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Congenital ichthyosis, otherwise known as harlequin fetus, is a severe, generally lethal, anomaly. Prenatal diagnosis is usually possible in families at risk but requires invasive fetoscopy for skin biopsy. The application of three-dimensional ultrasound enables a greatly improved analysis of the facial morphology and thus provides an important contribution to prenatal diagnosis. Although such three-dimensional diagnostic procedures are performed in specialized centers, sonographers should be aware of the signs observed at routine two-dimensional ultrasound examination in order to ensure appropriate referral for diagnosis. We describe two consecutive pregnancies of the same parents in which two- and three-dimensional ultrasound were used in the prenatal diagnosis of harlequin fetus.

Resumen La toxicomania es un problema que afecta sobre todo a personas menores de 30 anos. En esa poblacion se incluyen muchos casos de embarazo, y aproximadamente el 5 % de las mujeres embarazadas consume toxicos. Ademas de los efectos directos especificos de la droga principal sobre la madre y el hijo, conviene tener en cuenta una vision global de esta situacion compleja que considere a la vez otras toxicomanias a menudo asociadas, otras patologias, especialmente infecciosas (virus de la inmunodeficiencia humana [VIH], hepatitis C), frecuentes entre los toxicomanos, y problemas sociales y psicologicos. Tambien es imperativo asegurar el tratamiento del feto y el recien nacido, ya que el desconocimiento de las patologias propias del recien nacido de madre toxicomana puede tener consecuencias nefastas a corto y mediano plazo. A largo plazo se plantea el problema de la repercusion de la toxicomania de los padres sobre el desarrollo de los hijos. El tratamiento precoz, especifico y multidisciplinario de esos pacientes ha demostrado su eficacia tanto en las complicaciones del embarazo como en la evolucion de la toxicomania. El embarazo puede ser un momento propicio para la desintoxicacion que hay que saber aprovechar.

Azidothymidine is effective and recommended for the prophylaxis of vertical HIV transmission. Data regarding this treatment have been collected over the last decade, leading to it being widely prescribed despite the lack of information concerning its long term toxicity. Antiretroviral drug combinations administered during pregnancy appear to ensure a better protection of both mothers and their offspring. However, data available on the adverse effects of these therapies during pregnancy are scarce and mainly obtained from in vitro or animal models. Therefore there is a need for multicentric trial including long-term follow-up of exposed patients.

Resume L'infection a VIH chez l'enfant est essentiellement la consequence d'une transmission de la mere a l'enfant verticale ou perinatale. La contamination au cours de la grossesse est maintenant admise et plusieurs arguments plaident pour une contamination lors de l'accouchement et par l'allaitement maternel. Les taux de transmission rapportes sont variables: 14,4% pour une enquete europeenne, 18,3% pour l'enquete francaise, 20 a 25% aux Etats-Unis, 35 a 50% en Afrique. Certains facteurs favorisant la contamination sont connus: lymphopenie CD4, antigenemie positive, charge virale elevee. D'autres parametres sont discutes: prematurite, role de cofacteurs de certains virus (cytomegalovirus, HTLV-1, virus de l'hepatite B et C), role protecteur de la cesarienne avant le debut du travail, rupture des membranes. La prevention de la contamination fait appel a la contre-indication de la grossesse chez la femme infectee, la desinfection du vagin en debut de travail, a la protection immediate du nouveau-ne (eviter les lesions dermiques et le laver rapidement) et au traitement preventif par Zidovudine en cours de grossesse.

We describe the case of a rudimentary horn pregnancy coexistent with an intrauterine pregnancy. This situation is usually associated with rupture of the rudimentary horn and death of the correspondent twin. This is the first report on a multiple gestation with the two siblings successfully delivered by caesarean section in the two horns of a unicornuate uterus with rudimentary horn before any complication. Since the maternal mortality is higher in this situation, early ultrasound diagnosis is important to make the right decisions.

Uterine artery embolization could be useful in the treatment of myoma, either before surgery to facilitate dissection, or totally in place of surgery. Nowadays, this technique seems attractive, considering the development of a conservative and non-invasive medicine. However the question of fertility in women of childbearing-age remains. The case of a pregnancy following uterine artery embolization is here described. All pregnancies from the literature have been reviewed and the discussion includes benefits and drawbacks of this method.

Congenital ichthyosis, otherwise known as harlequin fetus, is a severe, generally lethal, anomaly. Prenatal diagnosis is usually possible in families at risk but requires invasive fetoscopy for skin biopsy. The application of three-dimensional ultrasound enables a greatly improved analysis of the facial morphology and thus provides an important contribution to prenatal diagnosis. Although such three-dimensional diagnostic procedures are performed in specialized centers, sonographers should be aware of the signs observed at routine two-dimensional ultrasound examination in order to ensure appropriate referral for diagnosis. We describe two consecutive pregnancies of the same parents in which two- and three-dimensional ultrasound were used in the prenatal diagnosis of harlequin fetus.

The authors report three cases of endometriosis of the rectus abdominis muscle, presenting as a mass of the abdominal wall associated with pain during menstruation in women with a history of cesarean section. Treatment consisted in wide surgical resection followed by prosthetic abdominal wall repair in one recurrent case. Abdominal wall endometriosis is a rare disease that can be explained by grafting of endometrial cells to the abdominal wall during laparotomy for pelvic surgery, particularly cesarean section. Isolation of the abdominal wall during cesarean section and irrigation of the abdominal wall at the end of the operation are two theoretical measures designed to prevent endometrial cell engraftment. When abdominal wall endometriosis occurs, only radical surgical resection can prevent recurrence.

Maternal infections with hepatitis C virus, human cutomegalovirus and HIV and their management problems continue to raise concern in obstetrics. What should we recommend to decrease the incidence of hepatitis C virus congenital infection? We know that congenital human cytomegalovirus infection can lead to major neurological disease with sensorineuronal loss. The current lack of trusted prognostic elements to predict impact on the infected fetus makes any prenatal diagnosis questionable. Should we thus track the initial maternal antibody status and the newborn infection? For the last 10 years, HIV mother-to-infant transmission has decreased from 25% to less than 3%. The new problem is how to answer the more and more frequent request for pregnancy from an infected woman. The treatment must be adapted to the pregnancy in order to reduce the risks for the mother and the infant. All these questions emphasize the problems of viral infection which will require answers in the years to come.

Sympathetic reflex dystrophy is an uncommon cause of pelvic pain not to be overlooked in pregnant women.At 8 months pregnancy, a 27-year-old woman complained of invalidating pain of the left hip. Magnetic resonance imaging of the pelvis performed the day after delivery evidenced a non-displaced fracture of the femoral neck and a typical aspect of sympathetic reflex dystrophy.The true frequency of sympathetic reflex dystrophy during pregnancy is probably underestimated. Approximately one hundred cases have been reported. The hip joint is involved in 9 out of 10 cases. Such localizations are uncommon outside pregnancy, accounting for 14 to 17% of all cases.

Azidothymidine is effective and recommended for the prophylaxis of vertical HIV transmission. Data regarding this treatment have been collected over the last decade, leading to it being widely prescribed despite the lack of information concerning its long term toxicity. Antiretroviral drug combinations administered during pregnancy appear to ensure a better protection of both mothers and their offspring. However, data available on the adverse effects of these therapies during pregnancy are scarce and mainly obtained from in vitro or animal models. Therefore there is a need for multicentric trial including long-term follow-up of exposed patients.

We present a case report of cervical pregnancy with medical treatment. Medical treatment consisted in injection of methotrexate (50 mg) into the pregnancy, on the first, third and seventh day. Ultrasound and Doppler give important information for follow up. The pregnancy totally resolved and the patient did not need any further treatment.

To assess knowledge and attitudes of pregnant women towards HIV infection and testing, and to compare them according to the outcome of the pregnancy (elective abortion vs delivery).Between March 30 and April 26, 1992, all women ending their pregnancy in a medical center located in South Eastern France, were asked to complete an anonymous questionnaire: 3,589 (89.6%) responded: 2,825 women who delivered and 764 who chose abortion.61.7% of the women who delivered and 24.1% of the women who chose abortion declared having been tested for HIV during pregnancy (p0.001). Among women who reported not having been tested, very few did so because they refused the test (2% among women who deliver and 1.5% among women who terminated pregnancy). A total of 2.6% of women tested during prenatal care and 19.6% in the context of abortion did not know the result of their test (p0.001). Knowledge about HIV transmission among women who delivered dit not differ significantly from that of women who terminated pregnancy. However risky behaviors were more frequent among the latter group (38.8% vs 17.7%, p0.001).This research confirms that systematic HIV screening during prenatal care was already diffused in France but remained mainly motive by foetal concerns and was not always associated with adequate preventive counselling, specially for migrant women and women with a low level of education. HIV screening and counselling is not guaranteed for women coming for elective abortion although they are more at risk for HIV infection. In spite of psychological difficulties, systematic proposal of HIV screening should be extended to the context of elective abortion.

To define the rate of maternal death on the basis of maternal deaths recorded from January 1986 to May 1993. To determine whether the patients had received "standard" quality health care.A Reproductive Age Mortality Survey was performed retrospectively on causes of death in women from 14 to 45 years of age; death registries and clinical records at the Nice University Hospital were used.There were 23 cases of pregnancy-associated death. Maternal mortality was 32.9 per 100000 live births. According to the INSERM survey, the "real" national rate would be 18.3 per 100000. This is a classical underestimation. The overmortality in Nice is partially explained by the AIDS epidemic which was the major cause of female deaths between 14 and 45 years (96/322). Nevertheless, there was an unsatisfactorily large number of cases in which standard obstetrical practises were not applied. This was often due to a combination of factors including poor obstetrical surveillance, insufficient attention by physicians, poor organisation of obstetrical care in the emergency room and referrals. Cesarean section was implicated in 7 out of 12 maternal deaths during the third trimester of pregnancy (58%). The cause of certain maternal deaths remained unexplained; amniotic embolus was always suggested. Unfortunately, an autopsy was performed in only 36% of the cases and its quality was insufficient to determine certain diagnosis.

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 33 - N° 4 - p. 363-364

Umbilical endometriosis is a rare site of the disease. The authors report a case of umbilical endometriosis only. Umbilical involvement is estimated at 0.5 to 1% of all site of the disease. This is a disorder affecting women of childbearing age, with a mean age of about 40. Medical treatment by progestogens or Danazol is inconstantly and partially effective regarding umbilical endometriosis. Surgical excision remains the only effective treatment: omphalectomy with wide removal of the tumor and reconstruction of an umbilicus. Surgery enables histologic study and, in the presence of suggestive symptomatology, search for and treatment of other genital sites.

Urinary incontinence is a frequently encountered and highly disabilitating disorder in women, especially after menopause. Several causes, sometimes associated, have been identified. After menopause, lower oestrogen levels lead to general cellular, biochemical, bacteriological and anatomic modifications in the urinary tract resulting in vaginal atrophy, diminished sphincter tone and increased bladder sensitivity. Treatment should always be based on results of urodynamic studies and adapted to the aetiologic diagnosis and patient demands. Medical treatment is usually associated with behavioural and physical therapy techniques. Drugs with an effect on bladder instability include: parasympathicolytic or anticholinergic agents which lower bladder pressure by inhibiting bladder receptors; tricyclic antidepressant for their central and peripheral anticholinergic effects; non-steroid anti-inflammatory agents which decrease urethral tone; antispasmodics; and oestrogens in menopaused women. Beta-mimetics, calcium inhibitors, opioids and myorelaxants are also used but in a limited number of cases due to side effects. Urethral instability may respond to tetracycline in case of infection or non-steroid antiinflammatory drugs. Oestrogens play an important role in improving urethral trophicity and sensitive response to alpha-stimulants. Surgery may be indicated in a limited number of specific cases.

The object of this study supported by the French Agency for AIDs Research (ANRS) was to assess knowledge and attitudes of pregnant women towards HIV infection and testing, and to compare them according to the outcome of the pregnancy (elective abortion vs delivery). Between March 22 and April 26, 1992, all women ending their pregnancy and attending one of the 72 medical centres located in South-Eastern France were asked to complete an anonymous questionnaire (n = 4303). 3,854 (89.6%) responded: 2,825 women at delivery (WD) and 764 who chose an elective abortion (WA). 61.7% of WD and 24.1% of WA declared having been tested for HIV during pregnancy (p < 0.001). Among women who reported not having been HIV tested, very few did so because they refused the test (1.7% among WD and 1.4% among WA-NS). Prior HIV testing was less frequent among WA than among WD (45.8% vs 58.8%--p < 0.001). 2.8% of women tested during prenatal care and 20% in the context of abortion did not know the result of their test (p < 0.001). Knowledge about HIV transmission declared by WD did not differ significantly from that declared by WA. However, risky behaviours were more frequent among WA than among WD (38.9% vs 17.7%--p < 0.001). This research shows that French screening HIV policy in the context of pregnancy remains mainly motivated by foetal concerns. Although women who abort voluntarily report risky behaviours more frequently, the opportunity of information and counselling towards them is relatively neglected in comparison with women who deliver.

There have been no other cases of migration of an intrauterin device reported to have caused venous compression. In the case reported here, the intrauterin device was removed surgically together with a portion of the damaged vein. A venous graft from the internal jugular vein was performed. The mechanisms of perforations, different localizations are discussed and diagnostic and therapeutic approaches are proposed.

We describe the case of a rudimentary horn pregnancy coexistent with an intrauterine pregnancy. This situation is usually associated with rupture of the rudimentary horn and death of the correspondent twin. This is the first report on a multiple gestation with the two siblings successfully delivered by caesarean section in the two horns of a unicornuate uterus with rudimentary horn before any complication. Since the maternal mortality is higher in this situation, early ultrasound diagnosis is important to make the right decisions.

The management of pregnancy in a seropositive woman implies awareness of the effects of the disease on pregnancy and, inversely, of the pregnancy on HIV infection. It is important to be aware of the risk of materno-fetal transmission, as well as of the recent positive results of therapeutic trials of AZT during pregnancy regarding the prevention of such transmission. This quite stereotyped management approach is relatively simple, both clinically and regarding laboratory investigations, and in particular when the patient is at an asymptomatic stage of the disease. Obstetric management is, for the present, the same as in normal women. It is important to stress the need for specialised management of the newborn infant and of taking advantage of the postpartum period to ensure future effective contraception.

HIV transmission risks were specified during infertility treatment. An investigation was performed by gynecologists who work in IVF. Most of gynecologist refuse to treat infertility in these cases.

Study of influence of different sequences of oral micronized progesterone (Pg) on endometrial morphology and the incidence of bleeding.Prospective comparative multicentric study conducted in 101 post-menopausal patients.98 patients who did not wish any regular withdrawal bleeding were given percutaneous oestradiol 17-beta (E2) (1.5 mg/d) associated with micronized Pg (100 mg/d) at bedtime during either 21 out of 28 days (group I), or 25 days per calendar month (group III), during a minimum of 6 months. For those wishing withdrawal bleeding (n = 3), E2 (3 mg/d) during 25 days was associated with Pg (300 mg/d) from the 16th to the 25th day of the month (group III). Endometrial biopsies were performed after 6 months of the same treatment and blindly analysed; transvaginal ultrasonography (measurement of endometrial mucosa thickness) was done in case of insufficient amount of tissue.Groups I and II: 61% of the endometrium were quiescent without mitosis, 23% were slightly active with rare mitoses, 8% partly secretory and 4% subatrophic. Sampling was inadequate in the remaining 4%. Mitotic activity of glands was low on the overall samplings (average0.53/1,000 cells). The average mucosa thickness was at 3.9 mm. No bleeding (spotting or withdrawal bleeding) occurred in 73.3% and 82.1% of cycles at the 3rd and 6th months of administration, respectively. Group III: endometrium were quiescent or slightly active and combined with frequent withdrawal bleeding.A relatively low dose of oral progesterone (100 mg/d) combined with E2 during 21d/28d or 25 d/month efficiently controls proliferation, induces a very low endometrial cyclic activity--while reducing spottings--and maintains an amenorrhea in the majority of women. This simple treatment is likely to improve compliance.

A case of twin pregnancy in a bicervical uterus with double vagina is reported. The malformation was known before conception. Caesarean section was performed for premature rupture of the membranes at 34 weeks. This enabled the extraction of two low-birth-weight premature infants free of any particular pathology. The possibility of twin pregnancy in a bicervical bicornuate uterus is 1/1,000,000 and implies the maturation of at least two oocytes. This is a high risk pregnancy. Spontaneous abortions, prematurity (40%), low-birth-weight (25%) are the most notable complications. Although the probability of dynamic dystocia is multiplied by 7, vaginal delivery is not excluded when the obstetric past history is satisfactory and the presentation of both twins cephalic. Caesarean involves hysterotomy of each horn and raises no special technical problems. Double delivery increases the risk of hemorrhage.

The effects of oral micronized progesterone-administered at a low dose-on the endometrium and on bleeding pattern have been evaluated during a multicenter study in which 101 patients were involved. For a minimum of 6 months, patients who did not wish to have withdrawal bleeding (98) received the association of 17 beta-percutaneous estradiol (1.5 mg/d) and oral micronized progesterone (100 mg/d, at bedtime) during 25 days per month (or 21 d/28). The few women (3) who wished regular bleeding were given progesterone (300 mg/d) with estradiol (3 mg/d), from the 16th to the 25th of the month. No hyperplasia was observed among the endometrial biopsies performed after 6 months minimum of treatment. 8% of the endometria were partially secretory, 4% were sub-atrophic, 23% were mildly active with rare mitoses and 61% were quiescent without mitoses. The remaining 4% were considered inadequate. Mitotic activity of the glands was minimal in all samplings (mean0.53/1,000 cells). The average thickness of the mucosa was measured by ultrasonography at 3.9 mm, in the cases of insufficient samplings. No bleeding (or spotting, or cyclic bleeding) occurred in 73.3% and 80.9% of the cycles, in the 3rd and 6th month of therapy. Therefore a low dose of oral Pg (100 mg/d) combined with E2 during 25 days/month efficiently controls endometrial proliferation, while allowing a very weak cyclic activity. This situation makes it possible to minimize spottings and to maintain an amenorrhea in the majority of patients, thus letting us hoping for an improvement in the observance of this simplified therapy.

The authors report two cases of puerperal right ovarian vein thrombophlebitis (POVT) with floating thrombus in the inferior vena cava (IVC). The originality of this report lies in the first line surgical treatment approach. POVT is recognized as presenting usually within the first week post-partum after about 0.05% of deliveries. The syndrome consists of lower abdominal or flank pain, unexplained fever and a tender abdominal mass. Abdominal or pelvic findings are often scanty. In some cases, the thrombus may extend to the inferior vena cava, leading to the risk of pulmonary embolism or low grade renal insufficiency. Diagnosis has been difficult in the past. Since acute appendicitis is the commonest differential diagnosis, laparotomy is frequent. CT scan provides a readily available, accurate, non invasive technique for the diagnosis of POVT. Criteria are: enlargement of the vein, a low density lumen within the vessel wall and a sharply defined vessel wall enhanced by contrast media. The treatment of POVT is initially medical. Antibiotics should be given to cover the commonest infecting organisms. Heparin should also be prescribed at therapeutic IV doses to be followed by oral anticoagulants for at least six weeks. Surgery is usually only recommended when the patient remains symptomatic despite proper medical management, develops clinical, scan or arteriographic evidence of pulmonary embolism, or cannot be anticoagulated. The recommended surgical technique is to clamp the anastomosis of the ovarian vein with the vena cava.(ABSTRACT TRUNCATED AT 250 WORDS)

The authors report two recent observations of thrombophlebitis of the right ovarian vein. The first occurred after a cesarotomy, due to a bigeminal pregnancy, and the second, after a breech delivery. The diagnosis was given when faced to a febrile syndrome and pains of the right flank and confirmed in both cases by an abdominal tomodensimetric examination. In both cases, an enlargement of the lower vena cava thrombosis was observed with a floating clot that reached the renal veins. Both patients underwent a surgery. The latter consisted in both cases in a thrombectomy of the lower vena cava as well as a ligature of the right ovarian vein. In both cases, the evolution was positive, thanks to a remote-control of the lower vena cava via tomodensimetry. This therapeutic procedure and other potential therapies were discussed.

Epidermal Growth Factor in a polypeptide growth factor of which receptor EGFR has a prognosis value for some malignant tumours. Data are limited concerning the EGFR value in cervix tumours. EGFR was measured in biopsies obtained in cervix cancer patients before any treatment. Twenty-two patients (18 squamous carcinomas, 4 adenocarcinomas) were studied. EGF binding was characterized in seven tumour samples. Scatchard representation identified a single family of binding sites. Kd value revealed high affinity for EGF binding: 0.645 +/- 0.769 nmol/l. EGFR values were determined by a simplified competition method using a radiolabeled ligand. EGFR was found to be more elevated in tumours (n = 20) than in normal tissue (n = 4): (59.5 vs 10.5 fmol/mg proteins). There was a tendency for higher EGFR values in squamous tumours (m = 83.5 fmol/mg proteins) as compared to adenocarcinomas (m = 35.5 fmol/mg proteins), P = 0.09. There was no difference in the distribution of EGFR values according to tumour differentiation and staging. This work confirms the presence of EGFR in cervix tumours. Interestingly, we found that tumours with high EGFR values were more radiosensitive than tumours with low values.

A laparotomy for hysterectomy was performed in a 46-year-old nulliparous woman who had worn an intra-uterine sterilization device for 8 years. The patient was in poor general health and had had abdominal pain and repeated episodes of fever over the preceding 3 months. An abscess of the abdominal muscle was found peroperatively. No perforations of the small or large intestine were observed. The pathology examination yielded the diagnosis of Actinomycosis. Actinomyces israeli is the most frequency observed Actinomycae in humans. It is a saprophyte organism of the intestinal flora, not usually found in the vagina and observed in 3.5% of cervical swabs of patients wearing an intra-uterine device (Gupta bodies). The frequency increases with the duration of insertion and the pathogenicity appears when the immune responses are deficient and/or when a cofactor is involved. Treatment relies on surgical exeresis and prolonged antibiotics (penicillin G or macrolides). Hyperbar treatment is sometimes used.

Pregnancy used to be considered a contraindication for endoscopic surgery of the digestive tract. We report a case of cholecystectomy carried out laparoscopically for complicated gall stones in a woman who was 14 weeks pregnant. There was no post-operative maternal or fetal morbidity. The mother carried on the pregnancy to term normally and gave birth to a normal infant. The same results have been reported in the literature for three other cases of cholecystectomy and six of appendicectomy. The sole technical precautions that had to be undertaken were in introducing and placing the trocars, taking into account the size of the uterus. There has been no scientific proof that CO2 is toxic for the fetus. Clinical practice shows that endoscopic surgery is possible without any obstetrical risk including thrombo-emboli, nor specific sepsis occurring in any of the three trimesters of pregnancy. The advantages of the endoscopic approach are that there is less post-operative pain and therefore less need to take analgesics. There are no complications because of an abdominal wound and the patient can both feed and walk about immediately after the operation with a reduction of the time spent in hospital. There is probably less risk of aborting when compared with classical laparotomy. The endoscopic route can be chosen when surgery is needed in the digestive tract during pregnancy.

In drug-addicted women pregnancy is always at risk and difficult to supervise owing to the social and psycological profiles of these women. At the moment, we are dealing in France mainly with pregnancies that occur in heroin addicts and frequently have the following complications: lack of follow-up, prematurity, short child stature, infections (notably HIV infection) and weaning syndrome in the newborn. Due to improvements in the management of these patients, the neonatal mortality has been considerably reduced and has become exceptional. In the USA the number of pregnancies occurring in cocaine addicts has increased, and complications similar to those of heroin addicts have been observed, particularly with crack. It is not impossible that we might soon be confronted with this type of drug addiction.

This paper deals with the management of pregnant women with HIV infection. The virus is transmitted by the mother to 20-30 percent of the infants, and therapeutic abortion should be offered to women whose pregnancy does not exceed 26 weeks of amenorrhoea. If pregnancy is pursued, the mother must be investigated for sexually transmitted diseases which are particularly frequent in this population and may have repercussions on the newborn. Pneumocystis carinii pneumonia is the most common opportunistic infection in pregnancy. In case of T4-cell depletion chemotherapy with pentamidine must be instituted. Hygienic and dietetic measures should be applied to avoid listeriosis and toxoplasmosis. Serological tests for toxoplasmosis are necessary in all HIV patients, with chemoprophylaxis in case of increased IgG levels. Thrombocytopenia usually responds to human immunoglobulins. At delivery, there is no need to modify the usual obstetrical procedures. During the post-partum period, another pregnancy must be avoided by good compliance with a reliable contraceptive method. As for the preventive treatment of mother-to-child HIV transmission, at the moment only AZT can be considered, but its effectiveness remains to be evaluated in therapeutic trials.

A retrospective study of 324 cases highlights the difficulties encountered in identifying indications for medical pregnancy terminations (MPTs) which are permitted by French law and medically justified. In addition, the ethical problems raised do not facilitate the decision to opt for a MPT, which must be made by a multi-disciplinary committee. The methods used to evaluate the pregnancy are largely surgical during the first three months, and these are succeeded during the next six months by medical methods involving the use of synthetic prostaglandins. The complications which may occur are far from minor. The various protocols used by the authors are described together with their results and complications.

The concentration of 25-(OH)D in the blood were measured in 61 pregnant women between the ages of 16 and 45 who were living in three towns that had different amounts of sun (Lyon, Chambery, Nice). The reason for doing this was to find out the influence of exposure or non-exposure to sun on the vitamin D status of these women. A subclinical lack of vitamin D was found in a number of women where ever they lived, seemingly linked to too little exposure to sun (5% of women exposed to sunshine and 59% of women who were not exposed to sunshine had concentrations of 25-(OH)D (less than 10 ng/ml). In the women who were not exposed to sunshine there was a higher frequency of low concentrations of 25-hydroxy vitamin D (less than 10 ng/ml) in Lyon in winter and in women who came from South Europe, Africa or the Middle East. But 39% of the caucasian women who did not go out into the sun, also had low levels of 25-(OH)D (less than 10 ng/ml). There was a positive correlation between the concentrations of 25-(OH)D in the mothers and in the new born (p less than 0.001) which confirmed the dependence of the infant on his mother to build up reserves of vitamin D. Vitamin D supplements should be given to all women in the last trimester of pregnancy who cannot have enough sunshine, where ever they are living in France, in order to avoid the repercussions of low maternal vitamin D levels for the mother and her new-born infant.

Foetal macrosomia is arbitrarily defined as an excessive weight for the gestational age, was found to be present in 36 p. 100 of 43 diabetic pregnancies. This finding may indicate incomplete normalization of maternal metabolic control despite the use of new forms of insulin delivery systems, such as insulin pumps. However, in our series the macrosomia was usually moderate and without consequences on the foetal outcome. The levels of insulin, but not those of the insulin-like growth factor (IgF1), were increased in the umbilical cord blood of macrosomic newborns of diabetic mothers. Cardiac septum hypertrophy correlated with maternal glycosylated haemoglobin levels better than with macrosomia. We therefore suggest that in all diabetic pregnancies the cardiac septum thickness should be measured in utero by sonocardiography.

The various ways in which infants may be contaminated with HIV are described. Transmission by blood perfusion persists in only some countries where HIV detection in blood products is not performed and sterilization is doubtful. Transplacental contamination is well documented by the finding of HIV in various foetal tissues, amniotic fluid, placenta and foetal blood; it seems to be predominant. Transmission during delivery and breast-feeding plays a lesser role, but it cannot be excluded. Horizontal transmission is extremely rare. The frequency of vertical transmission varies from one series to another, but the most often quoted figure is approximately 30 p. 100. An Atlanta C.D.C. stage III or IV and a low percentage of T4 lymphocytes are thought to facilitate the mother-to-foetus transmission. Many elements are still imperfectly known; their elucidation requires further studies on large series of subjects.

The authors selected six patients who were HIV positive and who had requested termination of pregnancy to study the passage of zidovudine through the placenta. After the patients had been warned about the procedure and given consent, 1 gram of zidovudine (Azitothymine) was given in five doses of 200 mg each orally. Ethical Committee consent had been obtained. At a mean age of 17.5 weeks of amenorrhoea, samples were taken from the mothers' blood, from the amniotic fluid and from the fetal blood between one and two hours and forty five minutes after the last dose of AZT had been taken. Pregnancy was terminated immediately after the amniotic fluid had been obtained. The levels of zidovudine and its metabolite glucuronide (G-AZT) were carried out using High Performance Liquid Chromatography (HPLC). The concentrations of the drug in the liquor and in the fetal blood were higher or equalled those found in the maternal blood. This makes it likely that the half life elimination was longer and the metabolism of the product slower when it had been metabolised to glucuronide. This study does not concern the teratogenic effect or the toxicity for the fetus. The drug remains contra-indicated in pregnancy. There is no proposal at present to use it to lessen transmission of the virus from the mother to the fetus.

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 33 - N° 4 - p. 344