Camille Le Ray

Mycophenolate mofetil in pregnancy after renal transplantation: a case of major fetal malformations.

BACKGROUND: Mycophenolate mofetil has teratogenic properties in rats and rabbits. Previous human studies have reported an increased rate of fetal losses with its use. We report a case of major fetal malformations due to mycophenolate mofetil. CASE: The patient was treated with mycophenolate mofetil before conception and during the first trimester of pregnancy. The fetus had multiple malformations, specifically, facial dysmorphology and midline anomalies, including agenesis of the corpus callosum. CONCLUSION: This case of fetal malformation attributable to mycophenolate mofetil must be taken into consideration when considering pregnancy in an organ-transplant recipient.

When to stop pushing: effects of duration of second―stage expulsion efforts on maternal and neonatal outcomes in nulliparous women with epidural analgesia

OBJECTIVE The purpose of this study was to assess the influence of the duration of active second-stage labor on maternal and neonatal outcomes. STUDY DESIGN Secondary analysis of the Pushing Early Or Pushing Late with Epidural trial that included 1862 nulliparous women with epidural analgesia who were in the second stage of labor. According to duration of active second-stage labor, we estimated the proportion of spontaneous vaginal deliveries (SVD) with a newborn infant without signs of asphyxia (5-minute Apgar score > or =7 and arterial pH >7.10). We also analyzed maternal and neonatal outcomes according to the duration of expulsive efforts. RESULTS Relative to the first hour of expulsive efforts, the chances of a SVD of a newborn infant without signs of asphyxia decreased significantly every hour (1- to 2-hour adjusted odds ratio, 0.4; 95% confidence interval [CI], 0.3-0.6; 2- to 3-hour adjusted odds ratio, 0.1; 95% CI, 0.09-0.2; >3-hour adjusted odds ratio, 0.03; 95% CI, 0.02-0.05). The risk of postpartum hemorrhage and intrapartum fever increased significantly after 2 hours of pushing. CONCLUSION Faced with a decreasing probability of SVD and increased maternal risk of morbidity after 2 hours, we raise the question as to whether expulsive efforts should be continued after this time.

Imaging in the Management of Abdominal Pregnancy: A Case Report and Review of the Literature

BACKGROUND Abdominal pregnancy is a rare condition that is potentially life-threatening for the mother. CASE A 29-year-old woman presented with abdominal pain at 17 weeks of pregnancy. An ultrasound scan demonstrated an active abdominal pregnancy. MRI was used for placental localization. After discussion with the woman, it was decided to proceed to termination of the pregnancy. A pelvic angiogram was performed to localize placental vascularization. Both uterine arteries were embolized. Catheterization of the ovarian arteries identified that the right ovarian artery was one of the main vessels supplying the placenta. Selective embolization was performed. Laparotomy was then performed with removal of the fetus, but the placenta was left in place. Use of methotrexate was not required in the postoperative period. The patient was discharged on the seventh postoperative day. Serum BhCG became negative within one month. CONCLUSION In the management of abdominal pregnancy, the use of imaging and radio-interventional techniques is critical in minimizing surgical and post-surgical interventions.

Routine versus indicated third trimester ultrasound: is a randomized trial feasible?

OBJECTIVE An adequate and contemporary randomized trial is needed to resolve whether routine third trimester ultrasound followed by adapted perinatal management improves perinatal outcomes in a population of women at low risk. We aimed to describe current practices regarding third trimester ultrasound in our centre and to evaluate the feasibility of a randomized trial. METHODS All women with a singleton pregnancy managed from the beginning of pregnancy in our maternity unit who delivered after 28 weeks (N = 335) were assessed prospectively over a 50-day period. Details of maternal characteristics, medical and obstetrical history, management of pregnancy and delivery, ultrasound practices, and results were recorded. One hundred women had a brief personal interview to define their expectations and experience of third trimester ultrasound. RESULTS The women who were assessed had 2.9 +/- 1.2 ultrasound scans during their pregnancy. All had a second trimester ultrasound scan and 53.7% had a third trimester scan. There was no medical indication for the third trimester ultrasound scan in 12.8% of the women. Among women with a low-risk pregnancy, 40% had a third trimester ultrasound, and 21.6% of those were done without medical indication. Among women with a low-risk pregnancy who had a third trimester ultrasound, the interview disclosed that 80% found that the test was not stressful. Of the low-risk population interviewed, 83.6% would agree to participate in a future trial. CONCLUSION Although any study designed to evaluate the effect of routine third trimester ultrasound on perinatal morbidity and mortality in a low-risk pregnant population would include a large patient sample, our study shows that a randomized trial is feasible because most women with a low-risk pregnancy do not consider this examination stressful and would volunteer to participate.

Fetal Transfusion of Red Blood Cells for Alloimmunization: Validity of a Published Equation

Objective: To validate the equation published in 1990 by Leduc et al. for red blood cell fetal transfusion where fetoplacental blood volume (VO) = 100 ml/kg, then improve its precision. Methods: We reviewed 101 fetal transfusions among 32 patients. We analyzed risk factors for an inaccurate estimation with uni- and multivariate analysis. We compared the obtained Leduc formula with three other published equations. Results: Fetal weight and gestational age were risk factors for an inaccurate estimation of the final Hct. Before 32 weeks the estimation of VO was 120 ml/kg instead of 100 ml/kg. All formulae overestimated the mean expected Hct value. However, expected Hct estimated by Leduc’s formula is the nearest of the observed final Hct. Conclusion: Leduc’s equation seems to be accurate, but less so for the youngest fetuses. We propose an adapted formula VO according to gestational age and fetal weight estimation.

Conséquences périnéales selon les pratiques obstétricales: une étude comparative « ici-ailleurs » Canada-France

OBJECTIVE To study how differences in birth management can influence the frequency and types of perineal lesions. MATERIAL AND METHODS We compared outcomes and obstetric practices during labour and birth in low-risk primiparous women in two maternity units: one Canadian (maternitA Sainte-Justine, Montreal, Quebec), one French (maternité Cochin-Port-Royal, Paris). We compared the occurrence of perineal lesions--episiotomy and severe perineal tear--in these two maternity units according to delivery method. Furthermore, we studied risk factors for perineal lesions using univariate and multivariate analyses. RESULTS Among the 1044 births in Montreal and the 1154 births in Paris, the Caesarian-section rate, about 19%, was comparable in both maternity units. Among primiparous women who had a vaginal delivery, the rate of instrumental extraction was higher in the French unit than in the Canadian one (28.2% vs. 21.5%, P < 0.001). The rate of episiotomy was significantly higher in the French unit (65.9%) than in the Canadian one (23.2%), whether the vaginal delivery was spontaneous (OR adjusted = 5.8 [4.4-7.7]) or assisted (OR adjusted = 120.2 [61.0-23.1]). The rate of severe perineal tear was significantly higher in the Canadian maternity unit (11.1%) than in the French one (1.3%), whether the vaginal delivery was spontaneous (OR adjusted = 17.4 [2.4-128.7]) or assisted (OR adjusted = 45.7 [6.1-343.4]). CONCLUSION The significant differences in episiotomy and severe perineal tear rates observed in low-risk primiparous women are in part due to the different methods used to manage delivery in these two maternity units, particularly with regard to the angle of incision during episiotomy: median in Canada and median-lateral in France.Resume Objectif Etudier comment les differences dans la prise en charge de l’accouchement peuvent influer sur la frequence et le type des lesions perineales. Materiel et methodes Etude ici-ailleurs comparant les issues et les pratiques obstetricales lors du travail et de l’accouchement chez les primipares a bas risque dans deux maternites, l’une canadienne (maternite Sainte-Justine, Montreal, Quebec), l’autre francaise (maternite Cochin-Port-Royal, Paris). Nous avons compare la survenue des lesions perineales – episiotomie et dechirure perineale severe – dans les deux maternites, en fonction du mode d’accouchement. Puis, nous avons analyse les facteurs de risque des lesions perineales a l’aide d’analyses univariees et multivariees. Resultats Parmi les 1 044 accouchements a Montreal et les 1 154 accouchements a Paris, le taux de cesarienne, environ 19 %, est comparable entre les deux maternites. Parmi les primipares ayant eu un accouchement vaginal, le taux d’extraction instrumentale est plus eleve dans la maternite francaise que dans la maternite canadienne (28,2 % contre 21,5 %, P Conclusion Les differences importantes quant aux taux d’episiotomie et de dechirures perineales severes chez les primipares a bas risque s’expliquent en partie par des prises en charge differentes de l’accouchement dans les deux maternites, en particulier l’angle de l’incision de l’episiotomie, mediane dans la maternite canadienne et mediolaterale dans la maternite francaise.

Contents Vol. 25, 2009

R. Achiron, Tel Hashomer N.S. Adzick, Philadelphia, Pa. L. Allan, London A.A. Baschat, Baltimore, Md. K.J. Blakemore, Baltimore, Md. T.-H. Bui, Stockholm F.A. Chervenak, New York, N.Y. T. Chiba, Tokyo Y. Chiba, Osaka W.H. Clewell, Phoenix, Ariz. F. Crispi, Barcelona J.E. De Lia, Milwaukee, Wisc. J.A. Deprest, Leuven G.C. Di Renzo, Perugia J.W. Dudenhausen, Berlin N.M. Fisk, Brisbane A.W. Flake, Philadelphia, Pa. W.D.A. Ford, North Adelaide U. Gembruch, Bonn P.D. Gluckman, Auckland M. Hansmann, Bonn M.R. Harrison, San Francisco, Calif. J.C. Hobbins, Denver, Colo. L.K. Hornberger, San Francisco, Calif. E.R.M. Jauniaux, London M.P. Johnson, Philadelphia, Pa. C. Jorgensen, Copenhagen J.-M. Jouannic, Paris H.H.H. Kanhai, Leiden A. Kurjak, Zagreb P.M. Kyle, London O. Lapaire, Basel S. Lipitz, Tel-Hashomer Y.M.D. Lo, Hong Kong S. Mancuso, Roma G. Mari, Detroit, Mich. M. Martinez-Ferro, Buenos Aires P. Miny, Basel K.J. Moise, Houston, Tex. K.H. Nicolaides, London L. Otaño, Buenos Aires Z. Papp, Budapest R. Quintero, Tampa, Fla. G. Ryan, Toronto J. Rychik, Philadelphia, Pa. G.R. Saade, Galveston, Tex. H. Sago, Tokyo W. Sepulveda, Santiago P. Stone, Auckland D.V. Surbek, Bern M. Tanemura, Nagoya S. Tercanli, Basel J.-L. Touraine, Lyon B.J. Trudinger, Westmead J.M.G. van Vugt, Amsterdam S.L. Warsof, Virginia Beach, Va. C.P. Weiner, Kansas City, Kans. R. Zimmermann, Zürich Clinical Advances and Basic Research