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The internist has a role to play in the practical approach of HELLP syndrome, a disease which can differ according to its symptoms, course and causes. Any recent epigastric pain during the end of pregnancy must be considered as a symptom of HELLP syndrome. Liver disease together with thrombocytopenia may be present even without any renovascular involvement. The disease can be threatening for the mother and lead to the foetal death. It can be sometimes difficult to be distinguished from thrombotic microangiopathy. Treatment consists mainly in rapid discontinuation of pregnancy. Steroid therapy could allow to simplify anaesthesia procedures and to avoid blood transfusion. Early-onset HELLP syndrome could be a marker a chronic nephropathy or a thrombophilic disorder. The HELLP syndrome is a very demonstrative example of the help the internist can afford to the obstetrician in the management of pregnancy-associated disorders.

To compare the efficacy and safety of atosiban and salbutamol in the treatment of preterm labor.A multicenter, double-blind, double-placebo, randomized, controlled trial. Women (n=241) diagnosed with preterm labor at 23-33 gestational weeks were enrolled and received either atosiban (n=119) or salbutamol (n=122). At randomization, women were stratified by gestational age (or =28 weeks and28 weeks). Atosiban (i.v. bolus dose of 6.75 mg, then 300 microg/min for 3h and 100 microg/min for up to 48h) and salbutamol (2.5-45 microg/min) were administered by i.v. infusion for up to 48h. Retreatment with study drug or an alternative tocolytic agent was allowed. Main outcome measures included tocolytic effectiveness which was assessed in terms of the number of women undelivered after 48h and 7 days. Tocolytic efficacy and tolerability were assessed in terms of the proportion of women undelivered and who did not require alternative tocolytic therapy at 48h and 7 days of starting treatment. Safety was assessed in terms of maternal side effects and neonatal morbidity.Tocolytic effectiveness at 48h was 93.3 versus 95.0% (P=0.67) and after 7 days was 89.9 versus 90.1% (P=0.93) in the atosiban and salbutamol groups, respectively. Tocolytic efficacy and tolerability within 48h was 79.8 versus 75.2% (P=0.15), and after 7 days was 58.8 versus 46.3% (P=0.021) in the atosiban and salbutamol groups, respectively. Maternal adverse events, including serious events, occurred more frequently in the salbutamol group. Neonatal outcomes were comparable between the study groups.The oxytocin antagonist atosiban was found to be better tolerated by both mother and fetus than salbutamol, with a comparable neonatal and infant safety profile, and atosiban was as effective as salbutamol in delaying threatened preterm birth. This study supports the clinical use of atosiban in the treatment of preterm labor.

Objective: To determine if external cephalic version (ECV) is a reasonable alternative to repeat cesarean section in case of breech presentation. Study design: Retrospective study of 38 women with one previous cesarean section and a breech presentation after 36 weeks of gestational age who have had at least one experience of ECV. Statistics used the Fisher's test with significance when P

Objective: To show that intrapartum prophylactic amnioinfusion (AI) in case of oligohydramnios or particulate meconiumstained amniotic fluid could be beneficial. Study design: From the first March 1993 until the 30th June 1995, 4031 women were delivered at the University Hospital of Poitiers. Patients presenting with oligohydramnios (G1) (71 patients with an amniotic fluid index below 5 cm) or a particulate meconium-stained amniotic fluid (G2) (64 patients) were included. Each group was compared to an historical control group constituted retrospectively according to the following criteria: oligohydramnios (CG1), particulate meconium-stained amniotic fluid (CG2)), age, parity, gestational age and duration of labor. Statistical analysis was performed using the Student's t-test and the Fisher's exact test when appropriate with a level of significance of P less than 0.05. Results: The mean infused volume was 893 ml in G1 and 734 ml in G2. A significant difference was found in terms of cesarean section between G1 and CG1 (11.3 vs. 24.5%; P < 0.05) and of assisted deliveries for fetal distress between G2 and CG2 (12.5 vs. 23.43%; P < 0.05). No other significant difference was found between the study groups and their control for all other studied criteria. When considering more specifically the presence of meconium below the vocal cords we also could not find any significant difference between G2 and CG2 (1.6 vs. 9.4%; P = 0.05). No neonatal or maternal adverse effect happened in this short study. Comment: AI is easy to perform during labour in case of oligohydramnios or particulate meconium-stained amniotic fluid. In case of oligohydramnios, a decreased rate of cesarean sections has been observed in the infused group. Considering patients with particulate meconium-stained amniotic fluid, less interventions for fetal distress and neonates with meconium below the vocal cords has been found in the infused group. Further prospective evaluation is needed to confirm these results in case of particulate meconium-stained amniotic fluid and to compare the advantage of prophylactic versus therapeutic AI performed in case of oligohydramnios and abnormal fetal heart rate.

There is no consensus concerning thromboembolic prophylaxis in high-risk pregnant women with a previous his tory of heparin-induced thrombocytopenia. An alternative an ticoagulant therapy is danaparoïd, whereas unfractioned and low-molecular-weight heparin therapy is contraindicated. We report a case of successful thrombosis prophylaxis using dan aparoid in a high-thrombosis-risk pregnant woman with a his tory of heparin-induced thrombocytopenia during a previous pregnancy and Widal's disease.

The internist has a role to play in the practical approach of HELLP syndrome, a disease which can differ according to its symptoms, course and causes. Any recent epigastric pain during the end of pregnancy must be considered as a symptom of HELLP syndrome. Liver disease together with thrombocytopenia may be present even without any renovascular involvement. The disease can be threatening for the mother and lead to the foetal death. It can be sometimes difficult to be distinguished from thrombotic microangiopathy. Treatment consists mainly in rapid discontinuation of pregnancy. Steroid therapy could allow to simplify anaesthesia procedures and to avoid blood transfusion. Early-onset HELLP syndrome could be a marker a chronic nephropathy or a thrombophilic disorder. The HELLP syndrome is a very demonstrative example of the help the internist can afford to the obstetrician in the management of pregnancy-associated disorders.

We report two cases of maternal diaphragmatic hernia during pregnancy. Diaphragmatic hernia is an unusual and severe disease. Maternal and fetal prognosis are threatened. Diagnosis is uncertain when confronted to respiratory and digestive symptoms without any specificity. The chest X ray is the first exam to perform. The objective of this work is to discuss the management of such a pathology in terms of ways of delivery and surgical cure of hernia.

To investigate the frequency of main symptoms of Obstructive Sleep Apnea Syndrom (OSAS) and their relationship with Pregnancy Induced-Hypertension (PIH) as well as Intrauterine Growth Retardation (IGR) as suggested by recent studies.Four hundred (and) thirty-eight enquiry forms completed during post-partum period were analysed, after exclusion of multiple pregnancies. Collected data were demographic characteristics, obstetrical events, sleep disorders during last trimester, screening of snoring and vigilance troubles with an Epworth score.Forty-five percentages of the patients reported to have habitual snoring during pregnancy. Among these, 85% were non-snorers before pregnancy. Daytime somnolence concerned 84,5% of the population with an Epworth score significatively increased (P0,0001). The prevalence of PIH was found to be 4,5%, with two apparently independent risk factors: the body mass index (OR=1,1) and an association between snoring and increased vigilance trouble (OR=2,6). No statistical difference was found concerning IGR.SAS symptoms are frequent during pregnancy and snoring appears to be linked with PIH. However, polysomnographic data are not yet sufficient to explain pathophysiological mechanisms and find relevant diagnostic markers during pregnancy.

The HELLP syndrome is usually treated by rapid termination of pregnancy as the most effective way of limiting the risk of disease aggravation and maternal complications. The drawback is the risk of fetal complications due to prematurity when pregnancy is terminated before 32 weeks gestation. A controlled study has suggested that corticosteroid therapy could be effective in early HELLP syndrome.From January 1, 1996 to March 1, 1999, we treated patients presenting early HELLP syndrome defined as platelet counts below 150,000 and ALAT above 50 U/l prior to 32 weeks gestation with dexamethazone (Soludecadron((R))) via intravenous administration of 10 every 12 hours to the end of pregnancy or until platelet counts rose above 150,000.Among 14 patients with early HELLP syndrome, 10 were treated (including 5 primiparous women). Six patients among the 10 had platelet counts between 50,000 and 100,000. Mean term at the first injection of dexamethazone was 29 weeks 3 days. Platelet counts rose and transaminase levels fell in all patients. Pregnancy was prolonged 7 2 days. The only maternal complication was one case of disseminated intravascular coagulation. There were no neonatal deaths.Our results are similar to those reported in the literature but such a treatment scheme can only be instituted within a rigorously controlled monitoring system in a unit with neonatal and maternal intensive care facilities. This protocol remains safe for patients with HELLP syndrome whose platelet count remains at least above 50,000.

Maternal mortality related to delivery is theoretically easy to quantify and constitutes a good indication of the security and quality of obstetrical care. Although its incidence continues to decrease in France, it is still higher than in several of our European neighbors. Hence management of pregnancy is still deficient in this country. Fifty per cent of deaths occur at the time of delivery or immediately thereafter, and case analysis shows that the majority of these deaths, particularly those due to haemorrhage, could have been avoided by earlier diagnosis or better adapted treatment.

To record maternal serum C-reactive protein levels during normal onset of labour and normal puerperium and to evaluate if inflammation or infection could be predicted during these two periods when serum C-reactive protein is increased.Eighty-five pregnant women were enrolled in a longitudinal prospective study and had a blood sample to assess serum C-reactive protein levels on admission to the labour ward for normal onset of labour and at day three post-partum. Inclusion criteria were no previous history, a normal single pregnancy, normal vaginal delivery and an uneventful post-partum course. Twelve non-pregnant women of the same age constitued a control group. An automatic Behring Nephelometer was used to measure serum C-reactive protein concentrations. The Student's t-test (significance p0.05) was used for statistical analysis.C-reactive protein was significantly increased during the onset of labour (4.10 +/- 2.79 mg/L) and reached very high levels during the post-partum period (24.07 +/- 18.28 mg/L) compared to the standard normal serum C-reactive protein level in a population of non-pregnant women of the same age (2.39 +/- 0.07 mg/L).Increased serum C-reactive protein has been reported to be a marker for subclinical infection during pregnancy in various situations including premature labour and premature rupture of membranes and for complications occurring during puerperium such as thrombophlebitis, thromboembolism or endometritis. This interpretation depends on which upper limit is considered as abnormal. Because serum C-reactive protein was raised during the onset of labour, values of less than 10 mg/L could not be considered as a marker for infection during this period. Elevated serum concentrations of estrogen, progestogen and prostaglandins during labour might be one explanation for those physiological changes. Normal vaginal delivery could be compared to a surgical procedure and tissue injury consecutive to vaginal birth as reflected by a dramatic increase in C-reactive protein. More studies using nephelometry are needed to determine normal and upper values of C-reactive protein during pregnancy.

To show that intrapartum prophylactic amnioinfusion in case of oligohydramnios or particulate meconium-stained amniotic fluid could be beneficial.From March 1st, 1993 until December 31st, 1996, 6845 women were delivered at the University Hospital of Poitiers. Patients presenting with oligohydramnios (G1) (118 patients with an amniotic fluid index below 5 cm) or a particulate meconium-stained amniotic fluid (G2)(77 patients) were included. Each group was compared with a historical control group constituted retrospectively according to the following criteria: oligohydramnios (CG1), particulate meconium-stained amniotic fluid (CG2)), age, parity, gestational age, and duration of labor. Statistical analysis was performed using the Student's t test and the Fisher's exact test when appropriate with a level of significance of p0.05.The mean infused volume was 883 ml in G1 and 751 ml in G2. A significant difference was found in terms of cesarean section between G1 and CG1 (14% versus 25%, p0.05) and of assisted deliveries for fetal distress between G2 and CG2 (5% versus 18%, p0.02). No other significant difference was found between the study groups and their control for all other studied criteria. When considering more specifically the presence of meconium below the vocal cords we also find a difference between G2 and CG2 (5% versus 14%) which was not significant. No neonatal or maternal adverse effects happened in this short study.Amnioinfusion is easy to perform during labor in case of oligohydramnios or particulate meconium-stained amniotic fluid. In case of oligohydramnios, a decreased rate of cesarean sections has been observed in the infused group. Considering patients with particulate meconium-stained amniotic fluid, less interventions for fetal distress and neonates with meconium below the vocal cords has been found in the infused group. Further prospective evaluation is needed to confirm these results in case of particulate meconium-stained amniotic fluid and to compare the advantage of prophylactic versus therapeutic amnioinfusion performed in case of oligohydramnios and abnormal fetal heart rate.

To compare the sensitivity (Se), specificity (Spe), positive predictive (PPV) and negative predictive (PNV) values of 2 tests used routinely for suspected premature rupture of the membranes (PROM) and their implication in the management of such cases.From 1 November 1995 to 31 July 1996, 87 patients: 16 with obvious PROM on physical examination (group I) and 71 with suspected PROM (group II) were tested with both DAO and Amnicator. PROM was arbitrary confirmed in group II when delivery occurred within 48 hours after the diagnosis was suspected. The corrected chi 2 test was used to compare both tests results in group II.In case of obvious PROM, the sensitivity of the DAO and Amnicator tests were 75 and 87.5% respectively. Eleven patients from group II delivered within 48 hours following admission and the 2 tests results were respectively: Se 90.9 and 81.81%, Spe 100 and 83.33%, PPV 100 and 52.63% and PNV 98.36 and 96.15%. DAO gave better results in terms of Spe and PPV (p0.05).The DAO test remains a reference test when PROM is suspected but when it is not available (during night or week-end), the quite good negative predictive value of Amnicator could avoid unnecessary hospitalisation and permit later DAO test.

A prospective clinical trial of cervical ripening with intracervical prostaglandin E2 gel in repeated administrations was performed.One hundred eighty-six patients were enrolled in this prospective trial between 01/01/89 and 31/12/93. these patients with unripe cervix (Bishop score5) required induction of labor because of pregnancy disorders. Mean patient age was 28.2 years (range 15 to 43), mean gestational age was 39.2 week's gestation (range 33 to 43) and mean parity was 1.8 (range 1 to 10). Our exclusion criterias were as follow: twin pregnancies, breech presentation and premature rupture of membranes. A 0.5 mg prostaglandin E2 gel was administered into the cervix every four hours maximal of three doses before induction of labor with oxytocin. Maternal and neonatal results were reviewed.Patients required a single dose of gel in 19.9% of cases, two doses in 26.3% and three doses in 53.8%. Induced labor during cervical ripening occurred in 55.4% of patients. A cesarean section was necessary in 22% of cases. This rate was both significantly related to the initial Bishop score and to the Bishop score at the end of the procedure. Patient with induced labor during the cervical ripening had a significantly lower cesarean section rate compared to these who needed induction with oxytocin (10.7% versus 33.8%; p0.01). The uterine hyperstimulation rate was 1.6%. A 1 min Apgar score less than 7 occurred in 1.1% of neonates.Our results do not demonstrate benefit of repeated administration comparison to a single administration described in literature. Maternal and neonatal morbidity is low in this study but cervical ripening should be used only when pregnancy disorders require prompt delivery within twenty-four hours.

Micronized natural progesterone is often prescribed alone or in association with beta-agonists in the treatment of preterm labor in France. We observed drug-induced hepatitis in 4 such patients. The main manifestation of liver disease was pruritus. After drug withdrawal, elevated transaminase levels continued to rise for one week then normalized within 10 to 30 days. The imputability of this undesirable effect was assessed and considered to be likely. The effectiveness of micronized natural progesterone in the prevention of premature delivery and in decreasing perinatal mortality and morbidity has not yet been proven. This drug should therefore be used with care, keeping in mind the risk of hepatitis, particularly in patients presenting with pruritus.

Determine whether the pH of fetal scalp blood gives a better evaluation of fetal status and whether cesarean section can be avoided in case of abnormal fetal heart rate.For last 100 patients in which the scalp blood was sampled, scalp pH was compared with cord pH, Agpar score at birth and immediate neonatal outcome.Among the 100 cases, there were 75 vaginal deliveries. There was a good correlation between scalp pH, umbilical artery pH and the 5-min Apgar score. The specificity of scalp pHor = 7.25 to identify infants with an umbilical artery pHor = 7.25 and 5-min Apgar scoreor = 7 was 98.5 and 90.7% respectively; the corresponding negative predictive values were 70.3 and 96.7%. Immediate neonatal outcome was favorable for all the vaginal deliveries (n = 75) even though fetal heart rate was abnormal. Scalp pH presumably helped avoid unnecessary cesareans in 60 cases as in 15 case delivery occurred within 30 min or less after fetal scalp blood sampling.Scalp blood sampling for determination of pH is questioned and other methods for evaluating fetal status are being examined. But until these methods can be validated, scalp pH provides a means of avoided some unnecessary cesareans in cases where the fetal heart rate is difficult to analyse.

Forty to sixty percent of main bile duct cysts are diagnosed before the age of 10 years, often at the time of a complication. Current progress in echography now makes it possible to diagnose such cysts antenatally. Wze report a case discovered at 33 gestation and focus on the difficulty of formal antenatal diagnosis and the unpredictable, sometimes rapid, course of the disease. The main prognosis factor is the development of complications, especially liver fibrosis. Antenatal suspicion of main bile duct cyst is important as they can then be managed early after echographic confirmation during the first days of life with the potential reduction in severe complications.

Retrospective study of results after intra-uterine artificial insemination performed in the Poitiers University Hospital.There were 95 infertile couples who benefited from intra-uterine artificial insemination. Indications involved pathology of the cervix in 53% of the cases and male infertility in 30%. Another cause of infertility was found in 5% and no cause could be identified in 12%.The technique was as follows. Ovary stimulation using clomifene and hMG, sonographic monitoring with oestradiol assay, hCG for triggering ovulation, 2 inseminations at 24 and 48 h after swim-up sperm preparation and luteal phase supplementation.The overall success rate was 32.6% with a mean success rate per cycle of 11.1%. The best results were obtained in couples with unexplained infertility and cervix-related infertility (42 and 32% respectively). These results are comparable to those in the literature.The results of this series and the data reported in the literature demonstrate the interest of intra-uterine artificial insemination in cases of cervical sterility where it is indicated as first intention treatment. In case of impaired ejaculation, unexplained sterility and certain other causes of male infertility, intra-uterine artificial insemination can be useful but requires further study in order to determine the criteria for indications and the techniques to be used. Associating ovary stimulation increases the probability of success, especially in cervical sterility. Finally, more than 4 to 5 attempts do not increased success rate.

To verify the importance of a wait-and-see attitude after premature rupture of the membranes before 34 weeks of amenorrhoea when allowed by the initial physical examination and of an intervening attitude after 34 weeks.A prospective study included 218 cases of premature ruptures of the membranes divided into four groups according to the weeks of amenorrhoea: Group 1, before 32 weeks (n = 11); Group 2, between 32 and 34 weeks (n = 26); Group 3, between 34 and 37 weeks (n = 18); Group 4 after 37 weeks (n = 163).Before 34 weeks of amenorrhoea, the frequency of premature rupture of the membranes was 0.72%, of germ-positive infants 8% and of infected infants, 11%. Perinatal mortality was 80% and 17.4% of the infants were delivered by cesarian section. Labour was induced in 100 cases (46%), when there was evidence of infection, after a 24-hour waiting period or at 34 weeks of amenorrhoea. When the aspect of the cervix was unfavourable, cervical maturation was induced by intravenous injection of prostaglandins in 75 cases (34%).When the rupture occurred before 34 weeks of amenorrhoea and without signs of infection, tocolysis should be entertained. From 28 to 34 weeks and when a favourable outcome is expected, maturation by corticoids can be proposed. When chorio-amniotic infection is suspected and is not confirmed by the laboratory, antibiotic prophylaxy does not appear to improve fetal outcome. The beneficial effect of a conservative wait-and-see attitude before 34 weeks and of intervening thereafter can only be demonstrated with a large randomized study. Thus each case must be managed individually, making it difficult to establish a standard recommended attitude.

Preeclampsia is a multisystem disorder of pregnancy whose clinical presentation is related to the importance and the extent of maternal microvasculature damage. 16 patients with preeclampsia, thrombocytopenia (100,000/mm3), elevated liver enzymes and hemolysis are described. Weinstein in 1982 assigned the acronym of Hellp syndrome for this clinical presentation of preeclampsia. This syndrome was seldom recognized during the first years of the study but was diagnosed later on, in 1 pregnancy out of 600 parturitions and in 5% of preeclampsia in 1991. Two out of the patients developed eclamptic seizures. The mode of delivery was as follows: 9 out of 16 had an emergency Caesarean section; the 7 other patients had vaginal delivery after induction of labor. Delivery occurred before 32 weeks of gestation for 6 out of 17 newborns. Outcome was good for 14 of the 17 newborns (one twin pregnancy). Two fetuses died: one in utero and one during interruption of the pregnancy at 24 weeks of gestation. A small for gestational age preterm of 32 weeks died on his second day of life. Early diagnosis of Hellp Syndrome, especially when abdominal pains are present, allows a prompt management of these patients, including delivery, which appeared in our experience, the only way to avoid fetomaternal complications. The thrombotic microangiopathics and acute fatty liver of pregnancy are potential imitations of Hellp syndrome and they must be considered for differential diagnosis. The frequency of Hellp Syndrome varies from one study to another. It can be increased up to 6 fold if referred to the number of pregnancies and up to 3 fold if referred to the number of preeclampsias. These differences can be real but may be due to bias related to differences in practice between centers and also differences in definitions of Hellp Syndrome and preeclampsia.

To collect informations about drugs prescribed during pregnancy in France we carried out a retrospective survey from august to december 1989. This study was based on a questionnaire at delivery for 225 women. Socio-economic status, obstetrical past history and patterns of prescribing medications were studied. 99.5% of the women were found to have used drugs during pregnancy with a mean of 6.84 medications per woman. There was no influence of age, geographic origins, number of previous pregnancies on drug consumption; socio-professional status was also found to have a poor correlation with drug intake. Patterns of prescribing were compared to those of a previous French study made in 1976: changing pattern of prescribing were found for progestatives, corticoids, neurotropes, aspirin and beta adrenergic agents. We also pointed out that self-administered drugs decreased from 25.9 to 17.9%. This evaluation supports the need of further epidemiological studies in our country.

We report a case found at the start of labour because of the presence of a "tumour praevia". Ultrasound, Doppler and tomodensitometric examination carried out after caesarean section confirmed the vascular origin of this lesion. Arteriography made it possible to decide the pattern of this arteriovenous malformation which was occurring in several branches of the left internal iliac artery. It was not possible to obliterate it completely by selective arterial embolisation, so it was removed surgically a few months later. Little is known about the complications that occur because of these arteriovenous malformations in pregnancy and during delivery. There is the theoretical risk that spontaneous rupture will occur in pregnancy but this does not justify terminating the pregnancy. It is better to carry out caesarean section because the tumour can obstruct delivery and may rupture as well as causing delay in labour. The treatment for these lesions is sometimes difficult and complex and one has to decide whether to preserve the uterus or not. Selective embolisation and pre-operative embolisation followed by surgical removal of dysplasic tissue are the therapies of choice.

The Hellp syndrome is a complication of raised blood pressure in pregnancy, haemolysis, a rise in liver enzymes and thrombopenia. In this retrospective study we report 12 cases of Hellp syndrome which occurred in the University Hospital Centre of Poitiers between 1982 and 1990 and we discuss causes, the progress, the prognosis and the management. Six patients were helped by prophylactic Caesarean operation. Two patients had eclamptic fits. Fortunately there was no maternal death. There were seven cases of intrauterine growth retardation, two of in utero fetal death and one of early neonatal death. When clinical and biological parameters of the Hellp syndrome come right following delivery, the outlook for the mother is quickly favourable, but the syndrome can continue and sometimes become worse after delivery. Stopping the pregnancy is the basic treatment and conservative treatment has only a very limited success. Finally, the prognosis for the future is usually good and it is unlikely to recur.

A case report is given of spontaneous abortion at 32 weeks brought about by Chlamydia psittaci following contact with a herd of goats. Severe symptoms were observed post-natally in this woman. Nine cases of materno-foetal infection with this pathogen are known, however, the source of infection is usually ewes suffering abortive chlamydiosis. Goats may also be infected, but caprine origin for the disease in pregnant women has not been reported previously.

We have studied the deliveries of 198 large fetuses over a period of 3 years between 1st January 1987 and 31st December 1989 in the University Hospital of Poitiers. By large fetus we mean the delivery of a child of 4,000 grammes or more. This occurs in 4.5% of deliveries. The following risk factors are present either singularly or together with others: previous delivery of a large child (12.6%), a previous history of pregnancy diabetes or its absence (2.5%), an increase of weight during pregnancy of more than 15 kgs (46.8%), obesity before the onset pregnancy (19.7%), the height of the uterus equal to or above 35 cms (75.8%). These factors were found in nearly 90% of the patients. Their presence should make one look for a large fetus. The obstetrical results were as follows: 18 ceasareans were carried out (9.09%); instrumental delivery was necessary in 43 cases (23.8%); there were 17 cases of shoulder dystocia treated by obstetrical manoeuvres (9.5%). There were therefore 122 vaginal deliveries without any interference (61%). Neonatal complications were: one lost because of malformation (0.5%), serious morbidity in 30 deliveries (15.15%); 16 fractures of the clavicle and two cases of brachial plexus paralysis of which one persisted, two facial palsies which recovered, six infections, three cases of hypoglycaemia and one serious fetal distress which recovered without any sequelae. Maternal complications were: no mortality, serious morbidity in 26 women (14.1%), 9 haemorrhages at delivery, 9 cases of trauma of the perineum, 6 infections, and 2 haematomata in the episiotomy wound.(ABSTRACT TRUNCATED AT 250 WORDS)

Some cases of late abortion occurring after a Coxiella burneti infection, more often with a chronic evolution, have already been mentioned in the literature. We reported here two cases of early abortion, contemporaneous of an acute infection due to C. burneti. Two patients, after a contact, before and at the beginning of the pregnancy, with an animal susceptible to contaminate human beings by C. burneti, presented no clinical symptom characteristic of Q fever. The fetal death for the two cases was found out at the 17th week of amenorrhoea. All the investigations in order to search for an abortion etiology remained negative. Only, the specific serologies showed an acute infection due to C. burneti.

We report two cases of non immunologic hydrops fetalis associated with intra-uterine human parvovirus B19 (PV B19) infection. The outcome was stillbirth in both cases. Infection by PV B19 was suspected by the presence of intranuclear inclusions in fetal erythroblasts. It was confirmed by the presence of specific immunoglobulins M (IgM) against PV B19 in maternal sera. Intra-uterine infection with human PV B19 is known since 1984; this virus may cause non immunologic hydrops fetalis and stillbirth; teratogenic effects have also been suggested. Epidemiological studies, published in 1988 and 1990 have evaluated the risk of PV B19 fetal related death at 9% and no association was found between infection and congenital anomalies. Subsequent management of infected pregnancies is studied. We emphasize the interest of pathological examination of hydropic stillbirth for this diagnosis.

A 26-year-old farmer's wife, in the 32nd week of her second pregnancy, presented with a temperature of 38.5 o C, cough and headache. She had been treated at home with amoxicillin for 2 days, without benefit. She was admitted to the hospital on 4 May 1988, presenting with a premature labour and a quick delivery (1 hour) of a stillborn boy, weighing 1800 g, dead per partum. Six hours after admission, her temperature rose to 39.5 o C and she developed acute adult respiratory distress syndrome. The chest radiogram showed bilateral and basal pulmonary oedema. She responded well to intravenous amoxicillin, clavulanic acid, gentamicin and spiramycin. On 10 May 1988, the pulmonary, renal, hepatic and haematological functions returned to normal, and the patient was discharged from the ICU. A follow-up of 6 months was uneventful

Considering the importance of haemorrhagic complications in gynaecology-obstetrics and the increasing fear of accidents during blood transfusion, the authors propose, from the literature and the study of 13 cases, a reflection on the indications of deferred autotransfusion (DAT) and of normovolemic haemodilution (NVH). In obstetrics, even if DAT has undoubtedly certain advantages (besides viral contaminations, appearance of allo-antibodies...), it can be indicated at present only for pregnant women exposed to a predictable risk of haemorrhage or for women with a rare blood group. In gynaecology, the authors have not found any significant advantages in our study as regards NVH associated with DAT. However, as in obstetrics, the technique is harmless, and no thrombo-embolic complications have been observed, even in women at high thrombotic risk. These methods are expensive and require qualified personnel. Their exact modalities and indications, as well as their medico-legal aspects, are yet to be defined.

This comparative study carried out on 550 patients has made it possible for us to show how valuable prophylactic antibiotic therapy is when certain intra-uterine manipulations (such as forceps delivery, manual removal of the placenta or exploration of the cavity of the uterus) are carried out during vaginal delivery. Furthermore, we have been able to show that there are certain risk factors of which the most important are premature rupture of the membranes, infected liquor, birth weight of the infant less than 2,500 g and epidural analgesia. The financial study has shown that it is cheaper to use prophylactic antibiotics when the comparison is made with the cost of treating complications of infection associated with these intra-uterine procedures.

There are similarities between the clinical, biological and histological features of thrombotic micro-angiopathy (TMA) when it is a complication of pregnancy and the "Help Syndrome" (HS). HS can be associated in pregnancy with pre-eclampsia, thrombocytopenia, micro-angiopathic haemolysis and hepatic cytolysis. We have analysed on the one hand biological features of six cases that occurred in the literature and two personal cases of thrombotic micro-angiopathy that had been proven histologically; and on the other hand the histological findings of the liver in two cases of the literature and in a personal case of HS. Demonstration that in HS deposits exist under the endothelium in the region of the hepatic biopsy suggest that the latter can only be a special clinical form of TMA.

The authors have reviewed 13 cases of hypertension of pregnancy associated with Hellp syndrome observed over a 7-year period. Pregnancy was interrupted in 11/13 cases. Six of the 13 children were eutrophic and 7 were hypothrophic (2 deaths). The mother rapidly improved and regular control examinations showed regression of all biological abnormalities. Two women subsequently had an uneventful pregnancy.

Using monoclonal antibodies (OKT3, OKT4, OKT8) peripheral blood lymphocyte subsets were determined in 40 normal primiparous pregnant women and compared with those of 31 nonpregnant controls. In pregnant women plasma concentrations of estradiol, progesterone, human placental lactogen (HPL), beta subunit of human chorionic gonadotropin (beta HCG), and alpha-fetoprotein were measured by means of radioimmunoassay. We studied if correlations between peripheral lymphocyte subsets and plasma hormone levels might exist. We observed in pregnant women from 10 to 40 wk of amenorrhea a decrease in the percentage of OKT3 and OKT8 cells, and during the course of pregnancy an increase in the percentage of OKT4 cells. This increase inversely correlated with plasma beta HCG levels and directly correlated with plasma HPL levels.

A total of 168 out of 196 pregnancies that were obtained after A.I.D. have been followed up. Six cases were lost for follow-up (3%). The mean age was 30 years and 65% of the women had their ovulation induced. 130 nullipara were delivered. They were compared with a series of nullipara of the same age group and selected from 300 primiparous pregnancies who delivered in the department in the same year. The abortion rate was 12.5%. 79% of the pregnancies were normal in the 2nd and 3rd trimesters as compared with 83% in the control series. 94% delivered at term as compared with 97% in the control series. 21% of the women had Caesarean section as compared with 19.2% in the control series. The sex ratio was 1.08 as compared with 1.06 in the control series. There was no significant difference between the two series. It does seem, however, that the age factor is the most important factor of all in determining how frequent pathological conditions will be and the number of Caesareans that will have to be carried out. 14% were under 30 years of age as compared with 28.5% who were over 30 years of age, which is a significant difference. These results should be followed up in a larger series.

The inhibitory effects of cyclofenil and bromocriptine on lactation as well as FSH, prolactin and estradiol levels have been compared in control and treated females. The clinical activity of cyclofenil was lower than that of bromocriptine but was virtually free of side-effects. Cyclofenil and bromocriptine only presented similar hormonal effects at the 20th day ; this suggests that the mechanism of action of cyclofenil is more linked to secondary increases in estrogen levels than to a primary effect. Cyclofenil is of particular value in cases of vascular hypersensitivity yo ergot derivatives and for toxemic patients treated with beta-blockers.

Accidental irradiation of an early and unknown pregnancy during abdomino-pelvic computed tomography has not yet been reported, but this situation will certainly occur as the indications for this type of investigation are extended. Assessment of foetal risk depends essentially, as in ordinary radiology, upon the X-ray dose received by the foetus. Only a few studies have been devoted to determination of the "gonad dose" received during an abdomino-pelvic scan. In ten patients undergoing abdomino-pelvic scan with a mean of 22.1 +/- 4.7 exposures per patient, the authors used a small thermoluminescent dose-meter placed in the uterus or endocervix to measure the gonad dose received. The dose delivered to the uterus was 1.67 cGy +/- 1.14 per patient, i.e. approximately the same as for hysterography (1.27 cGy). Thus any abdomino-pelvic scan before twelve weeks should be viewed as an indication for therapeutic abortion, whilst after twelve weeks the amount of radiation received does not in itself represent an indication for abortion.

Pregnancies with a high risk of fetal growth retardation are at present watched by using clinical observations and biological parameters including ultrasound and estimation of the fetal heart rate. The Doppler waveform in the umbilical arteries provides information about circulatory resistance in the placenta. An index of resistance "R" is evaluated on the Doppler trace. The purpose of this study is to describe the score (with its possibilities and limitations) for this parameter "R" to follow-up pregnancies with fetal growth retardation and to compare it with ultrasound, biological and clinical parameters that are commonly used. Two groups of pregnancies have been explored: pregnancies with hypertension and pregnancies with idiopathic fetal growth retardation. Abnormal values of "R" correlate well with failure of fetal growth. Furthermore pathological values of "R" do not correspond to the same population as abnormal values of the other parameters. In some cases "R" is disturbed before the others are. In conclusion, this study shows that the index increases the accuracy of detection and the follow-up of chronic fetal growth retardation, particularly in cases of pregnancies with vascular placental pathology.

In pregnancy pre-eclampsia can be complicated by the nephrotic syndrome. We report on the clinical findings in 23 patients who had the nephrotic syndrome in pregnancy with hypertension. None of these patients had any previous sign of nephropathy. In most patients clinical signs first showed up in the 3rd trimester. The prognosis for the fetus was poor. This was because of the degree of proteinuria and of uraemia (5 fetuses died). After delivery all signs cleared up, as they would have done in moderately severe pre-eclampsia. All patients were considered to be cured by six months. In spite of this the longterm prognosis is difficult to assess. It is necessary to find out whether the nephrotic syndrome was evidence of an underlying nephropathy or just was due to the pre-eclampsia. Treatment consists mainly of rest, control of hypertension, correction of low blood volume and delivery of the fetus with regard to the degree of maturity and the viability of the fetus.