Damien Subtil

Fetal macrosomia : risk factors and outcome. A study of the outcome concerning 100 cases>4500 g

OBJECTIVE Because difficult vaginal delivery is more frequent with macrosomic fetuses, some authors recommend routine caesarean section for the delivery of fetuses >4500 g. The purpose of this study was to evaluate the appropriateness of this recommendation, in particular, to analyze maternal and fetal complications according to the mode of delivery. METHOD Maternal and neonatal records of 100 infants with weights of at least 4500 g were identified retrospectively from January 1991 to December 1996. Outcome variables included the mode of delivery and the incidence of maternal and perinatal complications. RESULTS The study sample consisted of 100 infant and mother pairs. Macrosomic fetuses represented 0.95% of all deliveries during this period and only ten were >5000 g. Mean birth weight was 4730 g (maximum, 5780 g). Gestational diabetes was present in nineteen patients. Diabetes was present in three patients. A trial of labour was allowed in 87 women, and elective caesarean delivery was performed in thirteen patients. The overall cesarean rate, including elective caesarean delivery and failed trial of labour, was 36%. Of those undergoing a trial of labour, 73% (64/87) delivered vaginally. Shoulder dystocia occurred fourteen times (22% of vaginal deliveries) and it was the most frequent complication in our series. There were five cases of Erbs palsy, one of which was associated with humeral fracture, and four cases of clavicular fracture. By three months of age, all affected infants were without sequelae. There was no related perinatal mortality and only two cases of birth asphyxia. Maternal complications with vaginal delivery of macrosomic infants included a high incidence of lacerations requiring repair (eleven cases). No complications were noticed in the patients who had a caesarean section. CONCLUSION Vaginal delivery is a reasonable alternative to elective cesarean section for infants with estimated birth weights of less than 5000 g and a trial of labour can be offered. For the fetuses with estimated birth weight >5000 g, an elective caesarean section should be recommended, especially in primiparous women.

Previous induced abortions and the risk of very preterm delivery: results of the EPIPAGE study

Objectives  To evaluate the risk of very preterm birth (22–32 weeks of gestation) associated with previous induced abortion according to the complications leading to very preterm delivery in singletons.

Apoptosis: A programmed cell death involved in ovarian and uterine physiology

Apoptosis is a form of programmed cell death which occurs through the activation of a cell-intrinsic suicide machinery. The biochemical machinery responsible for apoptosis is expressed in most, if not all, cells. Contrary to necrosis, an accidental form of cell death, apoptosis does not induce inflammatory reaction noxious for the vicinity. Apoptosis is primarily a physiologic process necessary to remove individual cells that are no longer needed or that function abnormally. Apoptosis plays a major role during development, homeostasis. Many stimuli can trigger apoptotic cell death, but expression of genes can modulate the sensibility of the cell. The aim of this review is to summarise current knowledge of the molecular mechanisms of apoptosis and its roles in human endometrium and ovary physiology.

Induction of labour versus expectant management for large-for-date fetuses: a randomised controlled trial

BACKGROUND Macrosomic fetuses are at increased risk of shoulder dystocia. We aimed to compare induction of labour with expectant management for large-for-date fetuses for prevention of shoulder dystocia and other neonatal and maternal morbidity associated with macrosomia. METHODS We did this pragmatic, randomised controlled trial between Oct 1, 2002, and Jan 1, 2009, in 19 tertiary-care centres in France, Switzerland, and Belgium. Women with singleton fetuses whose estimated weight exceeded the 95th percentile, were randomly assigned (1:1), via computer-generated permuted-block randomisation (block size of four to eight) to receive induction of labour within 3 days between 37(+0) weeks and 38(+6) weeks of gestation, or expectant management. Randomisation was stratified by centre. Participants and caregivers were not masked to group assignment. Our primary outcome was a composite of clinically significant shoulder dystocia, fracture of the clavicle, brachial plexus injury, intracranial haemorrhage, or death. We did analyses by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00190320. FINDINGS We randomly assigned 409 women to the induction group and 413 women to the expectant management group, of whom 407 women and 411 women, respectively, were included in the final analysis. Mean birthweight was 3831 g (SD 324) in the induction group and 4118 g (392) in the expectant group. Induction of labour significantly reduced the risk of shoulder dystocia or associated morbidity (n=8) compared with expectant management (n=25; relative risk [RR] 0·32, 95% CI 0·15-0·71; p=0·004). We recorded no brachial plexus injuries, intracranial haemorrhages, or perinatal deaths. The likelihood of spontaneous vaginal delivery was higher in women in the induction group than in those in the expectant management group (RR 1·14, 95% CI 1·01-1·29). Caesarean delivery and neonatal morbidity did not differ significantly between the groups. INTERPRETATION Induction of labour for suspected large-for-date fetuses is associated with a reduced risk of shoulder dystocia and associated morbidity compared with expectant management. Induction of labour does not increase the risk of caesarean delivery and improves the likelihood of spontaneous vaginal delivery. These benefits should be balanced with the effects of early-term induction of labour. FUNDING Assistance Publique-Hôpitaux de Paris and the University of Geneva.

Aspirin (100 mg) used for prevention of pre‐eclampsia in nulliparous women: the Essai Régional Aspirine Mère–Enfant study (Part 1)

Objective To reduce the incidence of pre‐eclampsia in nulliparous women, in accordance with the suggestion of a recent meta‐analysis that low dose aspirin might decrease this incidence by more than half if used early enough in and at a sufficient dose during pregnancy (more than 75 mg).

Survival analysis of fertility after ectopic pregnancy

OBJECTIVE To evaluate the reproductive outcome after ectopic pregnancy and to assess the contribution of risk factors to future fertility. DESIGN Prospective follow-up in a population-based sample. SETTING Register of ectopic pregnancies established in an urban area around Lille, France. PATIENT(S) Three hundred and twenty-eight women treated between April 1994 and March 1997 who had not been using an IUCD at the time of the ectopic pregnancy and were trying to become pregnant. INTERVENTION(S) Interviews by telephone every 6 months for 2 years and once yearly thereafter. MAIN OUTCOME MEASURE(S) Cumulative pregnancy rate. RESULT(S) Two hundred fifteen (65.5%) women became pregnant after a mean of 5 months. One hundred eighty-two (84.7%) pregnancies were intrauterine; 22 (10.2%) were recurrent ectopic pregnancies; and in 11 women (5.1%), it was too early to define implantation. The cumulative intrauterine pregnancy rate was 56% at 1 year and 67% at 2 years. After applying Cox regression, three factors associated with fertility seemed to decrease reproductive performance: age > 35 years, history of infertility, and anterior tubal damage . CONCLUSION(S) More than half of the women treated for ectopic pregnancy spontaneously conceived and had a normally progressive pregnancy at 1 year. Fertility depends more on established patient characteristics than characteristics of ectopic pregnancy itself or treatment thereof.

Randomised comparison of uterine artery Doppler and aspirin (100 mg) with placebo in nulliparous women: the Essai Régional Aspirine Mère-Enfant study (Part 2).

Objective To assess the effectiveness of a pre‐eclampsia prevention strategy based on routine uterine artery Doppler flow velocity waveform examination during the second trimester of pregnancy, followed by a prescription for 100 mg aspirin in the case of abnormal Doppler findings.

Thrombotic thrombocytopenic purpura: medical and biological monitoring of six pregnancies

BACKGROUND Thrombotic thrombocytopenic purpura (TTP) is a rare cause of severe thrombocytopenia in pregnancy. METHODS Six pregnancies in five patients with TTP were followed prospectively over 5 years. Ultralarge von Willebrand factor (ULvWF) multimers and cleaving protease (cp) levels were measured. RESULTS TTP relapsed, complicating four of the six pregnancies. Of three patients who relapsed, two had complete or partial vWF-cleaving protease (vWF-cp) deficiency, and one had a normal vWF-cleaving protease level. In all three we found abnormal UL multimers. The two women who did not relapse had normal vWF-cleaving protease level and an absence or loss of UL multimers. CONCLUSIONS Pregnant patients with a history of TTP must be followed in a tertiary obstetric unit with plasmapheresis available. Influence of vWF-cleaving protease and vWF multimeric abnormalities on TTP relapsing during pregnancy has to be evaluated in a further multicentre study.

Long-term prognosis for infants after massive fetomaternal hemorrhage.

OBJECTIVE: To evaluate the fetal, neonatal, and long-term prognosis of massive fetomaternal hemorrhage (20 mL or more). METHODS: This series includes all patients with Kleihauer test values of 40 per 10,000 or higher over an 8-year period at two university hospitals. We examined obstetric, neonatal, and subsequent outcome data for the children. RESULTS: During the study period, 48 patients had massive fetomaternal hemorrhage (crude incidence 1.1 per 1,000; corrected incidence for Rh-negative women 4.6 per 1,000). Six fetal deaths were observed, representing 1.6% of all fetal deaths during the period. Nine newborns (18.7%) were transferred to neonatal intensive care unit (NICU) and five (10.4%) had transfusions. Fetomaternal hemorrhages of 20 mL/kg or more significantly increased the risk of fetal death, induced preterm delivery, transfer to NICU, and neonatal anemia requiring transfusion. Long-term follow-up was not associated with neurological sequelae (0%, 95% confidence interval 0.0–11.6%). CONCLUSION: When the transfused volume equals or exceeds 20 mL/kg, massive fetomaternal hemorrhage may lead to severe prenatal or neonatal complications. LEVEL OF EVIDENCE: III

The role of bacterial vaginosis in preterm labor and preterm birth: a case-control study

OBJECTIVE To study the association between preterm labor and bacterial vaginosis; in women with preterm labor, to determine whether vaginosis modifies the risk of preterm delivery. STUDY DESIGN Case-control study. We used Amsels clinical criteria to test 102 patients hospitalized for preterm labor and 102 control patients for bacterial vaginosis. RESULTS Patients with preterm labor were diagnosed with bacterial vaginosis significantly more often (13.8%, 95% confidence interval (CI) (7.7-22.0) than control patients (0.0%, 95% CI (0.0-3.6)) (P<0.001). Among the former, the time elapsed to delivery was identical regardless of the patients bacterial vaginosis status (elapsed time: 35.9 versus 37.1 days, rate of spontaneous preterm birth 42.9 versus 43.2%, not significant). CONCLUSION Bacterial vaginosis is associated with preterm labor. Nonetheless, it does not appear to predict preterm birth among these patients.