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To overcome the difficulties in interpreting fetal heart rate (FHR), several tools based on the autonomic nervous system and heart rate variability (HRV) have been developed. The objective of this study was to use FHR and HRV parameters for the prediction of fetal hypoxia. It was an experimental study in the instrumented fetal sheep. Repeated umbilical cord occlusions were performed to achieve severe acidosis. Hemodynamic parameters, ECG, and blood gases were analyzed. The variables used were heart rate baseline, HRV analysis (RMSSD, SDNN, LF, HF, HFnu, Fetal Stress Index (FSI), …), and morphological analysis of decelerations. The gold standard used to classify hypoxia was the fetal arterial pH (pH

Objective To evaluate the use of the intracervical balloon compared with locally applied prostaglandins for cervical ripening for induction in patients with preterm premature rupture of membranes. Methods Monocentric, retrospective (from 2002 to 2017) observational cohort study of singleton pregnancies complicated by preterm premature rupture of membranes and induced between 34 and 37 weeks. The primary outcome measure was balloon catheter efficiency evaluated by Cesarean section rate. Secondary outcomes were : interval from induction to delivery, labor duration, oxytocin use, intrauterine infection rate, maternal complications (i.e., postpartum hemorrhage and endometritis), and neonatal complications. Results 60 patients had cervical ripening with prostaglandins alone and 58 had balloon catheter. Demographic characteristics were similar between the groups, except for induction term and neonatal weight. There was not a significant difference in occurrence of Cesarean section rate (p = 0.14). Nor were there significant differences in time from induction to birth (p = 0.32) or in intrauterine infection rate (p = 0.95). Labor duration was shorter (p = 0.006) and total oxytocin dose lower (p = 0.005) in patients induced by prostaglandins alone. Concerning neonatal outcomes, there were more transfers to intensive care (p = 0.008) and more respiratory distress (p = 0.005) among newborns induced by prostaglandins. Conclusion Compared with locally applied prostaglandins, balloon catheter induction is not associated with an increase of Cesarean section rate in patients with preterm premature rupture of membranes.

Breech presentation of the first twin occurs in 20% of twin pregnancies. However, the impact of delivery mode on morbimortality in breech fetuses remains controversial in the literature generally, and has been infrequently studied in twin pregnancies specifically. The aim herein was to evaluate neonatal and maternal outcomes according to delivery mode when the first twin was in breech presentation, and to compare these results with those in the current literature.This was a single-center, retrospective study in Lille, France, from January 2010 to December 2017, including twin pregnancies in which the first twin was in breech presentation and delivery was after 32 weeks of amenorrhea. Two groups were defined: planned vaginal delivery (PVD) and planned cesarean delivery (PCD). The primary outcome was neonatal morbidities, defined as a 5-minute Apgar score 7, cord pH 7.10 at birth, sepsis, and acute respiratory distress syndrome.Among the 184 patients included, 116 attempted a vaginal delivery (63%). Morbidity did not differ between PVD and PCD for the first twin (12/116 (10.3%) versus 7/68 (10.3%), respectively, p = 0.99), the second twin (18/116 (15.5%) versus 7/68 (10.3%), respectively, p = 0.31), or either twin (27/116 (23.2%) versus 11/68 (16.2%), respectively, p = 0.25). The rate of postpartum hemorrhage was significantly lower in the PVD group (PVD 36/116 (31%) versus PCD 41/68 (58.8%), p = 0.001).PVD is a reasonable option when the first twin is in breech presentation with probably no higher neonatal mortality and morbidity and less risk of maternal severe postpartum hemorrhage.

Delivery mode of term breech presentation is still being discussed. The aim of this study was to compare the labor management of a breech presentation to a vertex presentation during a vaginal delivery attempt.It was a single-center, comparative, descriptive retrospective study from 2014 to 2017. We studied fetal heart rate (FHR) during labor and expulsion, duration of the different stage of labor, mode of delivery and neonatal outcomes for breech and vertex presentations.Two hundred and thirty-nine patients were included whom 106 (44%) breech presentation. The use of oxytocin was more common in breech group (63,2% versus 48,1%, P=0.020). Average dilatation rate was slower for breech presentation than for vertex presentation (1.9cm/h vs. 2.8cm/h; P=0.005). There was more FHR with high risk of acidosis in the breech presentations (37.2% vs 19.1%, P=0.001) and Melchior's FHR classification were comparable in both groups.The per-partum management of a fetus in breech presentation differs from a fetus in cephalic presentation. It must be known and anticipated for an optimal management in the delivery room.

Delivery mode of term breech presentation is debated because of higher rate of neonatal acidosis (pH7.15) in planned vaginal delivery than in planned caesarean section. The objective was to evaluate per-partum risk factors of neonatal acidosis in vaginal delivery for podalic fetuses.It was a single-centre, case-control retrospective study that included planned vaginal delivery in singleton term breech presentation between 2012 and 2016. The "case" group defined by neonatal pH≤7.10 and the "control" group defined by neonatal pH≥7.20 were matched. The maternal, labor, and neonatal characteristics were noted.One hundred and thirty-two patients were included: each of 44 patients in "case" group, has been matched according to breech type (legs position) to 2 patients in the "control" group, so 88. In multivariate analysis, significant risk factors identified were oxytocin use [ORa=5.663 (95% CI=1.844-17.397)], "high risk" fetal heart rate (FHR) abnormalities according to FIGO classification [ORa=10.997 (95% CI=1.864-64.866)] and FHR abnormalities during expulsion, Melchior 2 [ORa=8.088 (95% CI=1.192-54.875)] and Melchior 4 [ORa=12.705 (95% CI=1.157-139.541)].These risk factors of neonatal acidemia have to be known to improve the labor management in case of breech planned vaginal delivery.

Background Almost 20% of parvovirus B19 foetal infections require intrauterine transfusions. In addition, myocardial dysfunction has been observed in severe parvovirus B19 infections. One objective of an intrauterine exchange transfusion (IUET) is to avoid an overload during the transfusion. Our aim was to study the obstetrical and neonatal outcomes in cases of IUETs performed for foetal parvovirus infections and to compare our survival rate to those studies in which simple in utero transfusions were chosen. Study design and methods This was a retrospective monocentre study of all patients followed up for parvovirus B19 infections in which IUETs were performed. An IUET was indicated when foetal hydrops was observed and/or when severe foetal anaemia was diagnosed though an elevation in the middle cerebral artery peak systolic velocity. The characteristics of each pregnancy and the neonatal outcomes were studied until hospital discharge. Results Thirty-five IUETs were performed in 26 foetuses. The median gestational age of the first IUET was 22.6 weeks. Only one foetal bradycardia incidence was recorded during the procedure. Three medical pregnancy terminations were observed in our series, secondary to severe cerebral anomalies confirmed in the magnetic resonance imaging. Five in utero deaths occurred, in which 2 of the foetuses underwent multiple IUETs. All the neonates had normal haemoglobin levels at birth, and none were transferred to the neonatal intensive care unit. The overall survival rate was 70%. Conclusion IUETs exhibit a survival rate similar to that of simple intrauterine transfusions in foetal parvovirus infection cases.

Present challenges are to improve the diagnosis rate of oesophageal atresia (OA) and evaluate as completely as possible a fetus affected by OA, specifically the type of OA and the length of the gap. Our aim was to evaluate the accuracy of fetal MR imaging (fMRI) for diagnosis of OA. We reviewed fMRI performed because of sonographic suspicion of an OA. The signs reviewed included stomach size, “pouch sign”, bowing of the trachea and visualization of the lower oesophageal lumen. The fetuses were assigned by consensus as having or not having EA, as well as having a tracheaoesophageal fistula (TOF). All findings were correlated with postnatal data. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated. Se, Sp, PPV and NPV of the technique were respectively 91 %, 100 %, 100 % and 88 %. The presence of the pouch sign yielded corresponding values of 82 %, 100 %, 100 % and 78 %. Mid-tracheal bowing was correlated positively with EA. The type of atresia was correctly evaluated in 90 % of patients. fMRI is useful for the diagnosis of EA through the visualization of the oesophageal pouch or through associated signs such as tracheal bowing. Visualization of the lower oesophageal lumen seems to be a good sign of TEF. • Challenges are to improve the prenatal diagnosis of EA and associated malformations. • fMRI is able to diagnose EA through demonstration of the pouch sign. • Tracheal bowing is a promising indirect sign of EA. • Tracheoesophageal fistula can also be suspected thanks to fMRI. • Obstetrical US, fMRI and fetal CT are complementary for assessing associated malformations.

To evaluate de performances of noninvasive prenatal testing using cell free circulating fetal DNA (cffDNA) for the detection of fetal trisomy 21, 18 and 13 in a French population.cffDNA analysis was performed by massive parallel sequencing during a multicenter, non interventional, prospective study and the results were compared with a standard fetal karyotype.Results were available for 886 patients who have been classified as high- or moderate-risk depending on the presence of fetal abnormalities on ultrasound examination. For the high-risk group (n=376), the sensitivity and specificity of the test were 100% and 99.9% for trisomy 21, 88% and 99.9% for trisomy 18 and 100% and 99.9% for trisomy 13. The rate of other pathogenic chromosomal abnormalities with a negative NIPT was 7.9%. In the low-risk group (n=510), the sensitivity was 100% and the specificity 99.8% for trisomy 21, and only 0.4% of pathogenic chromosomal abnormalities were revealed by fetal karyotyping but not detected by cffDNA analysis.Noninvasive prenatal testing using cffDNA for high risk patients without fetal anomalies at ultrasound could be recommended in France after counseling on the possible risk of undiagnosed anomalies.

Evaluate neonatal management and outcome of neonates with either a prenatal or a post-natal diagnosis of EA type III.Population-based study using data from the French National Register for EA from 2008 to 2010. We compared children with prenatal versus post-natal diagnosis in regards to prenatal, maternal and neonatal characteristics. We define a composite variable of morbidity (anastomotic esophageal leaks, recurrent fistula, stenosis) and mortality at 1 year.Four hundred and eight live births with EA type III were recorded with a prenatal diagnosis rate of 18.1%. Transfer after birth was lower in prenatal subset (32.4% versus 81.5%, P0.001). Delay between birth and first intervention was not significantly different. Defect size (2cm vs 1.4cm, P0.001), gastrostomy (21.6% versus 8.7%, P0.001) and length in neonatal unit care were higher in prenatal subset (47.9 days versus 33.6 days, P0.001). The composite variables were higher in prenatal diagnosis subset (38.7% vs 26.1%, P=0.044).Despite the excellent survival rate of EA, cases with antenatal detection have a higher morbidity related to the EA type (longer gap). Even if it does not modify neonatal management and 1-year outcome, prenatal diagnosis allows antenatal parental counseling and avoids post-natal transfer.

Both the improvement of pathophysiological knowledge of major fetal anomalies and the development of therapeutic tools have allowed in some specific cases in utero therapy by foetoscopy. We discuss the state of art and recent advances for four major anomalies: twin-to-twin transfusion syndrome, congenital diaphragmatic hernia, myelomeningocele and lower urinary tract obstruction. Fetoscopic laser surgery for twin-to-twin transfusion syndrome has become the gold standard for treatment of TTS. In terms of fetal surgery, severe congenital diaphragmatic hernia and myelomeningocele are the two main indications, even if open fetal surgery is still the gold standard for management of myelomeningocele. New techniques using fetal cystoscopy are currently under development. Although the maternal morbidity associated with foetoscopy is low, preterm rupture of membranes and preterm delivery remain an important problem. Long-term evaluation of those neonates remains mandatory.

In case of hyperechogenic fetal bowel (HFB), invasive procedures such as amniocentesis are often proposed to detect an underlying cause. Our goal is to study etiologies and prognosis of HFB according to antenatal sonographic findings in order to evaluate the relevance of antenatal assessment.It is a retrospective monocentric study lead from 2008 to 2012, including all patients with a suspicion of HFB on routine sonography. We analysed the antenatal and neonatal results, distinguishing four situations: isolated HFB, HFB+other digestive anomalies, HFB+vascular pathology, HFB+other associated anomalies.For 149 patients, HBF was confirmed. Sixty-nine were isolated HFB, 24 associated with other digestive anomalies, 16 with vascular pathology and 40 with other anomalies. Pregnancy outcomes were different with 92.8, 41.7, 0 and 45.0% of healthy newborns. In the case of isolated HBF, we noted 2.9% cystic fibrosis and 2.9% congenital infection.Isolated HBF seems to have a better prognosis than associated forms. However, prenatal investigations to eliminate cystic fibrosis or congenital infection should be offered and may be initially non-invasive, if a larger series confirmed the absence of dyschromosomy in this population.

Analyze factors leading to isolated clubfoot's occurrence, identify clubfeet associated pathologies, and discuss the opportunity of performing an amniocentesis in cases of isolated clubfoot.Between January 2007 and December 2011, all patients diagnosed with clubfoot in our prenatal diagnostic center were retrospectively included. We then defined and analyzed idiopathic or isolated talipses equinovarus (ITEV) and clubfeet associated with others morphologic abnormalities or syndromic talipses equinovarus (STEV).One hundred and twenty-four clubfeet were analyzed. Forty-seven cases of ITEV, for which 34 caryotypes were performed with a normal result. Risk factors of ITEV in our series were male gender (P=0.0017), a family history of clubfoot (P=0.001) and primiparity (P=0.04). Seventy-seven cases of STEV were diagnosed, 14 of which had chromosomal abnormalities, 18 spina bifida and 10 musculo-skeletal abnormalities. Among the 124 cases of clubfeet, 25 were unilateral and 99 were bilateral. Bilateral talipses equinovarus do not constitute a risk factor of STEV (P=0.8).We did not find any chromosomic abnormalities in cases of ITEV. The results of our study could lead to defer systematic amniocentesis in cases of primiparous women diagnosed with an ITEV, with a familial history of clubfoot and a male fetus. A referent echographist in prenatal diagnosis should still perform a systematic morphologic echography.

Study, based on the literature, of the use of misoprostol for induction of labor in cases of second or third trimester fetal death or termination of pregnancy and define the different mode of administration.Bibliographic review using the Medline and Pubmed databases and the guidelines of the international professional societies. Selection of papers in French and English. Keywords used: misoprostol, termination of pregnancy, mid and third trimester, scarred uterus, previous cesarean section, uterine rupture.Misoprostol is effective for induction of labor in case of second or third fetal death or termination of pregnancy. Comparing to oral route, vaginal route reduces the induction-expulsion time and the rate of patients remaining undelivered in the first 24 hours without increasing side effects. Oral route is a possible alternative if preferred by the patient. Sublingual route seems interesting but data are limited. The use of moderate doses (800-2400 μg/day) every 3 to 6 hours seems to be the best compromise between efficiency and tolerance. It is not possible to recommend a specific dosing schedule. The risk of uterine rupture in case of previous cesarean section justifies the use of minimum effective dose for these patients. In this case, it is recommended not to exceed a dose of 100 μg for each dose. The induction-birth period and doses of misoprostol required to induce labor are reduced when combined with mifepristone administered 36 to 48 hours before.Misoprostol is effective and safe for induction of labor in case of second or third trimester fetal death or termination of pregnancy.

Prenatal diagnosis of esophageal atresia (EA) remains a challenge. Our objective was to evaluate the combination of sonography, magnetic resonance imaging (MRI), and amniotic fluid biochemical markers in prenatal diagnosis of EA.A retrospective study of all cases with prenatal suspicion of EA from January 2008 to May 2013 in our regional reference center was carried out. Patients were included if all the three tests were performed. For each test, sensitivity (Se), specificity (Sp), positive predictive value (PPV), and negative predictive value (NPV) were evaluated. Each test was compared using Fisher's exact test.Fifteen patients were referred at a median gestational age of 28(+5) weeks (24-36) for suspicion of EA on the basis of small or non-visualized fetal stomach bubble and/or polyhydramnios. Se, Sp, PPV, and NPV for sonographic pouch sign/MRI/biochemical amniotic fluid were respectively 40/100/100/45.5%, 80/100/100/71.4%, and 90/60/81.8/75%. MRI was the best predictive test (p = 0.007).In case of ultrasound prenatal suspicion of EA (with or without visualization of the pouch sign), an MRI at 30-32 weeks using fast imaging employing steady-state acquisition should be proposed. Biochemical amniotic fluid may be helpful and should be evaluated in a larger study.

Discuss the place of medical termination of pregnancy and palliative care in case of vascular intra uterine growth retardation.Bibliographic review using the Medline and PubMed databases and the guidelines of the international professional societies.The prognostic evaluation in case of IUGR is essential. It is based on several criteria, including gestational age and ultrasound (estimated fetal weight and Doppler). In some situations, postnatal prognosis may seem so pejorative that absence of active care can be decided with the parents. The choice can then be focused on a decision not to proceed with fetal extraction while Doppler or fetal heart rate abnormalities could justify it and "wait" for spontaneous fetal death or have a more active attitude of medical termination of pregnancy (TOP) with or without feticide or palliative care after birth. In some cases, IUGR is accompanied by maternal complications such as preeclampsia. The severity of the maternal disease may sometimes justify a termination of pregnancy for maternal rescue. That either maternal or fetal indication, these situations are often difficult to manage because of the difficulty in establishing fetal prognosis, particularly when the maternal condition requires urgent decision.In these difficult situations, ultrasound assessment must be conducted by a senior and the discussion should always be multidisciplinary. If TOP is requested by the parents, it must be discussed in a multidisciplinary center for prenatal diagnosis in accordance with French law. Maternal emergency is the only derogatory status.

The objective of this study is to highlight the factors that may affect prenatal diagnosis of transposition of the great arteries (TGA) in order to improve it.This is a retrospective study performed between 2004 and 2009 in the maternity units from North of France. We identified a total of 68 cases of TGA (isolated or associated with only VSD or coarctation of aorta), of which 32 (47.1%) had prenatal diagnosis (PND+) and 36 did not (PND-). Maternal characteristics and ultrasound factors were studied in relation to PND.Maternal weight and body mass index were significantly higher in the PND- group (70.4 kg and 26.5 kg/m(2) vs 63.6 kg and 23.6 kg/m(2) , respectively). Maternal obesity (body mass index30) was significantly more frequent in the PND- group (27.8% vs 12.5%). More than a quarter of TGA (28.1%) were diagnosed during the third trimester.Obesity is the main cause of missed PND of TGA. Obese patients with suboptimal prenatal scans may benefit from reassessment of fetal cardiac anatomy and/or from referral for fetal echocardiography.

Esophageal atresia (EA) is a rare congenital malformation (1 in 2,500 to 3,500 births). Prenatal diagnosis (PN) is particularly interesting allowing search for associated malformations related to worse prognosis forms (reference ultrasound, MRI and amniocentesis) and planning the birth in an adapted medico-surgical center. Diagnosis of EA is usually suspected because of indirect and non-specific signs: association of polyhydramnios and absent or small stomach bubble. The visualization in ultrasound or MRI of cervical or thoracic fluid image corresponding to the expansion of the bottom of upper esophageal ("pouch sign") increases the specificity of diagnosis. However, prenatal diagnosis remains difficult and less than 50 % of EA are diagnosed prenatally. Biochemical analysis could improve these results. If EA is confirmed at birth, surgical management consists in a primary end-to-end anastomosis in first days of life, or in two-steps surgery if the defect is too large. Although current prognosis of EA is good, frequency of surgical complications and esophageal lesions secondary to gastroesophageal reflux justify a systematic and multidisciplinary extended follow-up.

Congenital diaphragmatic hernia has a physiopathology unfully understood, and is the cause of an important morbimortality. We report the case of a fetus suffering from a diaphragmatic hernia associated with a EDNRA gene triplication, coding for the endothelin 1 receptor. High-resolution genetic techniques were able to find the possible origin of this pathology, and showed that it was an isolated form with a good prognostic. ET-A receptor over-expression in lung vessels may cause a vascular remodeling and a lung arterial high blood pressure. This lung abnormality would have occurred before the diaphragmatic defect.

To list ultrasonography signs identified when a placenta accreta is suspected. Secondary objectives are to analyze the relevance of diagnosis with ultrasonography and magnetic resonance imaging, and to know diagnosis circumstances in order to identify main risk factors.We present a monocentric retrospective study. All the cases of placentas accreta, observed from 2005 to 2010 at Lille University Hospital (France), have been included.Twenty-seven patients had a placenta accreta during this period. There was an antenatal suspicion for 22 cases and 21 were confirmed after delivery. Six cases were discovered per-partum. Diagnosis was suspected after metrorrhagia for 41% of women. In case of antenatal diagnosis, 100% of the patients had an anterior placenta praevia and an uterine scare. Fifty percent of the placentas accreta diagnosed per-partum were posterior. The most frequently ultrasonography signs are "intra-placental lacuna" (85.7%), "abnormal vascularization" (71.4%), "loss of normal hypoechoic retroplacental myometrial zone" (66.7%), "irregularity of the vesical wall" (66.7%). Sensibility of ultrasonography screening is 78%. Twenty-one magnetic resonance imaging examinations executed secondarily confirmed the diagnosis in 66.7% of the cases.Ultrasonography is a relevant exam for the diagnosis of placenta accreta. Posterior placenta should not be forsaken. Anterior placenta praevia in multiparous patients with a uterine scare should be a warning.

The poisoning of carbon monoxide (CO) is the leading cause of death by poisoning in France. Its consequences are potentially serious to the fetus. Literature is ancient and little known.Make an inventory of knowledge about carbon monoxide poisoning during pregnancy.The CO causes maternal then fetal tissue hypoxia primarily by binding to hemoglobin with which it has a high affinity. Its transplacental passage may cause fetal harm, predominantly in the brain. Severity seems correlated with maternal symptoms during exposure. In the absence of maternal symptoms, however, the available data are reassuring. Hyperbaric oxygen therapy may reduce the risk to the fetus.Oxygen therapy should be offered in all cases of CO poisoning, especially if there are maternal symptoms during exposure. In addition, a fetal echography directed on the cephalic pole - even a fetal magnetic resonance imaging three weeks after exposure - should also be proposed.

Toxoplasmosis is a cosmopolitan zoonose led by an intracellular protozoon, Toxoplasma gondii. Severe fetal consequences can be encountered in case of infection during pregnancy. Since 1978, a specific screening program has been implemented in France during pregnancy. The purpose of our study is to evaluate the fetal consequences of a maternal contamination during the periconceptional period.We retrospectively analyzed, over a 10-year period, the outcome of all the pregnancies with a suspicion of periconceptional seroconversion. Periconceptional seroconversion was defined as infection occurring during the two months prior to or following the assumed date of the conception. The obstetric care, the fetal ultrasound scan and the neonatal features were all closely looked at.Seventy-nine patients (81 fetus) showed evidence of the diagnosis criteria of periconceptional infection. Three cases (3.8%) of congenital infection were observed: two late miscarriages (at 15 weeks and 24 weeks) and one case of an alive child with infraclinic toxoplasmosis.In our study, the rate of congenital toxoplasmosis (3.8%) in the event of a periconceptional infection is slightly above the rate previously described in the literature (0.6 to 3.3%). The rate of miscarriage is also high: 66% in case of congenital infection. A regular ultrasound follow-up until the end of the pregnancy is necessary to ensure the best care available. The decision whether to carry out an amniocentesis is discussed in that case.

Invasive prenatal diagnosis procedures are numerous and more or less painful and stressful. The purpose of this study was to investigate maternal perception of both anxiety and pain before and after amniocentesis (AC) or transabdominal chorionic villus sampling (CVS), to determine factors associated with pain and anxiety, and to evaluate the pain support. This is a prospective study evaluating the professional practices at CHRU of Lille between March and May 2009 with 132 AC and 22 CVS by aspiration. An original questionnaire has been elaborated in three parts: the first one fulfilled by patients before the procedure, the second one, after the procedure, and the last one by the medical team. Statistical comparisons have used the Chi(2) test, the Fisher exact test, the Student's t test and the U test of Mann Whitney.The anxiety level is high but does not differ between the two groups AC and CVS. CVS are more painful than AC (EVA 5.77 versus 3.07, P0.0001). No predisposing factor for anxiety has been found. On the other side, procedures are more painful when they are long lasting, considered difficult by the medical team, when needles used are large, the number of needle insertions increases, puncture is performed along a side of the uterus, patients are anxious, and then procedure indication is an hygroma. Patients are satisfied in 98.7% of cases of the support of the medical team. Few drug treatments was prescribed (only 4.5%), however, patients are generally applicant.An analgesic, anxiolytic, or a relaxation technique can be proposed to anxious and applicant patients undergoing CVS. Technical conditions of the procedure are more difficult to improve, however, we should use if possible thinner needles, and avoid, wherever technically possible, the punctures on the lateral side of the uterus. Finally, further studies seem necessary for the evaluation of a treatment protocol.

To evaluate the prenatal diagnosis and the prognostic value of ultrasound in case of fetal hyperechogenic kidneys.Seventeen prenatally diagnosed cases of hyperechogenic kidneys were retrospectively reviewed at the University Hospital of Lille from 1997 to 2008. The clinical and ultrasound data were compared to the postnatal follow-up and the long-term prognosis.The aetiologies are nine recessive polycystic kidney diseases, three dominant, two Bardet-Biedl syndromes and three cases of transient renal hyperechogenicity. No renal ultrasonographic criterion is specific of aetiology. Five pregnancies were terminated. We observed one neonatal death and 11 survivors (median follow-up: 30months) including two infants with hypertension. All oligohydramnios (n=8) were associated with poor prenatal outcomes (terminations of pregnancy, neonatal death or hypertension) compared to the other nine with normal amniotic fluid volume (nine children symptom-free). Kidneys less or equal to +4 S.D. and a normal amniotic fluid volume were associated with a good prognosis (n=7, seven symptom-free).The fetal kidneys characteristics on prenatal ultrasound fail to provide an accurate etiological diagnosis. Only congenital defects and family history adjust the aetiology. Amniotic fluid volume and fetal kidney size are the best prenatal predictors of outcome.

Improvement in prenatal diagnosis of Down syndrome imposes to sonographers to realize good quality nuchal translucency measurements, which can be used for assessment of combined risk. The aim of our study was to evaluate a training program of 109 sonographers for measuring nuchal translucency and scoring their own image.After a proximity training program, trainees submitted 20 images scored by themselves with Herman image-scoring method. All images were reviewed by two experts.One hundred and nine sonographers have accomplished the training program (87.3%), collecting 2162 images. After reviewing, the mean score was 6.8+/-1.8. The rate of inacceptable scan (scoreor =3) was in 6.0%. On the other hand, 48.1% of scans were excellent (scoreor =8). Only 6.5% of scores were discordant for at least three points between self-scoring and reviewing. After the fourth scan, there was no significant scoring difference between self-scoring and reviewing. Finally, 84% of trainees were very satisfied of this program.As part of HAS evaluation of practitioners practices, it is possible to realize proximity training program for measuring nuchal translucency. Learning curve seems to be fast. Good handling of Herman scoring method by sonographers allows their accreditation after this kind of training program.

To define where should twin pregnancies be managed and delivered.A literature search was performed using the Pubmed and Cochrane database. Foreign societies guidelines were also consulted.There is little or no evidence to answer the question. Risk of premature labor and chorionicity are the two main factors involved in twin management. When there is a risk of prematurity, in utero transfer is recommended. Twin care must be performed by a team trained in the specificity of management according to chorionicity. There is not enough evidence to support specialized clinics. Labor and delivery need permanent and immediate disponibility of a perinatal team including an OB-gyn, an anesthesiologist and a pediatrician.Needs assessment and chorionicity are the best indicators to define the optimal place of care and delivery for twin pregnancies. More than a specific location, it seems more logical to define all necessary means to enforce an optimal management of these pregnancies.

Ultrasonography is an essential tool in the management of twin pregnancies. Fetal weight estimation is useful to anticipate neonatal care in case of prematurity, growth restriction or growth discordance. The aim of this study was to evaluate the accuracy of ultrasound fetal weight prediction in twin pregnancies.Two hundred and twenty-four patients with an ultrasonography within 7 days before birth were retrospectively studied. Estimated fetal weight (EFW) was calculated with the Hadlock's formula and was compared with birth weight (BW). Growth restriction and growth discordance superior or equal to 25% between the first (T1) and the second twin (T2) were recorded.Absolute differences between EFW and BW were similar for both twins (127g [56.25-210] for T1 and 110g [50-206.25] for T2). Mean absolute percentage error was 5.41% (2.32-9.65) for T1 and 5.64% (2.46-10.37) for T2 and was superior to 10% for 24% of T1 and 27% of T2. Gestational age inferior to 32 weeks, obesity and oligoamnios were associated with a better accuracy of ultrasonography. Chorionicity as well as fetal presentation did not influence fetal weight estimation. Ultrasonography in the diagnosis of growth restriction had a sensitivity of 82%, a specificity of 76%, a positive predictive value (PPV) of 22% and a negative predictive value (NPV) of 98%. For diagnosis of growth discordance, sensitivity was 72%, specificity 95%, PPV 72% and NPV 95%.Fetal weight can be accurately predicted in twin pregnancies. The contribution of ultrasonography in the diagnosis of growth restriction and growth discordance is mainly due to a high NPV.

The purpose of this study was to describe outcome of subsequent pregnancy after preeclampsia or HELLP syndrome during the first pregnancy and to evaluate potential risk factors for gestational vascular complications.Follow-up data were obtained from 445 women who were delivered between March 1996 and December 2006. Medical records of the index pregnancy and subsequent outcomes were available for review. To have adequate time to study subsequent pregnancy outcome, only patients who were delivered2 years before the analysis were included.There were 151 subsequent pregnancies of which 142 pregnancies progressed beyond 20 weeks of gestation. The median duration of follow-up was 6 years (range: 2-9 years). Thirty-nine (27.5%) had a gestational vascular complication. Preeclampsia reoccurred in the second pregnancy in 20 women (51.3%), HELLP syndrome developed in three of these pregnancies. Gestational hypertension occurred in 14 patients (35.9%) and abruptio placentae in one (2.6%). Four of the newborn infants (10.3%) were small for gestational age (3(rd) percentile). Obesity, delivery32 weeks of gestation and small for gestational age newborns at index pregnancy were related to a higher incidence of gestational vascular complication during the subsequent pregnancy.Patients with a history of preeclampsia or HELLP syndrome during the index pregnancy are at increased risk for obstetric complications in subsequent pregnancies.

To evaluate the management and outcome of pregnancy in women with essential thrombocytemia.We conducted a retrospective study including all the pregnant women with essential thrombocytemia followed between January 2000 and January 2008 in a University Hospital (hôpital Jeanne-de-Flandre, Lille, France). We report our experience of 18 pregnancies in 13 women. The management and the complications of these pregnancies were reported.All the patients were treated with low dose aspirin during the pregnancy. We observed one intrauterine death, one premature delivery at 29 weeks of gestation and six maternal haemorrhages at delivery (33%).It is essential to treat these patients with low dose aspirin as soon as the pregnancy begins. Aspirin will be continued in postpartum with anticoagulant treatment. This management appears to improve the obstetric outcome and decrease the thrombotic complications usually described. A national register seems to be necessary to evaluate the complications occurring during pregnancy and the optimum follow-up.

We describe an acute onset of diabetes mellitus during third trimester of pregnancy revealed by ketoacidosis, complicated by fetal death, which could evoke fulminant type 1 diabetes, a novel subtype of type 1 diabetes first described in Japan and rarely described in Caucasian people. Diagnosis of diabetic ketoacidosis could be made on simple signs as abdominal pain, vomiting or ketone bodies on urinary multistix. Capillary glycaemic control is necessary to distinguish fast from ketoacidosis. The treatment of this severe imbalance must be initiated in emergency.

Isolated congenital heart block is linked to transplacental passage of maternal anti-SSA/Ro and/or anti-SSB/La antibodies that may be related to a connective tissue disease. Ultrasonography and Doppler are essential to screen fetus at risk. They allow the diagnosis of first- and second-degree blocks which are probably preliminary stages in conducting tissue's injury. In these situations, a maternal treatment by fluorinated steroids can be proposed because of its possible effect on partial blocks. However, these early signs of nodal injury can be lacking: some fetus present a complete heart block without previously detected less advanced block. Moreover, the significance of first-degree block is unclear since it could reverse spontaneously. Other markers of nodal injury would be valuable. In case of complete congenital heart block, ultrasonography is useful to detect congestive heart failure and help the obstetrical management when unfavorable prognostic signs occur.

Intrapartum asphyxia is increased in several situations such as intrauterine growth retardation, preterm labor, postdate pregnancy or maternal diabetes. In all these cases, fetal heart rate monitoring should be preferred to intermittent auscultation. Fetal scalp blood pH or lactates can be used to identify fetuses at risk of intrapartum asphyxia. However, fetal scalp blood sampling should not delay delivery in case of severe abnormal fetal heart rate as fetal asphyxia could occur rapidly in theses high-risk pregnancies. Data is insufficient to recommend fetal pulse oximetry or ECG analysis. Research should be undertaken to evaluate their performance in these situations.

Early premature rapture of the membranes (PROM) during pregnancy is associated with a high risk of perinatal morbidity and mortality. Early PROM impairs lung structures and function through 3 mechanisms : 1) oligo-hydramnios ; 2) fetal inflammatory syndrome ; and 3) prematurity. Thus, the related causes of respiratory failure at birth after PROM are: hyaline membrane disease, persistent pulmonary hypertension induced by impaired endothelial function and/or lung hypoplasia, materno-fetal infection, and bronchopulmonary dysplasia resulting at least in part from the fetal inflammatory syndrome. Severity of the respiratory morbidity is largely unpredictable. Even if gestational age at PROM is considered as a prognostic factor, survival without morbidity exist after PROM as early as 18 weeks GA. Better knowledge of the pathophysiology improved the outcome of the preterm infants born after early PROM. Optimal management of the respiratory failure including minimizing barotrauma is required to prevent from bronchopulmonary dysplasia.

Exclusive hepatocele is defined as a hernia containing in majority the liver with possibly some intestinal loops. This study was undertaken to evaluate neonatal morbidity and mortality in this series of exclusive hepatoceles.We reviewed 11 cases of exclusive hepatoceles with delivery at the hospital Jeanne-de-Flandre in the CHRU of Lille, in France.The mean gestational age of diagnosis was 14.5+/-3.4 weeks of gestation. Karyotype determination was performed in 100% of cases: it was abnormal in one case of 11. One termination of pregnancy was performed because of trisomy 13. The mean gestational age at delivery was 38+/-1.8 weeks of gestation. Cesarean deliveries were performed in nine cases. Morbidity was important with: one case of fetal growth retardation on total hepatocele, three cases of severe respiratory distress, two cases of severe digestive complications. The mean length of stay was 42.8 days. The mean length of parenteral feeding was 14.4 days. Postnatal mortality concerned one child, which died because of a severe respiratory distress due to pulmonary hypoplasia.In this series, morbidity is thus important, making of exclusive hepatoceles a full entity among the omphaloceles. The multidisciplinary take care is more complex but conceivable.

To assess the effect of the twin-to-twin delivery interval on the umbilical cord blood gas status and the neonatal outcome of the second twin following vaginal delivery.Retrospective study of twin deliveries at or beyond 34 weeks of gestation over a period of five years. The correlation between the twin-to-twin delivery interval, and the umbilical arterial blood gas parameters of the second twin, including pH, PO(2), PCO(2), HCO(3-) and base excess, was studied. A second analysis was performed after exclusion of non-vertex presentation, need for general anesthesia, growth restriction and weight difference between the twin30%.Two hundred and thirty-nine patients were studied. The mean twin-to-twin delivery interval was 11.3+/-6.4 minutes (between 6 and 14 minutes in 56.1% of cases). The second twin had more Apgar score7 at 1 minute (P0.02) and more arterial ombilical pH7.20 (P0.01) than the first twin. Over 15 minutes, the mean arterial pH was lower (P0.01) and the number of arterial pH7.20 increased (P0.03). In contrast, the mean Apgar score and the rate of neonatal transfer did not differ significantly. There were significant negative correlations between arterial pH, base excess and bicarbonates and the twin-to-twin delivery interval (P0.05). Similar results were found in the homogenised population. The reduction in the second twin arterial pH was expressed as pH=7.282-0.003 x time.Umbilical cord arterial blood gas parameters deteriorate with increasing twin-to-twin delivery interval. Our results suggest that this interval should be less than 15 minutes, but obstetrician should adapt to every clinic situation.

Placental abruption is a syndrome, which occurs in the third trimester of the pregnancy or during labour. It is the main cause of pregnancy last term bleeding and is also responsible for a high stillbirth rate. The objective is to describe the epidemiological, clinical, paraclinical and therapeutic characteristics in order to decrease the fetal and maternal mortality and morbidity.It is a prospective and descriptive study in continuous series, over a twelve-month period, from 1st January 2003 to 31st December 2003, at Issaka Gazobi maternity of Niamey, Niger.During the study period, 3255 deliveries have been done. One hundred and eighteen placental abruptions have been observed, which corresponds to a frequency of 3.6% with the highest rate during raining season. The average age and parity were: 31 years and 5th with a predominance of grand multiparous (38.2%). The majority of the patients were in-utero transfers (83,1%) and had done at least 10 km before arriving. One hundred and eleven patients had a caesarean section (94,1%) and 7 delivered through the vaginal route (5.9%). The fetal prognosis was characterized by a high stillbirth rate of 71.3% (87/122), fetal hypotrophy (64.8%) and prematurity (23.8%). The main cause of maternal morbidity was anaemia (76.3%) and Disseminated Intravascular Coagulation (5.9%). Further, 81 patients have been transfused (68.7%). The maternal mortality was 5.1% (6/118).Placental abruption, a medical and obstetrical emergency, is a serious obstetric condition, especially in our country. Physicians must be aware that patients with high blood pressure, preeclampsia, eclampsia, particularly in case of multiparity are at increased risk of placental abruption. Early diagnosis, prenatal follow-up and caesarean section improve the maternal and fetal prognosis.

The aim of our study was to evaluate the possibility of identifying the fetal RhD status in maternal plasma using conventional hemi nested PCR analysis.After informed written consent, 20 mL of peripheral blood were collected in 99 D-negative pregnant women either at an amniocentesis for prenatal diagnosis or at a prenatal checkup. Fetal DNA extracted from 400 microL of maternal plasma was analyzed by two different operators with a hemi-nested PCR extending an area of the RhD gene exon 10. The results were compared to the fetal RhD status obtained by PCR amniotic fluid analysis or blood analysis of newborns after delivery. The influence of mother's and baby's phenotype were also studied.Among the 99 D-negative pregnant women, all Caucasian, 47 were in their second trimester and 52 in their third trimester (mean: 27.20 weeks of gestation +/-8.25). Sixty-nine fetuses were D-positive and thirty D-negative. The sensitivity and specificity of our technique were respectively 100% and 86.7% and 15% of discordant results were observed between the two operators. Four false positives were observed. According to maternal phenotype, a fetal unexpressed RHD gene was suspected in only one case because of a particular fetal phenotype (ddCcEe).A conventional hemi nested PCR analysis of maternal plasma could be used for accurate fetal RhD status. However this procedure is difficult to apply for routine analysis because of the importance of anti-contamination measures required to obtain good results. Real time quantitative PCR analysis on fetal DNA is more suitable. Whatever the operating procedure used, polymorphism of RhD gene may follow in either false negative from presence of rearranged gene or false positive from occasional presence of a non functional RHD gene.

Amniotic fluid embolism is a rare, unpredictable and often lethal complication of pregnancy and childbirth. Because of its variable presentation, an early biologic test would help to establish the diagnosis. We investigated in maternal serum 4 components of amniotic fluid, i.e., alpha-fetoprotein (AFP), l'insuline like growth factor binding protein-1 (IGFBP-1), fetal fibronectin (fFN) and placental alpha1-microglobulin (PAMG-1). On the 6 cesareans controls involved, none of the makers increased after membranes section. PAMG-1 is unsuitable because its detection is always positive or doubtful even in the baseline. On the 7 cases suspected of amniotic fluid embolism, no detectable increase in any of those markers was noted in 3 cases, which is not in favour of this diagnosis. In the remaining cases, IGFBP-1 and fFN became detectable, confirming histological evidences of amniotic fluid embolism in 2 cases. The follow up of those markers in maternal blood confirmed the suspicion of amniotic fluid embolism at 21 wg in one case of ongoing pregnancy. These preliminary results point out the potential interest to assay maternal serum AFP, IGFBP-1 and fFN to confirm amniotic fluid embolism using rapid laboratory tests.

The ex utero intrapartum treatment (EXIT) procedure is a surgical procedure maintaining utero-placental circulation during caesarean section. Anaesthetic implications are described: foetal transplacental anaesthesia to avoid first breathing and to permit surgical procedure on obstructed foetal airway, deep maternal haemodynamically stable anaesthesia to relax uterine smooth muscle during a long caesarean procedure but avoiding post-partum haemorrhage. Volatile anaesthesia with sevoflurane seems to be adequate for these aims. Two cases are described.

We report five cases of vomiting associated with a very important increase of maternal plasma uric acid (595 mmol/l, 100 mg/l) at the third trimester of pregnancy. In all cases, elevation was transitory and regressive with rehydratation. Pregnancies proceeded normally to term and delivered healthy babies. An important rise of plasmatic uric acid during pregnancy can be found in severe hypertensive disorders (preeclampsia, HELLP syndrome, acute fatty liver). Nevertheless, it can be related to transient renal insufficiency without any severe pathology. In our five observations, digestive disorders seem to be the reason for this phenomenon and spontaneous prognosis was excellent in all cases.

To study the effects of increased gestational weight gain in women of normal prepregnant weight.We compared 174 patients gaining more than 18 kg to 174 patients gaining between 9 and 15 kg. Body mass index was normal for every woman included in the study.Weight gainor =18 kg was associated with increased risk of vascular complications (5.2% vs. 1.1%, P0.05) but not with increased risk of mellitus diabetes (5.2% vs. 4.0%, NS). Weight gainor =18 kg prolonged labor length (414.4 +/- 147 min vs. 376.5 +/- 166.4 min, P0.05) and increased the rate of cesarean section (19.5% vs. 10.3%, P0.05). Neonatal outcome was similar in both groups, mean birth weight was greater (3413.6 +/- 427.0 g vs. 3163.4 +/- 495.1 g, P0.05) and the frequency of infants weighing more than 4000 g at birth was increased (8.0% vs. 4.0%, P0.05) among women gaining more than 18 kg.Excess weight gain in pregnancy affects gestational and delivery outcomes and results in higher frequency of fetal macrosomia. These results confirm recommendations on weight gain in pregnancy as guidelines for pregnant women.

Pericardial teratoma is a potentially curable lesion that may become life threatening when it induces mediastinal compression and fetal hydrops. So far, cases with fetal hydrops have been managed by elective delivery or pericardial needle decompression. We report a case in which pericardial teratoma resulted in fetal hydrops. Following transpleural needling of the fetal pericardium at 29 weeks and 6 days, pericardial effusion decreased but hydrops persisted, while major unilateral pleural effusion appeared. A thoracoamniotic shunt was placed at 30 weeks and 5 days. Hydrops resolved, although incompletely. The baby was delivered at 32 weeks and was operated upon on day 3. This observation suggests that fetal hydrops associated with pericardial teratoma may improve following thoracoamniotic shunting. Fetal therapy may limit the risks of respiratory distress arising from the combined effect of airways compression and lung immaturity.

Rate scales are used to analyse urinary incontinence. There are many scales making it difficult to compare the different studies of urinary incontinence. The purpose of this study was to evaluate and compare the rate scales pertaining specifically to urinary incontinence.A review of the literature was performed for publications specifically addressing rate scales of urinary incontinence. Each scale was evaluated using the following four criteria: principal characteristics (reference source, number of items addressed, scoring method, language), objectives (type of incontinence, severity and quality of life measures), psychometric properties (scientific validity, reliability and responsiveness) and linguistic validation.Thirteen scales were identified. These were divided into two groups: (1) those based on "classifications" and (2) those based on specific questionnaires. Scales based on classifications were not precise and are never scientifically validated. Scales based on questionnaires were more elaborate and more detailed; nevertheless, the study of their psychometric properties was often incomplete.Classification-based rate scales are inadequate to analyse urinary incontinence. Questionnaire-based rate scales are superior, but at minimum, they should address the previously stated objective and psychometric criteria. The choice of questionnaire should depend on whether it is to be used in clinical practice or for research protocol.

Our objectives were to link hyperemesis gravidarum with biochemical hyperthyroidism and hormonal modification (HCG and estradiol) and to test the hypothesis that biological abnormalities (ionogram and liver enzyme) are more often reported in hyperemesis gravidarum with biochemical hyperthyroidism.Thirty three patients admitted in "Hôpital Jeanne de Flandre" with hyperemesis gravidarum were studied prospectively.Twenty-two patients (66.7%) had biochemical hyperthyroïdsm (suppressed thyroid stimulating hormone or increased triiodothyronine index or tetraiodothyronine index). Hyperthyroid patients were more likely than euthyroid patients to have abnormal electrolyte levels (16/22 [72.7%] vs 3/1 [27.3%], P0.02) or increased liver enzyme levels (8/22 [36.4%] vs 3/11 [27.3%]). The severity of hyperemesis was found to vary directly with the degree of hyperthyroidism. We report a female predominance among the offspring of mothers with hyperemesis gravidarum.Our results are suggestive of the involvement of hyperthyroidism and fetal sex in the pathogenesis of hyperemesis gravidarum. Also these hypothesis are not clearly understood, human chorionic gonadotrophin occurred in the two mechanisms.

One of the major progress in fetal medicine in recent years is the increased sensitivity of sonographic screening for foetal malformations, due to technical improvement but also to a better training of professionals. Screening for chromosomal abnormalities is no longer based on maternal age alone. Second trimester maternal serum screening (MSS) is increasingly used: thus in 1997, 376,798 MSS tests were performed in France, yielding to the prenatal diagnosis of 391 cases of Down's syndrome. First trimester sonographic nuchal translucency measurement (NTM) is an effective screening method when performed under stringent conditions. Quality control however, is more difficult to implement on a large scale for NTM than for MSS. Performing screening tests sequentially carries a danger of generating an unnecessarily high number of amniocentesis, which may be obviated by a rational calculation of an individual's risk to carry an aneuploid baby. First trimester MSS is expected to become standard practice in the next years, probably in combination with NTM. Cytogenetics underwent substantial innovations recently, due to the ever-increasing use of molecular cytogenetics. FISH techniques allow: 1) precise analysis of unexpected structural chromosomal abnormalities diagnosed by routine amniocentesis, 2) rapid screening of the most common aneuploidies by amniocentesis when a fetal structural anomaly is detected by 3rd trimester ultrasound, 3) diagnosis of micro-deletions suspected by fetal ultrasound or post-mortem. Prenatal diagnosis by maternal blood sampling and fetal cells or DNA analysis is now part of routine clinical practice in selected cases, such as fetal sexing in families affected by an X linked disease. Thus one can select those pregnancies eligible to invasive prenatal diagnosis. Pre implantation diagnosis, which has not been legal in France until 1999 is now increasingly used as an alternative to first trimester diagnosis. As for fetal therapy, a major recent breakthrough is the prenatal management of twin to twin transfusion syndrome by either amnioreduction or laser coagulation of inter-twin vascular shunts. In addition, new pathophysiologic concepts involving the renin angiotestin system could lead to further therapeutic innovations. A European randomised trial is now being completed to establish the respective indications of drainage and Laser. All this underscores that fetal medicine is no longer solely a succession of dramatic technical breakthroughs, but is entered an era of large-scale diffusion that requires evidence based evaluation.

Mechanisms that modulate fetal pulmonary circulation and transitional circulation at birth are incompletely understood. The aim of this experimental study was to describe an animal model in order to study the perinatal pulmonary circulation.Pregnant ewes were operated on between 126 and 128 days gestation (term = 145 days). A skin incision was performed to the fetal lambs in utero and catheters were placed into the ascending aorta and the superior vena cava after insertion in the axillary artery and vein. Then, catheters were inserted into the left pulmonary artery (LPA), main pulmonary artery, and left atrium via a thoracotomy. Moreover, an ultrasonic flow transducer, and an inflatable vascular occluder were placed around the LPA and around the ductus arteriosus. During 10 days, studies were performed in utero (possibly continued when fetal lambs were delivered by caesarean section). This chronically prepared animal may be used to perform hemodynamic studies according to different protocols (drugs injection to the fetus or to the ewes, ductus arteriosus compression, oxygen test). The main pulmonary artery, aortic, left atrial and amniotic pressures, heart rhythm, and flow signal were continuously recorded.Eighteen pregnant ewes were operated on and nine only could be used for experimentation. This ovine model permitted several studies, particularly about effects of catecholamines on the pulmonary circulation, and about effects of ductus arteriosus compression on the pulmonary circulation.Chronically instrumented fetal lambs are an excellent model in order to study the perinatal pulmonary circulation.