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Congenital abnormalities of the genitourinary tract are the most common sonographically identified malformations. Although prenatal diagnosis seldom modifies perinatal management, it can cause significant anxiety in parents. We aimed to assess how parents perceived the prenatal counseling they had received in our institution. Using a questionnaire, we evaluated by phone the mothers of 78 children diagnosed prenatally with urological tract anomalies between January 2018 and May 2019. Overall, mothers were satisfied and reassured by the prenatal counseling they received, although 19% of the mothers found the time from diagnosis to specialist consultation to be too long. Forty percent of the responders stated that the most important information they needed to hear during the specialist consultation was management and not diagnosis. Specialist counseling should focus on explaining postnatal management, should be offered as soon as possible, and should include practical aspects, especially concerning outpatient care.

Las infecciones urinarias son afecciones frecuentes y potencialmente graves durante el embarazo. Los cambios hormonales, anatomicos, quimicos e inmunologicos relacionados con el embarazo favorecen su aparicion. La contaminacion es principalmente ascendente. Escherichia coli es responsable del 75-90% de las infecciones urinarias gravidicas. Los factores de riesgo para la colonizacion y la infeccion urinaria durante el embarazo son: antecedentes de infeccion urinaria, bajo nivel socioeconomico, actividad sexual regular y diabetes pregestacional. La colonizacion urinaria se define por una bacteriuria asintomatica significativa mayor o igual a 105 unidades formadoras de colonias por mililitro. Su prevalencia se estima en el 2-10%. Puede complicarse en el 30% de los casos por pielonefritis aguda. Por lo tanto, la deteccion sistematica de la colonizacion urinaria esta indicada durante el embarazo. El tratamiento de la colonizacion urinaria durante el embarazo debe adaptarse a los resultados del antibiograma. La duracion recomendada del tratamiento es de 7 dias (a excepcion del tratamiento de dosis unica con fosfomicina-trometamol). La prevalencia de cistitis aguda en el embarazo se estima en el 1-2%. El diagnostico se basa en la presencia de signos clinicos sugestivos y un examen citobacteriologico de orina (ECBO) que muestra leucocituria y bacteriuria significativas. El tratamiento de la cistitis aguda es probabilista y secundariamente adaptado a los resultados del antibiograma. La fosfomicina-trometamol en dosis unica es el tratamiento probabilista de eleccion. La prevalencia de pielonefritis aguda gravidica se estima en el 0,5-2%. El principal riesgo de la pielonefritis aguda en el embarazo es la sepsis materna o incluso el shock septico. Tambien parece estar asociada con un mayor riesgo de prematuridad. En primer lugar, se deben buscar los signos de gravedad a favor de la sepsis materna, la pielonefritis obstructiva aguda o la amenaza de parto prematuro. El diagnostico se basa en la presencia de signos clinicos sugestivos, asociados con la deteccion de leucocituria y bacteriuria significativas en el ECBO. Para evaluar las repercusiones en la madre, se solicita un analisis de sangre con hemograma, proteina C reactiva y creatinina serica, asi como una ecografia renal y de vias urinarias. Una evaluacion de la repercusion fetal tambien es esencial. La hospitalizacion inicial generalmente es necesaria. El tratamiento de la pielonefritis aguda gravidica es probabilista y secundariamente adaptado a los resultados del antibiograma. Debe iniciarse tan pronto como sea posible despues de obtener las muestras bacteriologicas. Las cefalosporinas inyectables de tercera generacion representan el tratamiento probabilista de eleccion para la pielonefritis aguda no grave y grave durante el embarazo, sin factor de riesgo de enterobacterias productoras de betalactamasas de espectro amplio. En presencia de signos de gravedad, se recomienda una biterapia que incluya amikacina durante 1-3 dias. La duracion total recomendada del tratamiento es de 10-14 dias. En estas tres situaciones de infecciones urinarias durante el embarazo, se debe realizar un ECBO de control 8-10 dias despues del final del tratamiento y luego una vigilancia mensual hasta el parto.

OBJECTIVES To evaluate the feelings and practices of French obstetrician-gynecologists in prescribing the noninvasive prenatal testing (NIPT) before the release of the French High Authority of Health recommendations. METHODS Descriptive, declarative and transversal study, analyzing the feelings and practices of obstetrician-gynecologists, members of the French College of Gynecologists and Obstetricians (CNGOF) between February and May 2017 using an online questionnaire. Practitioners' feedback was self-assessed for several clinical situations using a numerical scale ranging from 1 to 10. This experience was rated as "good" (grades 6 to 10) or "bad" (grades 1-5). RESULTS Overall, 529 practitioners (29.2%) of 1812 CNGOF members, answered the online questionnaire. A "good" feeling was found for more than 65% of the practitioners audited. Feelings were significantly better for obstetricians, sonographers (P

The use of low-dose aspirin in pregnancy should remain a highly targeted indication since its long-term safety has not been established and should be restricted to women at high risk of vascular complications. Indications for which the benefit of aspirin has been shown are women with a history of preeclampsia responsible for a premature birth before 34 weeks, those having at least two history of preeclampsia, those with an antiphospholipid syndrome and those with lupus associated with positive antiphospholipid antibodies or renal failure. In all other cases, the level of evidence of the benefit of aspirin is insufficient to recommend its routine prescription.

La principal causa de utero cicatricial es la cesarea (en mas del 95% de los casos). En Francia, por ejemplo, cuando a las pacientes que tienen un utero cicatricial se les propone una prueba de trabajo de parto, el 75% da a luz por via vaginal. El riesgo de ruptura uterina aumenta de forma significativa durante una prueba de trabajo de parto, en comparacion con una cesarea programada. Sin embargo, un parto por via vaginal en caso de utero cicatricial reduce los riesgos vinculados a las cesareas multiples, sobre todo en lo que se refiere a la morbilidad materna del acto quirurgico a corto plazo y a las anomalias de insercion placentaria a largo plazo. Por esta razon, en caso de utero cicatricial es indispensable optar, de acuerdo con la paciente, por la solucion mas adecuada y con la mejor relacion beneficios/riesgos, teniendo en cuenta situaciones clinicas particulares, maternas o fetales, que podrian influir en la decision del modo de parto. La via vaginal es la opcion de preferencia en la gran mayoria de los casos, ya que pocas situaciones clinicas justifican por si solas una cesarea programada. Tres factores pronosticos principales correlacionan fuertemente con el exito de una prueba por via vaginal tras una cesarea y, en ausencia de contraindicacion, inducen a recomendar el nacimiento por via vaginal: un antecedente de parto por via vaginal, el inicio espontaneo del trabajo de parto y un cuello uterino considerado favorable al ingresar a la sala de trabajo de parto. Las dos posibilidades razonables de induccion (indicacion medica) en caso de utero unicicatricial, a pesar de un aumento moderado del riesgo de ruptura uterina, son el uso de oxitocina (cuello favorable) o el metodo mecanico con globo transcervical (cuello desfavorable). La cesarea programada por antecedente de cesarea sigue estando indicada de forma sistematica en caso de antecedente de cicatriz uterina corporal o de al menos tres cesareas.

A lo largo de los ultimos 30 anos, ha aumentado considerablemente el conocimiento de las interacciones existentes entre el feto y su entorno, el liquido amniotico, lo que ha puesto de manifiesto que el liquido amniotico esta en constante estado dinamico y estrechamente vinculado a la fisiologia de la madre y el feto. Este concepto dinamico es esencial para la evaluacion y la comprension de las anomalias del liquido amniotico. El volumen de liquido amniotico es un indicador esencial del bienestar fetal. Su cantidad varia a lo largo del embarazo: aumenta gradualmente hasta las 20 semanas de amenorrea (SA) para alcanzar un maximo hacia las 34 SA. Existen en total ocho vias de transferencia del liquido amniotico. Las dos fuentes principales de produccion, la diuresis fetal y las secreciones pulmonares, se oponen las dos vias principales de reabsorcion, la absorcion intramembranosa a traves de la superficie placentaria y la deglucion fetal. Las vias menores de intercambio son: las secreciones oronasales, la via transmembranosa a traves de las membranas amniocorionicas y las transferencias transcordonales y transcutaneas. El liquido amniotico desempena tambien funciones antibacteriana, ambiental y mecanica (que permite los movimientos activos del feto y el desarrollo pulmonar fetal, previniendo la aparicion de bridas amnioticas). Las tecnicas indirectas de medicion del volumen de liquido amniotico mediante ecografia y, de forma semicuantitativa, mediante la medicion de la cisterna magna (CM) o la medicion del indice de liquido amniotico (ILA) son las mas pertinentes. Algunos autores proponen utilizar curvas del ILA y de medicion de la CM en percentiles para la edad gestacional, debido a las variaciones fisiologicas del volumen en funcion del termino. Sin embargo, el diagnostico de oligoamnios o de hidramnios no resulta mejor que con los valores umbral utilizados comunmente. Para la evaluacion del bienestar fetal (es decir, el diagnostico de oligoamnios), a termino, es preferible utilizar la medicion de la CM.

To evaluate the feelings and practices of French obstetrician-gynecologists in prescribing the noninvasive prenatal testing (NIPT) before the release of the French High Authority of Health recommendations.Descriptive, declarative and transversal study, analyzing the feelings and practices of obstetrician-gynecologists, members of the French College of Gynecologists and Obstetricians (CNGOF) between February and May 2017 using an online questionnaire. Practitioners' feedback was self-assessed for several clinical situations using a numerical scale ranging from 1 to 10. This experience was rated as "good" (grades 6 to 10) or "bad" (grades 1-5).Overall, 529 practitioners (29.2%) of 1812 CNGOF members, answered the online questionnaire. A "good" feeling was found for more than 65% of the practitioners audited. Feelings were significantly better for obstetricians, sonographers (P0.05) and CPDPN members (P=0.003) compared to other practitioners. Situations where the DPNI was proposed "systematically" were risks greater than 1/250 (70.9%), between 1/250 and 1/500 (59.4%), greater than 1/250 associated with history of spontaneous miscarriages and/or fetal death in utero (66%), greater than 1/250 associated with pregnancy resulting from PMA (68.3%), history of fetal aneuploidy (54%) and a parent carrying a Robertsonian translocation (51.6%).This study highlights a good overall feeling of the practitioners with the NIPT.

Aim: The aim of this study was to compare the performance of tests based on the detection of insulin-like growth factor binding protein 1 (IGFBP-1) and placental α-microglobulin-1 (PAMG-1) in diagnosing rupture of fetal membranes (ROM) across different patient populations. Methods: A meta-analysis was conducted on prospective observational or cohort studies investigating ROM tests based on the detection of IGFBP-1 and PAMG-1 meeting the following criteria: (1) performance metrics calculated by comparing results to an adequate reference method; (2) sensitivity thresholds of the investigated tests matching those of the currently available tests; (3) study population, as a minimum, included patients between 25 and 37 weeks of gestation. Sensitivities, specificities, and diagnostic odds ratios were calculated. Results: Across all patient populations, the analyzed performance measures of the PAMG-1 test were significantly superior compared with those of the IGFBP-1 test. Of particular clinical relevance, PAMG-1 outperformed IGFBP-1 in the equivocal group, which comprised patients with uncertain rupture of membranes (sensitivity, 96.0% vs. 73.9%; specificity, 98.9% vs. 77.8%; PAMG-1 vs. IGFBP-1 tests, respectively). Conclusions: Compared with its performance in women with known membrane status, the accuracy of the IGFBP-1 test decreases significantly when used on patients whose membrane status is unknown. In this latter clinically relevant population, the PAMG-1 test has higher accuracy than the IGFBP-1 test.

We report a case of bilateral spontaneous uterine rupture of an unscarred uterus occured in a primigravida at 32 weeks to take care in our department after in utero transfert. Uterine rupture occurs mainly on scarred uterus during labor. This is an unfrequent but serious complication involving fetal-maternal prognosis in the absence of immediate care. We are conducting a review about spontaneous uterine rupture of unscarred uterus, before and during labor.

The duration of pregnancy varies between 40(+0) and 41(+3) weeks. Conventionally, and essentially arbitrarily, a pregnancy is considered to be "prolonged" after 41(+0) weeks, but the infant is not considered "post-term" until 42(+0) weeks (Professional consensus). A term birth thus occurs during the period from 37(+0) to 41(+6) weeks. In France, prolonged pregnancies (≥41(+0)weeks) involve 15-20% of pregnant women, and post-term pregnancies (≥42(+0) weeks) approximately 1%. The frequency of post-term pregnancies is very heterogeneous: in Europe and the United States, it ranges from 0.5% to 10% according to country. In prolonged pregnancies, the cesarean section rate-especially the emergency cesarean rate-is multiplied by approximately 1.5 (grade B). From 37(0-6) to 43(0-6) weeks, the risk of perinatal mortality increases regularly, from 0.7‰ to 5.8‰. Meconium aspiration syndrome is responsible for substantial morbidity and mortality, and its incidence increases regularly between 38(+0) and 42(+6) weeks, from 0.24‰ to 1.42‰ (grade B). Similarly, the risks of neonatal acidosis (grade B), 5-min Apgar scores less than 7 (grade B) and admissions to neonatal intensive care (grade B) increase progressively between 38(+0) and 42(+6) weeks. These risks appear to double for post-term growth-restricted newborns (grade C). Ultrasound dating of the pregnancy makes it possible to reduce the risk that it will be incorrectly considered prolonged and that labor will therefore be induced unnecessarily. To harmonize practices, if the crown-rump length (CRL) is correctly measured (this measurement should be taken between 11(+0) and 13(+6) weeks, when CRL should measure from 45 to 84mm), ultrasound dating based on it should be used to determine the official date pregnancy began, regardless of its difference from the date assumed by the patient or estimated based on the date of the last menstrual period. This rule does not apply to pregnancies by IVF, for which the date pregnancy began is defined by the date of oocyte retrieval (Professional consensus). From 37(0-6) to 43(0-6) weeks, the risk of perinatal mortality increases regularly and there is no threshold at which a clear increase in perinatal mortality becomes visible. Fetal monitoring by cardiotocography (CTG) that begins at 41(+0) weeks would cover approximately 20% of women and reduce perinatal morbidity compared with monitoring that begins at 42(+0) weeks (grade C). The frequency recommended for this monitoring ranges between two and three times a week (Professional consensus). For ultrasonography assessment, measurement of the largest fluid pocket is recommended, because measurement of the amniotic fluid index (that is, the sum of the four quadrants) is accompanied by more diagnoses of oligohydramnios, inductions of labor, and cesareans for fetal distress without any improvement in neonatal prognosis (grade A). The practice of assessing the Manning biophysical score increases the number of diagnoses of oligohydramnios and fetal heart rage (FHR) abnormalities and generates an increase in the rates of inductions and cesareans without improving neonatal prognosis. The use of this biophysical score in monitoring prolonged pregnancies is therefore not recommended (grade B). In the absence of a specific disorder, induction of labor can be proposed in patients between 41(+0) and 42(+6) weeks (grade B). Nonetheless, the choice of prolongation beyond above 42(+0) weeks appears to involve an increase in fetal risk, which must be explained to the patient and balanced against the potential disadvantages of induction (Professional consensus). Stripping the membranes can reduce the duration of pregnancy by increasing the number of patients going into labor spontaneously during the week afterward (grade B). Compared to an expectant approach, it does not increase the cesarean section rate (grade A). It reduces recourse to induction by 41% at 41(+0) weeks and by 72% at 42(+0) weeks (grade B), without increasing the risk of either membrane rupture or maternal or neonatal infection (grade B). Used as a tampon or vaginal gel, prostaglandins E2 (PGE2) are an effective method of inducing labor (grade A). They can be used to induce labor successfully, regardless of cervical ripeness (grade A). If misoprostol is chosen, the lowest dose is to be preferred, starting with a vaginal dose of 25μg every 3-6h (grade A). For misoprostol, more powerful studies remain necessary for better defining the doses, routes of administration, tolerance and indications. Misoprostol at any dose is contraindicated in women with uterine scars (grade B). Placement of an intracervical Foley catheter is an effective mechanical means of inducing labor, with less uterine hyperstimulation than prostaglandins and no increase in the cesarean section rate (grade A). Nonetheless, as the risk of infection might be increased, this technique requires more robust evaluation before entering general practice (grade B). In cases of meconium-stained amniotic fluid, pharyngeal aspiration before delivery of the shoulders is not recommended (grade A). The team managing a post-term newborn with meconium-stained amniotic fluid at birth must know how to perform intubation and, if the intubation is not helpful, endotracheal aspiration (grade C) and ventilation with a mask. Routine endotracheal intubation of a vigorous newborn is not recommended (grade A).

Resume Objectif Evaluer la pertinence d’un test sequentiel (detection de la fibronectine fœtale dans une population selectionnee par la mesure echographique du col uterin) pour apprecier le risque de prematurite spontanee des grossesses gemellaires en cas de menace d’accouchement premature a membranes intactes. Patientes et methodes Suivi d’une cohorte de 50 patientes enceintes de jumeaux hospitalisees pour menace d’accouchement premature entre 24 et 34 semaines d’amenorrhee (SA) revolues. Les parametres de jugement etaient la probabilite d’un accouchement dans les sept ou 14 jours suivant le test ou avant 34 ou 37 SA. L’utilisation sequentielle de la fibronectine apres mesure echographique du col a ete evaluee, avec un test considere comme positif si le col etait inferieur ou egal a 15 mm ou si le col etait entre 16 et 30 mm avec une fibronectine positive. Resultats Une fibronectine fœtale positive predisait le mieux un accouchement dans les sept jours avec des sensibilite/specificite/valeurs predictives positive et negative (VPP et VPN) respectives de 71 %, 64 %, 26 %, et 93 %. Une longueur cervicale inferieure ou egale a 20 mm predisait le mieux un accouchement dans les 14 jours avec des sensibilite/specificite/VPP et VPN respectives de 89 %, 51 %, 31 %, et 95 %. Le test sequentiel semblait plus efficace que chaque marqueur pris isolement et qu’en population de singletons en conservant notamment une excellente VPN tout en evitant 50 % de fibronectines : prediction d’un accouchement dans les 14 jours avec une sensibilite, une specificite, et des VPP et VPN respectives de 89 %, 57 %, 35 %, et 95 %. Discussion et conclusion Un test sequentiel avec utilisation selective de la detection de la fibronectine fœtale dans une population de grossesses gemellaires en menace d’accouchement premature selectionnee par la mesure echographique de la longueur cervicale parait efficace pour predire une prematurite spontanee en cas de menace d’accouchement premature a membranes intactes, tout en reduisant de moitie le nombre de tests de fibronectine fœtale realises.

Resume Objectif Determiner la place du dosage des lactates au scalp et a l’artere ombilicale par rapport au pH (Gold standard) devant des anomalies du rythme cardiaque fœtal pendant le travail. Methodes Etude de cohorte prospective du 01/07/2007 au 31/03/2008 regroupant 162 patientes presentant des anomalies du rythme cardiaque fœtal pendant le travail. Resultats La frequence des echecs de prelevements au scalp etait plus faible pour le dosage des lactates par rapport au pH ( Conclusion Le microdosage des lactates se revele etre un bon test diagnostique d’hypoxie fœtale (bonnes specificite et valeur predictive negative). Nous pouvons aussi conclure, que ce test peut se substituer au pH comme predicteur de devenir neonatal. Nous estimons qu’il existe un interet evident a combiner les deux analyses.

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 40 - N° 8 - p. 774-784

Resume Objectif Evaluer la pertinence d’un test sequentiel (detection de la fibronectine fœtale dans une population selectionnee par la mesure echographique du col uterin) pour apprecier le risque de prematurite spontanee en cas de menace d’accouchement premature a membranes intactes. Methodes Etude de 111 patientes hospitalisees pour menace d’accouchement premature entre 24 et 34 semaines d’amenorrhee revolues. Les parametres de jugement etaient la probabilite d’un accouchement dans les sept ou 14 jours suivant le test ou avant 34 ou 37 semaines d’amenorrhee. L’utilisation sequentielle de la detection de la fibronectine fœtale apres mesure echographique de la longueur cervicale a ete evaluee, avec un test considere comme positif si le col etait inferieur ou egal a 15 mm ou si le col etait entre 16 et 30 mm, avec une fibronectine positive. Resultats Une fibronectine fœtale positive predisait le mieux un accouchement dans les 14 jours avec des sensibilites/specificites/valeurs predictives, positive et negative, respectives de 75, 71, 17 et 97 %. Une longueur cervicale inferieure ou egale a 20 mm predisait le mieux un accouchement avant 34 semaines d’amenorrhee revolues avec des sensibilites/specificites/valeurs predictives, positive et negative, respectives de 75, 52, 21, et 92 %. Le test sequentiel presentait des performances similaires en conservant notamment une excellente valeur predictive negative, tout en evitant 37 % de fibronectines : prediction d’un accouchement avant 34 semaines d’amenorrhee revolues avec une sensibilite, une specificite et des valeurs predictives, positive et negative, respectives de 75, 63, 26 et 93,5 %. Conclusion Un test sequentiel avec utilisation selective de la detection de la fibronectine fœtale dans une population de singletons en menace d’accouchement premature, selectionnee par la mesure echographique de la longueur cervicale, parait efficace pour predire un accouchement premature en cas de menace d’accouchement premature a membranes intactes, tout en economisant plus d’un tiers des tests de fibronectine fœtale.

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 45 - N° 1 - p. 92-93

We report a case of bilateral spontaneous uterine rupture of an unscarred uterus occured in a primigravida at 32 weeks to take care in our department after in utero transfert. Uterine rupture occurs mainly on scarred uterus during labor. This is an unfrequent but serious complication involving fetal-maternal prognosis in the absence of immediate care. We are conducting a review about spontaneous uterine rupture of unscarred uterus, before and during labor.

Introduction L’index systolique a l’isthme aortique (ISI) est un index cardiaque de la balance des performances ventriculaires recemment decrit avec ses valeurs de reference dans une cohorte retrospective canadienne, ouvrant sur de nombreuses applications cliniques obstetricales, et notamment le retard de croissance intra-uterin d’origine vasculaire. Objectifs L’objectif principal de ce travail est de comparer les valeurs de l’ISI obtenues en coupe sagittale a celles obtenues en coupe transverse de Yagel dans une population de fœtus sans cardiopathie issus de mere residant en France, entre 18 et 38 SA, lors d’une echographie obstetricale de routine dite de depistage, et de comparer ces valeurs a celles de l’etude princeps de Chabaneix et al. L’objectif secondaire est d’evaluer la faisabilite en echographie obstetricale de la mesure de l’ISI par analyse du flux Doppler a l’isthme aortique par des echographistes obstetricaux non experimentes a la technique, c’est-a-dire non specialises en cardiologie fœtale. Materiels et methodes Il s’agit d’une etude prospective bicentrique, chez tous les singletons eutrophes consecutifs eligibles, de juin a juillet 2014. Les investigateurs de l’etude comprenaient un medecin cardiologue fœtal et trois echographistes obstetricaux (referent, depisteur et interne). Les echographies etaient realisees soit par un medecin seul, soit en binome : le cardiologue et l’interne ou un des obstetriciens et l’interne. La mesure de l’ISI etait obtenue en echographie-Doppler par analyse du signal Doppler pulse positionne a l’isthme aortique. Ce dernier etait realise sur une coupe sagittale de la crosse aortique (technique de reference) ou sur une coupe transverse dite de Yagel en faisant le rapport de la velocite telesystolique (Nadir en cm/s) sur la velocite au pic systolique (Pic en cm/s). Pour chaque tentative d’ISI, la faisabilite du tir Doppler etait appreciee par l’operateur de maniere qualitative. L’ensemble des mesures a ete relu a posteriori par le cardiologue qui a juge de la recevabilite de l’ISI. Resultats Le test de comparaison des moyennes ne montre pas de difference significative ISI sur coupe sagittale et ISI sur coupe transversale versus etude princeps (test de Student avec p = 0,6375). En termes de faisabilite, l’ISI a pu etre calcule dans une majorite de cas par des operateurs non specialises en cardiologie fœtale (75 %). Il existe d’ailleurs une excellente reproductibilite inter-observateur pour la mesure de l’ISI dans cette etude, puisque le coefficient de correlation intra-class est superieur a 0,80 pour l’ensemble des mesures realisees en binome. Conclusion L’index systolique a l’isthme aortique represente donc un nouvel index cardiaque de la balance des performances ventriculaires du fœtus, realisable par l’obstetricien forme a la technique en coupe sagittale de la crosse aortique comme en coupe transverse de Yagel, et ouvrant sur de nombreuses applications cliniques obstetricales comme notamment le retard de croissance intra-uterin d’origine vasculaire ou les mecanismes adaptatifs pourraient modifier l’evolution normale des flux systoliques isthmiques.

To determine the place and the respective value of both visual and computerized analysis of cardiotocography (CTG) during the surveillance of prolonged pregnancy, to show their potential impacts on the obstetric care according to their results and their possible integration in the surveillance programs of prolonged pregnancies while awaiting better cervical conditions or spontaneous labour.Bibliographic research by consulting database of both Pubmed and Cochrane Library.In the case of prolonged pregnancy, CTG is the first line examination for the detection of antepartum asphyxia. In the case of prolonged pregnancy, the predictive criteria of acidosis remain unchanged. The use of computerized CTG analysis instead of visual analysis is a possible alternative as it enables to reduce the length and the repetition of the CTGs. It has however not proved its superiority over visual analysis in improving the overall perinatal prognosis of prolonged pregnancies.In the case of fetal surveillance in prolonged pregnancies without risks associated, evidence is lacking to attest that the use of visual and computerized CTG analysis improves perinatal prognosis. CTG plays all the same a dominating role in surveillance programs and remains used in the first intention. The contraction stress test and the fetal vibroacoustic stimulation test have not demonstrated their usefulness in this indication.

To compare the interest of lactate microanalysis with pH measurement (Gold Standard procedure) in cord blood and fetal scalp blood samples for the assessment of abnormal fetal heart rate (FHR) during labour.A prospective observational study conducted from July 1st 2007 till March 31st 2008 on 162 patients with abnormal FHR during labour.Sampling failure for scalp lactate was less than 1 % compared to a failure of 10.5 % for scalp pH (P0.001). There was a good correlation between pH and lactates in fetal scalp blood samples and in cord blood samples, between lactate in the last fetal scalp sample and in cord blood. When there was umbilical acidosis (pH≤7.15 or lactate≥5mmol/L), Apgar score at 5 minutes was significantly lower than when there was no acidosis (4.66±3.59 versus 8.35±2.73 for pH ; 6.6±3.77 versus 8.45±2.58 for lactate). The specificity of the lactate in the umbilical cord artery (≥5 mmol/laws) was 76.4 % for predicting an Apgar score at 5 minutes less than 7 ; 79.7 % for predicting the need for immediate neonatal care ; 77.3 % for predicting an hospital stay in neonatal unit. These figures were generally worse but close to those found for a threshold value of umbilical artery pH≤7.15.The values of lactate in cord blood and fetal scalp blood samples were comparable to pH values (Gold standard procedure). This method is easy to perform and is an attractive alternative to pH for monitoring fetal asphyxia. It is our opinion that the combination of the two methods is of interest.

To test a sequential test with fetal fibronectin detection after ultrasound measurement of cervical length to predict preterm delivery in twin pregnancies with preterm labor.Descriptive retrospective study on 50 women with twin pregnancy hospitalised for preterm labor between 24 and 34 weeks and 6 days of gestation. The primary outcomes were preterm delivery before 34 or 37 weeks of gestation or within 7 or 14 days. Selective use of fibronectin after cervical length measurement has been tested, with a sequential test considered positive if cervical length was less than or equal to 15mm or if cervical length was between 16 and 30mm with fetal fibronectin positive.The sensitivity/specificity/and positive and negative predictive values of fetal fibronectin positive were 71%, 64%, 26%, et 93% for delivery within 7 days; those of cervical length less than or equal to 20mm were 89%, 51%, 31%, et 95% for delivery before 34 weeks and 6 days. The efficiency of the sequential test seemed better than each test and than for singleton pregnancies keeping an excellent negative predictive value: sensitivity of 75%, specificity of 63%, positive predictive value of 26% and negative predictive value of 93.5% for prediction of preterm delivery within 14 days. The use of this sequential test could have decreased half of fibronectin tests.A sequential test with selective use of fetal fibronectin detection in twin pregnancies selected by ultrasound measurement of cervical length appears to be effective for predicting preterm birth if preterm labor, avoiding half of fibronectin tests.

To test a sequential test with fetal fibronectin detection after ultrasound measurement of cervical length to predict preterm delivery in women with preterm labor.Descriptive retrospective study on 111 women hospitalised for preterm labor between 24 and 34 weeks and six days of gestation. The primary outcomes were preterm delivery before 34 or 37 weeks of gestation or within seven or 14 days. Selective use of fetal fibronectin detection after cervical length measurement has been tested, with a sequential test considered positive if cervical length was inferior or equal to 15 mm or if cervical length was between 16 and 30 mm with fetal fibronectin positive.The sensitivity/specificity/and positive and negative predictive values of fetal fibronectin positive were 75, 71, 17 and 97% for delivery within 14 days; those of cervical length inferior or equal to 20mm were 75, 52, 21, and 92% for delivery before 34 weeks. The efficiency of the sequential test was similar with excellent negative predictive value: sensitivity/specificity/and positive and negative predictive values of 75, 63, 26, and 93.5% for prediction of preterm delivery before 34 entire weeks. The use of this sequential test could have avoided 37% of fibronectin tests.A sequential test with selective use of fetal fibronectin detection in population selected by ultrasound measurement of cervical length appears to be as effective than fetal fibronectin detection or cervical length alone for predicting preterm birth, if preterm labor, avoiding more than one third of fibronectin tests.

Introduction L’hypertension arterielle pulmonaire (HTAP) est une maladie caracterisee par une obstruction progressive du lit vasculaire pulmonaire causant une augmentation des resistances vasculaires pulmonaires (RVP) et une insuffisance cardiaque droite secondaire. La grossesse chez la femme atteinte d’HTAP est un evenement rare (1/100 000). Elle est responsable d’une mortalite et morbidite maternelle et fœtale tres importantes avec un taux de mortalite maternelle compris entre 30 a 50 %. Par consequent les experts contre-indiquent la grossesse chez ces femmes souffrant d’HTAP. Cependant, grâce a de recentes avancees dans le traitement specifique de l’HTAP et a des soins pluridisciplinaires, le taux de mortalite maternelle dans HTAP semble avoir diminue. Cas clinique Nous rapportons le cas d’une femme de 39 ans pour laquelle une HTAP severe a ete diagnostiquee au decours du troisieme trimestre de sa huitieme grossesse, devant une dyspnee d’aggravation progressive puis un episode de detresse respiratoire aigue, confirmee par echographie cardiaque trans-thoracique et catheterisme cardiaque. Elle presente comme antecedent un syndrome de Raynaud, trois accouchements voie basse a terme, une interruption medicale de grossesse pour trisomie 21 et trois fausses couches spontanees precoces. Le bilan etiologique de cette HTAP etait en faveur d’une origine auto-immune (terrain dysimmunitaire et possible, syndrome des anticorps anti-phospholipides). Une hospitalisation aux soins intensifs cardiologiques a ete necessaire pour la mise en place d’un traitement par analogue de la prostacycline (epoprostenol), inhibiteurs de la phosphodiesterase de type 5 (sildenafil), et bolus de corticoides (solumedrol). Une cesarienne et ligature de trompes sous anesthesie generale ont ete programmees a 34 SA. La patiente a donne naissance a une fille pesant 2230 g, Apgar 10, transferee en neonatologie. La cesarienne s’est compliquee d’une hemorragie de la delivrance ayant necessite une hysterectomie d’hemostase inter-annexielle. L’evolution clinique a ete favorable pour la mere, sous surveillance continue aux soins intensifs de cardiologie, en poursuivant le traitement et ajout d’un antagoniste du recepteur de l’endotheline (bosentan) et une anticoagulation preventive. Elle est rentree a domicile apres deux semaines d’hospitalisation. Discussion Les changements physiologiques qui accompagnent la grossesse normale et le post-partum, tels que l’hypervolemie et l’augmentation du debit cardiaque peuvent, chez les patientes atteintes d’HTAP, decompenser la fonction du ventricule droit et provoquer une insuffisance cardiaque droite et des arythmies. Il a ete identifie trois periodes de la grossesse, a risque de decompensation : le troisieme trimestre, l’accouchement et le post-partum. Cette meilleure comprehension de la physiopathologie a permis des avancees therapeutiques avec l’utilisation de vasodilatateurs plus specifiques tels que les analogues de la prostacycline, ayant directement un effet sur le remodelage vasculaire. Les inhibiteurs calciques et les inhibiteurs de la phosphodiesterase de type 5 peuvent s’associer egalement au traitement. Les antagonistes du recepteur de l’endotheline (bosentan) sont une classe therapeutique efficace mais contre-indiques pendant la grossesse du fait du risque teratogene. Une anticoagulation efficace est preconisee. Une oxygenotherapie est parfois necessaire. Les donnees de la litterature sont limitees et il n’existe pas de consensus concernant ces traitements. La cesarienne prophylactique entre 32 et 35 SA semble etre de meilleur pronostic que l’accouchement voie basse, de part une gestion hemodynamique maternelle plus facile. Le type d’anesthesie est en revanche plus controverse. Une vigilance accrue doit etre apportee a la mere, dans le post-partum, avec une surveillance continue aux soins intensifs, avec poursuite d’un traitement adapte efficace. Conclusion Apres une information claire sur les risques maternels et fœtaux et sur les possibilites d’interruption medicale de la grossesse, les patientes atteintes d’HTAP, desirant poursuivre une grossesse, doivent etre prises en charge dans un centre hospitalier adapte. La gestion de ces grossesses a haut risque implique une approche pluridisciplinaire avec des experts de l’hypertension pulmonaire, cardiologues, obstetriciens et anesthesistes. Les recentes avancees therapeutiques necessitent des etudes plus nombreuses afin de conclure a un effet sur la mortalite et aboutir a des consensus.

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 42 - N° 2 - p. 198-199

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 41 - N° 6 - p. 593-594

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 43 - N° 7 - p. 549

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 43 - N° 6 - p. 478