterns of variation; both then remained stable between the 25th and 36th weeks. Δ6-Desaturation was higher in n-3 than n-6 fatty acids and peaked at the 18th gestational week. The percentages of linoleic and docosahexaenoic acids in liver microsomes were positively correlated with the gestation age ( P Conclusion: Significant n-3 and n-6 Δ5- and Δ6-desaturase activities are expressed in human fetal liver as early as the 17th gestational week and are stable throughout the third trimester. Their theoretic capacity evaluated from in vitro measurements appears lower than polyunsaturated fatty acid requirements and is not directly related to liver microsomal membrane fatty acid composition. (Am J Obstet Gynecol 1998;179:1063-70.)

Objective: To evaluate the technical aspects, efficacy and safety of first-trimester multifetal pregnancy reduction in the management of multifetal pregnancies, an analysis of the international literature on first-trimester multifetal pregnancy reduction was made. Materials: Thirty-three studies were selected from an international review of the literature. Total fetal loss rate, risk of fetal loss after the procedure with the different techniques and gestational age at delivery were the main parameters studied. The Kruskal-Wallis test and Mann-Whitney test were used for statistical analysis. Results: 2,756 multifetal pregnancy reductions were performed (2,145 transabdominal, 363 transcervical, and 248 transvaginal procedures). Total fetal loss rates were different: 16.7% for the transabdominal, 24.8% for the transcervical and 10.9% for the transvaginal procedure (p = 0.03). The risk of fetal loss was 12% for the transabdominal, 20% for the transcervical, and 10% for the transvaginal approach at less 24 weeks of gestation (p = 0.04). There was no difference for the gestational age at the time of the procedure, the initial and final number of embryos, and the gestational age at delivery. Conclusion: Because the transvaginal approach seems to be the safer procedure, surgeons may opt for it. The transcervical approach has a high fetal loss rate and should be excluded.

To compare the prognostic value of fetal serum α1-microglobulin with that of β2-microglobulin and cystatin C for postnatal renal function.Retrospective study of α1-microglobulin, β2-microglobulin, and cystatin C in fetal serum from 126 fetuses with congenital abnormalities of the kidney and urinary tract (73 and 53, respectively). Two groups were defined: group with normal renal function and group with renal failure. For live born infants, renal function was assessed on the basis of serum creatinine (cutoff 50 µmol/L) or glomerular filtration rate (cutoff 75 mL/min/1.73 m2) or both. In case of infant or fetal death, histological kidney lesions were considered.Significant differences (p 0.001) were observed for the three markers between fetuses with good renal prognosis and those with renal failure (34.4 mg/L vs 67.6 mg/L for α1-microglobulin, respectively; 3.9 mg/L vs 7.35 mg/L, for β2-microglobulin, respectively; and 1.67 mg/L vs 2.12 mg/L for cystatin C, respectively). Areas under receiver operator curves were used to compare the three markers, 0.96, 0.90, and 0.74 for β2-microglobulin, α1-microglobulin, and cystatin C, respectively.Although α1-microglobulin is significantly different in fetuses with good renal prognosis and those with renal failure, overall, it is a less reliable prognostic marker than fetal serum β2-microglobulin.

OBJECTIVE: The purpose was to establish which blood characteristics of vitamin E status were highly correlated between mothers and fetuses during gestation. STUDY DESIGN: Twenty-four pregnant women were selected because of suspicion of toxoplasmosis or other disease and malformation or intrauterine growth delay justifying cord blood puncture. After maternal and fetal blood was collected, analyses of plasma and red blood cell vitamin E contents were performed together with analyses of standard lipid parameters and lipoprotein (a) in maternal plasma and fatty acid compositions of maternal and fetal red blood cells. RESULTS: The maternal population was characterized by a plasma lipid-normalized vitamin E mean content higher (3.5 mmol/mol lipids) than usually found in nonpregnant adults. There was no relationship between plasma and red blood cell vitamin E contents. This was also true for fetuses. When the vitamin E status of mothers was compared with that of fetuses, we found no correlation in plasma vitamin E in the whole population and in the high lipoprotein (a) (>300 mg/L) and low lipoprotein (a) ( r = 0.94 for the red blood cell content). Improved correlations were also found in the high lipoprotein (a) group for the interrelationship between vitamin E and plasma lipid contents (cholesterol and triglycerides), whereas improvement was noted in the low lipoprotein (a) group by positive correlation between age and vitamin E red blood cell content or red blood cell relative charge. CONCLUSION: Determination of red blood cell vitamin E and plasma lipoprotein (a) in mothers could be useful in antenatal blood analysis in cases of ris of prematurity at birth, to prevent peroxidative membrane damage in neonates, and > 85% of the mothers in the current population would benefit from vitamin E supplementation from the viewpoint of the fetal red blood cell vitamin E requirement in spite of the rather high maternal lipid-normalized vitamin E plasma content.

In a prospective case-control study, early amniocenteses (EAC, n = 242) at between 12 and 14 weeks gestation, were compared with standard amniocenteses (SAC, n = 242) performed at between 15 and 24 weeks gestation. The medical records of these 484 cases were reviewed for indications, success rate, color and volume of amniotic fluid, gestational age, number of needle insertions, location of the placenta, culture failure rate, obstetric complications and therapeutic abortion rate. There were no significant differences between the two groups in success rate, in culture success rate or in the outcome of the pregnancies. The volume of the sample taken was smaller in the EAC patients (P < 0.001), and therapeutic abortions were performed significantly earlier (P < 0.02.) Results show that EAC is feasible from 11 weeks' gestation, and can be performed for the usual indications as an alternative to chorionic villus sampling. In the near future, cytogenetic techniques will enable results to be obtained in less than a week.

The quantification of ‘faint-positive’ cholinesterases in amniotic fluid was performed in 40 patients with positive acetylcholinesterase (AchE) tests. Fetuses with anencephaly and open spina bifida presented an AchE/butyrylcholinesterase (A/B) ratio of more than 0.3 with clearly dense bands. Fetuses with gastroschisis showed a ‘faint-positive’ AchE band (A/B < 0.3). In 5 fetuses (1 teratoma, 3 open spina bifida, 1 unaffected) we found faint AchE and butyrylcholinesterase bands.

Since most stresses are known to modify blood rheology, we studied .hemorheologlcal parameters during labor and delivery, which are highly stressful physiological events. In 80 pregnant women we measured blood viscosity, plasma viscosity and red blood cell (RBe) aggregation during labor (b~fore and atter 4 cm diratation), during delivery, and during ~elivery of the placenta. Blood viscosity at both native and corrected ,",ematocrlt increases (p < 0.001) with a peak during delivery followed by a rapid normalization during delivery of the placenta (p < 0.01). Hematocrit and plasma viscosity do not change during labor and delivery, but decrease during delivery of the placenta. RBe aggregation (physrologically increased during late pregnancy) acutely returns to normal during delivery (p

From a prospective cohort of 344 women who seroconverted for toxoplasmosis during pregnancy, 344 amniotic fluid, 264 placenta, and 216 cord blood samples were tested for diagnosis of congenital toxoplasmosis using the same PCR assay. The sensitivity and negative predictive value of the PCR assay using amniotic fluid were 86.3% and 97.2%, respectively, and both specificity and positive predictive value were 100%. Using placenta and cord blood, sensitivities were 79.5% and 21.2%, and specificities were 92% and 100%, respectively. In addition, the calculation of pretest and posttest probabilities and the use of logistic regression allowed us to obtain curves that give a dynamic interpretation of the risk of congenital toxoplasmosis according to gestational age at maternal infection, as represented by the three sample types (amniotic fluid, placenta, and cord blood). Two examples are cited here: for a maternal infection at 25 weeks of amenorrhea, a negative result of prenatal diagnosis allowed estimation of the probability of congenital toxoplasmosis at 5% instead of an a priori (pretest) risk estimate of 33%. For an infection at 10 weeks of amenorrhea associated with a pretest congenital toxoplasmosis risk of 7%, a positive PCR result using placenta at birth yields a risk increase to 43%, while a negative result damps down the risk to 0.02%. Thus, with a molecular diagnosis performing at a high level, and in spite of the persistence of false negatives, posttest risk curves using both negative and positive results prove highly informative, allowing a better assessment of the actual risk of congenital toxoplasmosis and finally an improved decision guide to treatment.

One hundred and ninety women who contracted toxoplasmosis after the seventh week of pregnancy underwent antenatal diagnosis, including ultrasound examination and biological tests. Tests included Toxoplasma isolation in fetal blood and amniotic fluid by mouse inoculation, specific IgM and IgA in fetal blood, and non-specific tests. Twenty fetuses had positive specific as well as non-specific tests for Toxoplasma infection. At birth, four of these presented with clinical congenital toxoplasmosis and 12 with subclinical forms. Antenatal diagnosis enabled the detection of 83 per cent of the infected fetuses. Under specific conditions, cordocentesis permits early diagnosis and considerably reduces the number of terminations of pregnancy.

OBJECTIVES: Two major approaches for multifetal pregnancy reduction have been developed over the past several years: transabdominal potassium chloride by injection and pelvic procedures by either transcervical aspiration or transvaginal potassium chloride injection or by an automated spring-loaded puncture device. The purpose of this study was to create the largest database from among the world's largest centers to assess possible differences in efficacy and complication rates by transabdominal or transcervical or multifetal pregnancy reduction. STUDY DESIGN: Data on over 1000 completed pregnancies that underwent multifetal pregnancy reduction by both methods from major centers with among the highest worldwide experience were combined. Transabdominal cases were divided temporally (1986 through 1991 and 1991 through 1993). RESULTS: Transabdominal multifetal pregnancy reduction was successfully performed on 846 patients and transcervical or transvaginal on 238 patients. Transcervical or transvaginal reduction is performed earlier and starts and finishes with fewer embryos. In 12.6% of cases transcervical or transvaginal reduction left a singleton as opposed to 4.4% for transabdominal reduction. Pregnancy losses (up to 24 weeks) were observed in 13.1% of transcervical or transvaginal cases and in 16.2% of transabdominal cases early in the series and 8.8% of late transabdominal cases. Transcervical or transvaginal reduction may be safer very early in gestation and transabdominal safer later in the first trimester. Premature deliveries were comparable, with only about 5% delivered between 25 and 28 weeks. The smaller starting numbers for transcervical and transvaginal reduction may explain a slightly higher term delivery rate. The transabdominal route tends to reduce the fundal embryos and the transcervical and transvaginal the lower ones. The significance of this is not clear. CONCLUSIONS: (1) Multifetal pregnancy reduction by either method is a relatively safe and efficient method for improving outcome in multifetal pregnancies. (2) More than 84% are delivered at >33 weeks. (3) The experience and preference of the operator are probably the key determinants for an individual patient. (4) An inverse relationship of starting and finishing number to loss rates and gestational age at delivery suggests that there still is a cost of iatrogenic multifetal pregnancies, even if multifetal pregnancy reduction can be successfully performed. (AM J OBSTET GYNECOL 1994;170:902-9.)

(Accepted by Guest Editor O. Linderkamp) Fetal blood can now be routinely studied by intrauterine sampling. Low erythrocyte aggregability is one of its most prominent hemorheological characteristics before 32 wk gestation. We investigated whether increased RBC aggregability is a marker of fetal pathologies. After we established in 119 fetuses a control group for fetal blood rheology, we measured erythrocyte aggregation with the Myrenne apparatus (i.e. a micromethod using 1 droplet of blood) in 111 fetuses explored for various diseases. RBC aggregation was increased (>2 Sd for gestational age) in 24 fetal blood samples, with the following diseases: 12.5% toxoplasmosis; 12.5% rhesus immunization; 8.33% autoimmune thrombocytopenia; 8.33% kidney polycystosis; 8.33% old maternal age; 8.33% heart malformation; 8.33% fetal hypotrophia. In autoimmune diseases (rhesus; thrombocytopenia) RBe aggregation was increased in 5/10 cases (50%); in heart or kidney malformations 5/10 (50%); in toxoplasmosis seroconversion 3/23 i.e. 13% of the fetuses had increased aggregation. These data suggest that RBC aggregation is increased in several fetal diseases and may be a nonspecific marker of them. key words: fetal blood, cordocentesis, hemorheology, erythrocyte deformability, blood viscosity. erythrocyte aggregation. 638 RBC AGGREGATION IN FETAL BLOOD Vol. 14, No.5

Objective To determine the prevalence and the timing of pregnancy termination relative to the type of central nervous system (CNS) malformations. Design Retrospective cohort study. Setting Multidisciplinary centre for prenatal diagnosis in the Languedoc-Roussillon region, France. Population A cohort of 481 pregnancy terminations performed between 2005 and 2009. Methods Detailed post-termination fetal and neuropathological analyses were carried out to identify the CNS malformations. Then, the prevalence and timing of pregnancy termination were assessed relative to the identified malformations. Results About one-third of pregnancy terminations (143/481) were performed for severe CNS malformations. Up to 24 weeks of gestation (WG), pregnancy terminations (56.6%) were carried out mainly for defects occurring during the two major first steps of CNS development (neurulation and differentiation of cerebral vesicles). After 24 WG, pregnancy terminations (43.3%) were mainly performed for corpus callosum agenesis (16/17), vermian agenesis (10/12) and gyral anomalies (13/15). For hindbrain malformations and gyral anomalies, there was a significant relationship between the timing of pregnancy termination and the presence of a severe ventriculomegaly at prenatal diagnosis (p=0.002 and p=0.02, respectively). Conclusion By classifying CNS malformations according to the neuropathological analysis, the authors show that the timing and prevalence of pregnancy termination are distributed in a manner that is consistent with what is currently known on the development of brain. They are also influenced by the French prenatal screening policy and the variable expressivity of the brain malformations and associated lesions.

Lymphangiomas or cystic hygromas are malformations of the lymphatic vessels and are characterized by single or multiple cysts which have developed within the soft tissues. They occur most commonly in the neck (75 per cent of cases) and are often associated with hydrops or chromosomal abnormalities (Romero et al., 1988). Mediastinal or abdominal locations are rare and represent less than 5 per cent of cases in the literature (Singh et al., 1971). This paper represents the first reported case of prenatal diagnosis of a lymphangioma in the neck, mediastinum, and abdomen. Diagnosis was made before fetal viability, and allowed us to recommend termination of the pregnancy because of the poor prognosis.

Objective To evaluate the effect of selective termination in triplet pregnancies. Design Comparative, prospective, nonrandomized study. Setting All 80 pregnancies were managed in a single tertiary center by the same obstetrical team. Patients Eighty women with triplet pregnancies were divided into two groups: group I consisted of 48 women who wished to continue their pregnancies without reduction; in group II were 32 women who choose reduction generally to obtain twins. Interventions Selective terminations were performed after an average term of 9.6 weeks of gestation by transcervical or transabdominal approaches. Main Outcome Measurements The rate of miscarriage and prematurity, fetal growth, perinatal morbidity and mortality, and maternal complications in the two groups. Results Prematurity was lower in reduced pregnancies (95.5% in triplets versus 53.5%), especially between 24 to 32 weeks' gestation where prematurity was reduced by half. Birth weight was >450g higher in the reduced group. The perinatal mortality rate was lower for reduced pregnancies, but this difference was not statistically significant. Five life-threatening maternal complications occurred in triplets, with none in the reduced group. Conclusions Selective terminations are effective in decreasing the rate of prematurity, improving fetal growth, and avoiding maternal complications. The procedure thus could be used in triplet gestations. The ultimate decision should be taken by the couple who must be well informed of the risks of the procedure before deciding.

This descriptive study was conducted to evaluate the risk of uterine rupture in cases of late vaginal induced abortions among women with previous cesarean sections. 23 women were referred at a mean gestational age of 23.9 (SD 6.9) weeks of gestation after one or two cesarean sections. Indications for terminating the pregnancy were maternal diseases in 4 cases and fetal anomalies in 19 cases. RU 486 and/or prostaglandins were used for cervical ripening and to induce labor. Vaginal birth was obtained in 20 cases (86.9%) with an average duration of 72 (SD 52) h. Cesarean section was performed in the remaining 3 women because no cervical dilation could be obtained. One uterine rupture occurred and was treated with conservation of the uterus. Late termination of pregnancy in such cases can be achieved without cesarean section with a high success rate.