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Continuous labor surveillance by fetal heart rate monitoring (FHR) is highly sensible but has a poor sensitivity. Fetal scalp pH testing has, therefore, been added to overcome this lack of sensitivity (cf. Bruno Carbonne). Later, other methods were introduced. After being initially promising, fetal oxymetry, developed by Nellcor, was evaluated by five randomized studies "of varying quality". These studies showed no decrease in caesarean section and operative extraction rate or metabolic acidosis. Fetal electrocardiogram (STAN) was studied in four randomized trials. Added to continuous FHR monitoring, STAN does not reduce caesarean section or operative extraction rates compared to FHR monitoring added to fetal scalp pH testing. However, it decreases the frequency of fetal scalp pH testing. There is no comparative trial on the computerized FHR monitoring using the Oxford System.

Objectives: We evaluate the level of information and informed consent given for the screening of Down syndrome (DS) before the first-trimester ultrasound scan. We evaluate the nature of the medical information given and the patient's understanding. This makes it possible to analyze the existence of the necessary elements (level of information and consent) for the patients to exercise their autonomy as to their decision making during the first-trimester ultrasound scan., Methods: A total of 350 patients were recruited prospectively in 2 hospitals. Patients were divided into 3 groups according to the results of maternal serum screening for DS. Group 1: Patients at high risk of having a child with DS with the second-trimester maternal serum screening (MSS) (risk >1/250). Group 2: Patients having a low risk (risk <1/250). Group 3: Patients who did not undergo maternal serum screening test. A questionnaire was completed before the medical consultation, to assess the quality of the medical consultation before the ultrasound, the level of prior knowledge and the maternal consent., Results: We excluded 45 of the 350 questionnaires from the analysis because they were incomplete (13.1%). We therefore analyzed a total of 305 questionnaires. The three groups analysed were: Group 1: 89 patients (29.2%) identified as at high risk after MSS. Group 2: 137 patients (44.9%) identified as at low risk accordingly to MSS. Group 3: 79 women (25.9%) who did not undergo maternal serum screening test for diverse reasons. The frequency of genuine informed consent was significantly (p < 0.001) higher in group 3 (56.9%) than in group 1 (52.8%) or group 2 (32.1%). Finally, the number of completely uninformed patients was significantly higher in group 2 (18%) than in the other two groups (7.8% for group 1 and 6.3% for group 3, p < 0.001). With multiple regression analysis, we found that maternal consent depended on 4 independent components: (1) Educational level ( or =10). The negative responses to the various questions calls into question the legitimacy of consent for first-trimester ultrasound scans, particularly as concerns the measurement of nucal translucency., (Copyright 2008 S. Karger AG, Basel.)

Objective: The purpose of this study was to assess whether knowledge of ST-segment analysis was associated with a reduction in operative deliveries for nonreassuring fetal status (NRFS) or with a need for at least 1 scalp pH during labor., Study Design: Seven hundred ninety-nine women at term with abnormal cardiotocography or meconium-stained amniotic fluid (7%) were assigned randomly to the intervention group (cardiotocography + STAN) or the control group (cardiotocography) in 2 university hospitals in Strasbourg, France. Scalp pH testing was optional in both groups. Abnormal neonatal outcome was pH <7.05 or umbilical cord blood artery base deficit of >12 or a 5-min Apgar score of <7 or neonatal intensive care unit admission or convulsions or neonatal death. Study power was 80% for the detection of a prespecified reduction from 50%-40% in operative delivery for NRFS., Results: The operative delivery (cesarean or instrumental) rate for NRFS did not differ between the 2 groups: 33.6% (134/399) in the cardiotocography + STAN analysis group vs 37% (148/400) in the cardiotocography group (relative risk, 0.91; 95% CI, 0.75-1.10). The rate of operative delivery for dystocia was also similar in both groups. The percentage of women whose fetus had at least 1 scalp pH measurement during labor was substantially lower in the group with ST-segment analysis: 27% compared with 62% (relative risk, 0.44; 95% CI, 0.36-0.52). Neonatal outcomes did not differ significantly between groups., Conclusion: In a population with abnormal cardiotocography in labor, cardiotocography combined with ST-segment analysis was not associated with a reduction in operative deliveries for NRFS. The proportion of infants without scalp pH sampling during labor increased substantially, however.

Objectives: To evaluate the level of information and informed consent for maternal serum screening (MSS) for Down syndrome (DS) in the second trimester of pregnancy and analyse the exercise of autonomy towards the test by the women concerned., Methods: We studied the population of pregnant women attending obstetric consultations in two French hospitals over a 3-month period. The women were assigned to three groups according to MSS results for DS: women at high risk of having a child with DS (group 1), women at low risk (group 2) and women who did not undergo the test (group 3). A questionnaire was completed before the medical consultation, to assess the quality of consent before amniocentesis for the group at high risk and before the second-trimester ultrasound scan for the other two groups., Results: We analysed 305 questionnaires for 89, 137 and 79 women belonging to groups 1, 2 and 3 respectively. In total, 123 women (40.3% [IC 95%, 35-46%]) were considered to be well informed; 33 (10%, [IC 95%, 8-12%]) had a high level of knowledge, but made choices not consistent with their stated attitude, and 149 (49.7% [IC 95%, 45-56%]) were considered uninformed. Logistic regression analysis showed that maternal consent depended on three independent components: The score attributed to the doctor for information about MSS (t = 4.216, p < 0.001). Whether the patient belonged to group 1 (t = -2.631, p < 0.009). Educational level (< high-school diploma, high-school diploma or at least two years of higher education after high school) (t = 2.324, p < 0.02). The rate of consent increased with educational level and was highest for the women in group 1 and for those whose doctor had a high information score., Conclusions: Our findings clearly show that women are provided with insufficient information concerning MSS screening for DS in the second trimester of pregnancy for real and valid consent to be obtained., (Copyright (c) 2007 John Wiley & Sons, Ltd.)

Objective: To describe the management of tobacco withdrawal in pregnant women., Study Design: The questionnaire-based, descriptive survey included 979 post-partum women. The variables analysed included the characteristics of the mother and neonate at delivery, her smoking habits, her level of exposure to passive smoking, and the barriers to giving up smoking. The chi square test was used to analyse qualitative variables and the Students t-test for quantitative variables., Results: 76% of women who smoked at the start of pregnancy said that they had been asked about their tobacco consumption. However, only 16% had been asked by a clinician or midwife about their attempts to stop smoking. Seven percent were offered a specialised consultation, but only one-third attended. Seventy-six percent of women who failed to stop smoking during pregnancy had a partner who smoked compared with 63% of women who gave up. Dependency and stress during pregnancy also were lower for women who stopped smoking., Conclusions: Healthcare professionals seems to offer only rudimentary care. Simple strategies to help women give up smoking are required. The partner is an important target, especially if he can be persuaded to give up at the same time.

Objectives: Two randomized trials found that monitoring labor by analyzing the fetal electrocardiogram (STAN) appears to offer better sensitivity and specificity in screening for metabolic acidosis than cardiotocography (CTG) does. We report here the results of a descriptive study of 173 cases between 1 June 2001 and 31 May 2002, the objectives of which were twofold: to determine the number of possible false negatives (defined by neonatal metabolic acidosis with a pH less than 7.05 and base deficit (BD) greater than 12 mmol/l, in the absence of a STAN decisions event more than 30 min before birth), and to assess whether STAN indicated the need for operative intervention too late in cases of fetal distress., Patients and Methods: Our study was conducted on an at-risk population with CTG changes. STAN was used with a scalp electrode to monitor labor according to a protocol based upon the FIGO CTG classification and the clinical instructions used in the Swedish trial. Accordingly, we compared two groups: in group 1, a STAN decision event required a rapid conclusion to labor, while in group 2, the absence of any STAN decision event meant that labor continued, despite the changes in the tracing., Results: We found seven cases with a neonatal pH less than 7.05, but only one may involve a false negative by this method. The mean arterial pH and the number of fetuses born with an arterial pH less than 7.10 did not differ significantly between the two groups, nor were there any significant differences in the mean BD at birth, or the number of children with a BD greater than 12 mmol/l., Conclusion: The results appear to indicate that use of STAN with the usual CTG enables an appropriate response to cases of fetal distress, but it remains difficult to determine the real benefits that can be expected from this method in France. Longer assessment in our population is required before we can assess its actual advantages.

Objective: Our aim was to determine the accuracy of cervical length and funneling of the internal os in the prediction of the spontaneous very preterm birth of twin pregnancies., Study Design: In a prospective study at 13 centers, routine transvaginal ultrasound scanning was used to examine 251 women with twin pregnancies at 22 weeks of gestation and 215 women at 27 weeks of gestation; cervical length, spontaneous cervical funneling, and funneling after transfundal pressure were evaluated. Receiver operating characteristic curve analysis was used to determine the best cervical length for the prediction of spontaneous preterm birth before 32 and 35 weeks of gestation. We calculated the sensitivity, specificity, and predictive values for cervical length and for funneling., Results: The median gestational age at delivery was 36 weeks in both populations. Of the population that was included at 22 weeks of gestation, 5.2% (13 women) gave birth spontaneously before 32 weeks of gestation, and 13.2% (33 women) gave birth spontaneously before 35 weeks of gestation; the median cervical length was 40 mm. The receiver operating characteristic curve showed no clear best cutoff point for cervical length. For spontaneous delivery before 32 and 35 weeks of gestation, the sensitivity of cervical length < or =30 mm was 46% and 27%, respectively; the specificity was 89% and 90%, respectively. The sensitivity of funneling was 54% and 33%, and its specificity 89% and 91%, respectively. After multivariate analysis, only funneling remained significant for delivery before both 32 and 35 weeks of gestation. Of the population that was included at 27 weeks, 3.3% (7 women) gave birth spontaneously before 32 weeks of gestation, and 12.4% (26 women) gave birth spontaneously before 35 weeks of gestation; the median cervical length was 35 mm. The receiver operating characteristic curve showed 25 mm to be the best cutoff point for cervical length. For spontaneous delivery before 32 and 35 weeks of gestation, the sensitivity of cervical length < or =25 mm was 100% and 54%, respectively, and the specificity was 84% and 87%, respectively. The sensitivity of funneling was 86% and 54%, and the specificity 78% and 82%, respectively. After multivariate analysis, both indicators remained significant for delivery before 35 weeks of gestation. Funneling after transfundal pressure at 22 or 27 weeks did not predict very preterm delivery., Conclusion: Cervical length and funneling both predict the very preterm birth of twins. Although cervical length is the predictor of choice at 27 weeks of gestation, at 22 weeks of gestation the diagnostic values of both parameters are close.

Objective: To evaluate the learning curve and principal learning steps for a novice ultrasound operator to master the technique for measuring cervical length by transvaginal ultrasound., Subjects and Methods: The study involved asymptomatic patients with a singleton pregnancy between 21 and 38 weeks attending for a routine ultrasound scan. Two operators new to cervical ultrasound including one with experience in transvaginal gynecological ultrasound were assessed during their training. After an initial lecture session on the technique of cervical measurement, the trainees had one or two supervised practice sessions, validated by two interobserver agreement studies with 30 patients at a time; these compared the level of agreement between trainer and trainee throughout. Five examinations were performed in the first practice session; a second session was planned if the trainee could not perform all five examinations alone satisfactorily, in agreement with four quality criteria predefined for good cervical measurements. The second session lasted until five consecutive examinations could be performed adequately without the trainer's aid. Agreement between the two operators was assessed by intraclass correlation coefficient (ICC). The ICCs were compared with Fisher's Z transformation., Results: Of the 150 patients included, 2.7% gave birth before term. The trainee with no experience in transvaginal ultrasound required two practice sessions; none of the five ultrasound scans performed in the first session was correct. In the second session, 18 consecutive ultrasound examinations were necessary to obtain five consecutive adequate results. During interobserver studies with the trainer, the ICC progressed from 0.43 in the first study to 0.64 in the second and 0.77 in the third (P = 0.049 between the first and third studies). The trainee with experience in transvaginal ultrasound required only one practice session. The ICC increased from 0.73 to 0.85 in the two interobserver studies with the trainer., Conclusions: Measurement of cervical length by transvaginal ultrasound examination is a technique that can be learnt rapidly. While roughly 23 supervised ultrasound scans appear necessary for an operator with no experience in transvaginal ultrasound, substantially fewer are required for an operator already familiar with this approach for other indications.

Spontaneous prematurity is more frequent in multiple than singleton pregnancies. It is estimated that 72% of the multiple pregnancies delivered before 33 weeks are spontaneous births, compared with 58% among singletons (NP3). As in singleton pregnancies, uterine contractions, close together, often precede preterm delivery by several days (NP2). The benefits of home tocodynamometry for patients who have already been hospitalized for threatened preterm delivery (TPD) (NP4) is difficult to assess from the data currently available, but it has not been shown to provide any benefits in a population of asymptomatic twin pregnancies (NP1). Cervical ultrasound appears to have good predictive value for preterm delivery when performed for TPD (NP3), although again few data are available. The efficacy of tocolysis appears similar to that for singleton pregnancies (NP3). Although the lack of data prevents us from judging the efficacy of tocolytics such as calcium channel blockers or oxytocin antagonists, it seems logical to use them as first-line drugs, especially because of the increased risk of pulmonary edema in multiple pregnancies with Bmimetics (NP3). Antenatal corticosteroid therapy appears to be less beneficial in multiple than singleton pregnancies (NP3). Pharmacological studies suggest that the dose currently used may be insufficient for multiple pregnancies (NP3). While awaiting results from clinical studies comparing the efficacy of higher doses, we must for now recommend antenatal corticosteroid therapy only at the usual doses. While the rate of in utero transfers to level III facilities is nearly 85% in the case of severe TPD (NP4), this practice must be encouraged still more in view of the benefits of inborn status compared with postnatal transfer. Finally, delayed-interval delivery is a relatively rare obstetrical practice that should be considered on a case-by-case basis when the first fetus is born before 26 weeks. This approach requires tocolysis and antibiotic therapy. The usefulness of cerclage in this situation has yet to be demonstrated. A delayed-interval delivery can prolong the pregnancy by an average of 15 to 30 days (NP4).

Objective: To assess mothers' knowledge of screening tests for trisomy 21., Study Design: Interview of all women who had recently delivered a healthy child and were present in 15 Paris maternity units during one of the two non-consecutive days in June 1999 (N = 734)., Results: Two-third said that they had access to a nuchal translucency measurement (NTM) and to maternal serum screening (MSS), and 16% to amniocentesis. Thirty-eight percent of the women who had NTMs and 69% of those who had serum screening said that they had been informed of the need for amniocentesis if the results were abnormal. Among the women who had amniocentesis, 20% did not know the risk of miscarriage and 41% had not been informed about the possibility of terminating the pregnancy if trisomy 21 was diagnosed., Conclusions: Mothers' knowledge about the screening tests for trisomy 21 remains fragmentary. Providing comprehensive information about all these tests should be considered in early pregnancy so that women can make informed choices.

Background: This study compared the administration of 0.1% ropivacaine and 0.5 microg/ml sufentanil with that of 0.1% bupivacaine and 0.5 microg/ml sufentanil via patient-controlled epidural analgesia route during labor., Methods: Two hundred healthy pregnant women at term with a single fetus with a vertex fetal presentation were randomized in a double-blind fashion to receive either 0.1% ropivacaine and 0.5 microg/ml sufentanil or 0.1% bupivacaine and 0.5 microg/ml sufentanil using a patient-controlled epidural analgesia pump (5-ml bolus dose, 10-min locked-out period, no basal infusion). Pain score on a visual analog scale, Bromage score (0-3), level of sensory block, patient-controlled epidural analgesia ratio, drug use, supplemental boluses, and side effects were recorded at 30 min and then hourly. Mode of delivery, duration of first and second stages of labor, umbilical cord pH, Apgar scores of the newborn, and a measure of maternal satisfaction were recorded after delivery., Results: No differences were seen between the two groups for pain scores on a visual analog scale during labor, volume of anesthetic solution used, mode of delivery, or side effects. Motor block during the first stage of labor was significantly less in the ropivacaine group than in the bupivacaine group (no motor block in 97.8 of patients vs. 88.3%, respectively; P < 0.01). Duration of the second stage of labor was shorter in the ropivacaine group (1.3 +/- 1.0 vs. 1.5 +/- 1.2 h [mean +/- SD]; P < 0.05). Maternal satisfaction was greater in the bupivacaine group (91 +/- 13 mm for contraction, 89 +/- 19 mm for delivery on a visual scale: 0 = not satisfied at all, 100 = fully satisfied) than in the ropivacaine group (84 +/- 21 and 80 +/- 25 mm; P < 0.0001). Patients in the ropivacaine group requested more supplemental boluses to achieve analgesia during the second stage of labor than those in the bupivacaine group (29.7 vs. 19.8%, respectively, requested one or more supplemental boluses; P < 0.05)., Conclusions: Delivered as patient-controlled epidural analgesia, 0.1% ropivacaine and 0.5 microg/ml sufentanil produce less motor block but are clinically less potent than 0.1% bupivacaine and 0.5 microg/ml sufentanil.

Objective: The aim of the study was to assess how the French legislation requiring physicians to offer human immunodeficiency virus screening routinely at the beginning of prenatal care has been implemented and to explore areas in which improvement is required., Study Design: The survey included all births in France during a 7-day period in February 1995. A total of 12,341 women were asked whether they knew whether they had undergone a human immunodeficiency virus antibody test before or during the pregnancy. Factors that could have influenced their knowledge of whether they had been tested were also assessed., Results: Of the women questioned, 87.3% stated that they had been tested before or during pregnancy, 7.6% said that they had not been tested, and 5.1% stated that they did not know whether a test had been performed. Among those who said that they had not been tested before the pregnancy in question, 84. 9% reported that they were tested during the pregnancy. The multivariate analysis revealed that women from North Africa differed significantly from French women in both unawareness of screening status and the proportion who reported not being screened (odds ratio 2.1 with 95% confidence interval 1.6-2.9 and odds ratio 2.4 with 95% confidence interval 1.8-3.1, respectively). There was, however, no significant difference between women from sub-Saharan Africa and French women in these variables. A lower educational level was an important predictor of unawareness of screening status (odds ratio 2.6 with 95% confidence interval 2.0-3.4). Associations were observed between reporting of unscreened status and low levels of use of prenatal care services (<6 prenatal consultations odds ratio 1.3 with 95% confidence interval 1.0-1.6, <3 ultrasonographic examinations odds ratio 1.7 with 95% confidence interval 1.3-2.0, and no prenatal consultation at the maternity hospital odds ratio 1. 5 with 95% confidence interval 1.2-1.8)., Conclusion: The 1995 National Perinatal Survey, which appears to indicate extensive human immunodeficiency virus screening of pregnant women in France, shows that the nonmandatory nature of the French policy of systematically offering prenatal human immunodeficiency virus screening has not prevented a high proportion of women from learning their screening status. The less comprehensive screening among women in certain subgroups suggests that human immunodeficiency virus information should be better adapted for these women.

Background: CADASIL (cerebral autosomal dominant arteriopathy with subcortical infarcts and leucoencephalopathy) is commonly overlooked or misdiagnosed owing to its recent identification and its variable mode of presentation. The defective gene in CADASIL is Notch3, which encodes a large transmembrane receptor. To set up a diagnostic test and to delineate the Notch3 domains involved in CADASIL., we undertook mutations analysis in this gene in a group of CADASIL patients., Methods: 50 unrelated patients with CADASIL and 100 healthy controls were screened for mutations along the entire Notch3 sequence, by means of single-strand conformation polymorphism, heteroduplex, and sequence analysis., Findings: Strongly stereotyped mis-sense mutations, located within the epidermal-growth-factor-like (EGF-like) repeats, in the extracellular domain of Notch3, were detected in 45 patients. Clustering of mutations within the two exons encoding the first five EGF-like repeats was observed (32 patients). All these mutations lead to loss or gain of a cysteine residue and therefore to an unpaired number of cysteine residues within a given EGF domain. None of these mutations was found in the 100 controls., Interpretation: Because of the strong clustering and highly stereotyped nature of the pathogenetic mutations detected in CADASIL patients, and easy and reliable diagnostic test for CADASIL is feasible. The findings suggest that aberrant dimerisation of Notch3, due to abnormal disulphide bridging with another Notch3 molecule or with another protein, may be involved in the pathogenesis of this disorder.

Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is an inherited condition whose key features include recurrent subcortical ischemic events, migraine attacks and vascular dementia in association with diffuse white-matter abnormalities seen on neuroimaging. Pathologic examination shows multiple small deep cerebral infarcts, a leukoencephalopathy and a nonatherosclerotic nonamyloid angiopathy involving mainly the media of small cerebral arteries. To progress in understanding the pathophysiological mechanisms of this condition, we undertook the identification of the mutated gene. We mapped the CADASIL gene on chromosome 19p13.1. More than 120 families have been referred to our lab. Genetic linkage analysis of 33 of these families allowed us to reduce the size of the genetic interval to less than 1 cM and to demonstrate the genetic homogeneity of this condition. In the absence of any candidate gene, we undertook positional cloning of this gene. We identified, within the CADASIL critical region, the human Notch3 gene, whose sequence analysis revealed deleterious mutations in CADASIL families co-segregating with the affected phenotype. These data establish that this gene causes CADASIL. Identification of the CADASIL gene will provide a valuable diagnostic tool for clinicians and could be used to estimate the prevalence of this underdiagnosed condition. It should help in the understanding of pathophysiological mechanisms of CADASIL and vascular dementia.

Objective: Our aim was to determine whether chorionicity in twin gestations can be diagnosed by use of high-frequency ultrasonography to count the layers of intraamniotic membrane., Study Design: This prospective study of 66 twin pregnancies between 13 and 38 weeks' gestation used transabdominal ultrasonography at 10 MHz. The pregnancy was classified as monochorionic when two layers were counted and as dichorionic when three or four layers were counted. The findings of the examiner, who had no other information about chorionicity, were compared with those of the histopathologic examination of the placenta., Results: Ultrasonography allowed chorionicity to be determined correctly in 60 of 63 cases (95%; 100% in the second trimester and 92% in the third. The predictive value for dichorionicity was 100% (48/48) and the sensitivity 94% (48/51). The 12 monochorionic diamniotic pregnancies in which the membrane was visualized were all correctly diagnosed. In a thirteenth case, with severe oligohydramnios, the membrane could not be seen. Two patients were lost to follow-up. In 95% of the cases (63/66) only one examination was required to diagnose chorionicity. Intraobserver variability was 0% (0/26). Interobserver variability, tested by photographs, was 3% (2/65)., Conclusions: This technique should be the first-line method for determining chorionicity in the second and third trimesters because it is the most effective. Its excellent reproducibility may be attributable to the use of high-frequency ultrasonography.

Objective: To better determined the usefulness of fetal fibronectin assay to identify patients at risk of premature delivery., Subjects: 155 primiparous or multiparous patients presenting with single or twin pregnancies between 24 and 34 weeks and divided into 3 groups: high risk (70 patients), medium risk (35 patients), and low risk (50 patients) of premature delivery., Main Outcome Measures: The occurrence of delivery in the 21 days following sampling and/or a premature delivery., Results: Among the 50 patients in the low risk group, there was one false positive and no premature delivery. Among the 35 patients in the medium risk group, there was no single positive fetal fibronectin test and no premature delivery. Among the 70 patients in the high risk group, 14 had a premature rupture of the membranes with very strongly positive fetal fibronectin test and all were delivery prematurely, 11 within a period of less than 21 days. The remaining 56 patients presented a threat of premature delivery without rupture of membranes; 20 gave birth prematurely (prevalence: 35.7%). In patients with a negative fetal fibronectin test, those with positive fetal fibronectin test were significantly more likely to experience preterm birth (odds ration: 12; 95% confidence interval: 3.4 to 42.1; p = 0.001) or to deliver within 21 days (odds ratio: 29.9; 95% confidence interval: 13.3 to 243; p < 0.001)., Conclusion: Measurement of fetal fibronectin in cervico-vaginal secretions enabled us to define an authentic sub-group at high risk of premature delivery among patients presenting uterine contractions and changes in the cervix. In contrast, measurement of fetal fibronectin in cervico-vaginal secretions of patients with low and medium risk is not suitable, due to the low rate of premature delivery in these groups and the significant increase in the cost of pregnancy monitoring.