Claude D'Ercole

Prenatal diagnosis of fetal corpus callosum agenesis by ultrasonography and magnetic resonance imaging

Corpus callosum agenesis (CCA) was evaluated by ultrasound examination and magnetic resonance imaging (MRI) in 14 cases. Ultrasonography was able to suspect CCA by indirect signs but a definitive diagnosis of CCA was achieved in only four cases. MRI was able to diagnose complete CCA in 13 cases and showed absence of the posterior portion of the corpus callosum in one case. Additional neurological abnormalities including heterotopia, gyration anomaly, asymmetry of the cerebral hemispheres, and Dandy‐Walker variant were documented in five cases, as well as an ocular anomaly which was present in one case, by MRI examination. Prenatal counselling for fetal agenesis of the corpus callosum is difficult as the prognosis is uncertain. The association with other cerebral abnormalities increases the likelihood of a poor outcome and ultrasonographic assessment of the fetal brain is limited. We found MRI to be a safe and useful additional procedure to complement ultrasonographic diagnosis or suspicion of CCA.

Assessment of Normal Fetal Brain Maturation In Utero by Proton Magnetic Resonance Spectroscopy

Cerebral maturation in the normal human fetal brain was investigated by in utero localized proton MR spectroscopy (1H MRS). Fifty‐eight subjects at 22–39 weeks of gestational age (GA) were explored. A combination of anterior body phased‐array coils (four elements) and posterior spinal coils (two to three elements) was used. Four sequences were performed (point‐resolved spectroscopy (PRESS) sequence with short and long TEs (30 and 135 ms), with and without water saturation). A significant reduction in myo‐inositol (myo‐Ins) and choline (Cho) levels, and an increase in N‐acetylaspartate (NAA) and creatine (Cr) content were observed with progressing age. A new finding is the detection of NAA as early as 22 weeks of GA. This result is probably related to the fact that oligodendrocytes (whether mature or not) express NAA, as demonstrated by in vitro studies. Cho and myo‐inositol were the predominant resonances from 22 to 30 weeks and decreased gradually, probably reflecting the variations in substrate needed for membrane synthesis and myelination. The normal MRS data for the second trimester of gestation (when fetal MRI is usually performed) reported here can help determine whether brain metabolism is altered or not, especially when subtle anatomic changes are observed on conventional images. Magn Reson Med, 2006.

MR imaging of acquired fetal brain disorders

IntroductionAcquired fetal brain disorders represent the third indication of fetal brain MRI, after ventricular dilatation and malformations of the central nervous system.DiscussionMRI is an adequate imaging technique for evaluating fetal brain damage. Fetal brain response to brain injury may be acute, chronic or a combination of acute and chronic. An acute response is not as common in the fetal brain as in the postnatal period. A chronic response or the combination of chronic and acute response are the most common responses of the fetal brain to injury, whatever its origin. MRI also provides the natural history of acquired fetal brain lesions with regard to the stage of development.

Fetal brain injury

Improvements in MRI techniques widen the indications for fetal brain imaging and fetal brain injury represents the third indication of fetal brain magnetic resonance imaging (MRI) after the evaluation of suspected central nervous system (CNS) malformations and ventricular dilatation. Optimal MR imaging technique is necessary in order to collect as much data as possible about the fetal brain. Diffusion images can be used routinely in addition to the standard protocol of fetal brain MRI that consists of T1 and T2 weighted images of the fetal brain. Monovoxel proton magnetic resonance spectroscopy can also be performed in utero, but this technique is still more part of research protocol than of routine clinical protocol. Fetal brain injury includes hypoxia-ischemia, congenital infections (especially toxoplasmosis and cytomegalovirus infections), brain damage due to malformation such as vascular brain malformation and heart malformation, pregnancies at risk of fetal brain damage, and even inherited metabolic diseases, especially mitochondrial diseases. MRI findings in fetal brain injury consist of acute or chronic lesions that can be seen alone or in combination. Acute response of the fetal brain is less commonly seen than the chronic response compared to the brain response encountered in the postnatal period.

Delivery for women with a previous cesarean: guidelines for clinical practice from the French College of Gynecologists and Obstetricians (CNGOF).

The primary cause of uterine scars is a previous cesarean. In women with a previous cesarean, the risks of maternal complications are rare and similar after a trial of labor after cesarean (TOLAC) and after an elective repeat cesarean delivery (ERCD), but the risk of uterine rupture is higher with TOLAC (level of evidence [LE]2). Maternal morbidity in women with previous cesareans is higher when TOLAC fails than when it leads to successful vaginal delivery (LE2). Although maternal morbidity increases progressively with the number of ERCD, maternal morbidity of TOLAC decreases with the number of successful previous TOLAC (LE2). The risk-benefit ratio considering the risks of short- and long-term maternal complications is favorable to TOLAC in most cases (LE3). Globally, neonatal complications are rare regardless of the mode of delivery for women with previous cesareans. The risks of fetal, perinatal, and neonatal mortality during TOLAC are low. Nonetheless, these risks are significantly higher than those associated with ERCD (LE2). The risks of mask ventilation, intubation for meconium-stained amniotic fluid, and neonatal sepsis all increase in TOLAC (LE2). The risk of transient respiratory distress increases in ERCD (LE2). To reduce this risk, and except in particular situations, ERCD must not be performed before 39 weeks (grade B). TOLAC is possible for women with a previous cesarean before 37 weeks, with 2 previous cesareans, with a uterine malformation, a low vertical incision or an unknown incision, with a myomectomy, postpartum fever, an interval of less than 6 months between the last cesarean delivery and the conception of the following pregnancy, if the obstetric conditions are favorable (professional consensus). ERCD is recommended in women with a scar in the uterine body (grade B) and a history of 3 or more cesareans (professional consensus). Ultrasound assessment of the risk of uterine rupture in women with uterine scars has not been shown to have any clinical utility and is therefore not recommended during pregnancy to help decide the mode of delivery (professional consensus). Use of X-ray pelvimetry to decide about TOLAC is associated with an increase in the repeat cesarean rate without any reduction in the rate of uterine rupture (LE2). It is unnecessary for deciding mode of delivery and for managing labor during TOLAC (grade C). TOLAC should be encouraged for women with a previous vaginal delivery either before or after the cesarean, a favorable Bishop score or spontaneous labor, and for preterm births (grade C). For women with a fetus with an estimated weight of more than 4500 g, especially in the absence of a previous vaginal delivery and those with supermorbid obesity (BMI>50), ERCD must be planned from the outset (grade C). For all of the other clinical situations envisioned (maternal age>35 years, diabetes, morbid obesity, prolonged pregnancy, breech presentation and twin pregnancy), TOLAC is possible but the available data do not allow specific guidelines about the choice of mode of delivery, in view of the low levels of proof (grade C). The decision about planned mode of delivery must be shared by the patient and her physician and made by the 8th month, taking into account the individual risk factors for TOLAC failure and uterine rupture (professional consensus). TOLAC is the preferred choice for women who do not have several risk factors (professional consensus). The availability onsite of an obstetrician and anesthetist must be pointed out to the patient. If the woman continues to prefer a repeat cesarean after adequate information and time to think about it, her preference should be honored (professional consensus). Labor should be induced in woman with a previous cesarean only for medical indications (professional consensus). Induction of labor increases the risk of uterine rupture, which can be estimated at 1% if oxytocin is used and 2% with vaginal prostaglandins (LE2). Mechanical methods of induction have not been studied sufficiently. Misoprostol appears to increase the risk of uterine rupture strongly (LE4). Based on the information now available, its use is not recommended (professional consensus). Routine use of internal tocodynamometry does not prevent uterine rupture (professional consensus). The increased risk of uterine rupture associated with oxytocin use is dose-dependent (LE3). In the active phase, it is recommended that the total duration of failure to progress should not exceed 3h; at that point, a cesarean should be performed (professional consensus). Epidural analgesia must be encouraged. The simple existence of a uterine scar is not an indication for a routine manual uterine examination after VBAC (grade C).

Maternal endothelial soluble cell adhesion molecules with isolated small for gestational age fetuses: comparison with pre‐eclampsia

Objective 1.To evaluate the activation profile of the endothelium in pregnancies complicated by small for gestational age fetuses compared with pre‐eclampsia and normal pregnancy, by measuring the plasma levels of soluble adhesion molecules soluble E‐selectin, intercellular cell adhesion molecule‐1 and vascular cell adhesion molecule‐1. 2. To determine whether soluble adhesion molecules were related to the severity of small for gestational age fetuses and pre‐eclampsia.

Prenatal diagnosis of fetal cerebral abnormalities by ultrasonography and magnetic resonance imaging

We found magnetic resonance imaging (MRI) of the fetal brain to be effective in confirming or denying diagnosis of fetal cerebral defects when ultrasonography was inconclusive or incomplete. In this paper we describe 31 cases in which ultrasonographic evidence of fetal brain defects was verified by MRI. MRI was performed after curarization of the fetus. In 21 cases, ultrasonographic evidence was confirmed by histological study of the fetus or postnatal radiological examination. In 10 cases, ultrasonographic diagnosis was denied by MRI and healthy infants were born. In one case of cerebral toxoplasmosis, ultrasonography detected periventricular calcifications but MRI was normal. In 20 cases MRI ascertained or further documented the ultrasonographic findings. However in 4 of these 20 cases autopsy of the fetus was required to determine the exact nature of the lesion.

Laparoscopic management of malignant ovarian cysts: a 78-case national survey. Part 1: pre-operative and laparoscopic evaluation

This paper reports a retrospective multi-institutional French survey carried out in 1992 to determine the incidence of laparoscopic management of malignant ovarian cysts. Of 5307 ovarian lesions treated endoscopically, 78 were malignant (1.47%) including 60 borderline tumors and 18 ovarian cancers. In 33% of cases preoperative diagnosis indicated that the tumor was benign. Preoperative findings were suspicious in 59%. Laparoscopic treatment was puncture in 23% of cases, partial exeresis in 51% and total removal in 26%.

Fertility and obstetric outcome after conservative management of placenta accreta

To determine the fertility and obstetric outcomes after conservative management of placenta accreta.

Laparoscopic management of malignant ovarian cysts: a 78-case national survey. Part 2: Follow-up and final treatment

This paper reports a retrospective multi-institutional French survey carried out in 1992 to determine the incidence of laparoscopic management of malignant ovarian cysts. Of 5307 ovarian lesions treated endoscopically, 78 were malignant (1.47%) including 60 borderline tumours (77%) and 18 ovarian cancers (23%). Laparoscopic treatment was puncture in 23% of cases, partial exeresis in 51% and total removal in 26%. Laparotomy was immediately performed in 25% of the cases and as a second stage procedure in 58% (mean delay: 78 days). Laparotomy was not performed in 16% of the cases. Our findings suggest that laparoscopic management of ovarian lesions that subsequently prove to be malignant is not uncommon. To prevent the risk of metastasis, thorough pre-operative and per-operative evaluation is mandatory. In 22.4% of the patients presenting lesions in this study, laparoscopic tampering resulted in an upgrading of FIGO stage.