Eric Boudier

Antenatal Diagnosis of Brain Damage in the Survivor after the Second Trimester Death of a Monochorionic Monoamniotic Co-Twin

At 28 weeks of amenorrhea, 1 fetus of a monoamniotic twin pregnancy died. Ultrasound and Doppler investigations of the surviving twin were normal. Three weeks later, endovaginal ultrasound and magnetic resonance imaging revealed massive bilateral cerebral ischemic necrosis in the surviving twin. In utero fetal blood sampling carried out before the termination did not reveal either anemia or thrombopenia. Current data suggest that cerebral or renal ischemic complications could set in immediately after the death of the first twin as a result of a period of acute hypotension. At least 2 weeks are necessary for them to be identifiable by ultrasound. It seems that they cannot be prevented by prompt delivery of the second twin.

Fetal pulse oximetry during labor of 62 patients.

The objectives of the study were to assess the ability of a fetal pulse oximeter to measure the fetal oxygen saturation (SPO2) continuously during labor and to assess the correlation between readings of fetal pulse oximetry and cord blood gases at birth. The Nellcor N-400 Fetal Oximeter was used in 62 women prospectively. The mean SPO2 was unchanged at the different stages of normal labor. 53.3 +/- 9.1 to 50.1 +/- 11.8% (n = 50). The SPO2 recorded during the pushing phase of stage II (n = 40) was correlated significantly with umbilical cord arterial pH (r = 0.55; p = 0.0002), venous pH (r = 0.63; p = 0.0001), venous PCO2 (r = 0.47; p = 0.002) and venous PO2 (r = 0.39; p = 0.01). SPO2 was also correlated with scalp pH (r = 0.52; p < 0.05; n = 21). No side effects were noted. Fetal pulse oximetry could be useful to assess fetal oxygenation during labor and at birth.

Cervico-vaginal fetal fibronectin: Predictive value during false labor

Objective. The purpose was to determine to what extent fetal fibronectin was a discriminative tesl of preterm delivery in patients hospitalized for uterine contractions without modification of I he cervix. Study design. The prospective double‐blind study included patients hospitalized between 24 and 34 weeks for false labor. Cervicovaginal swabs were obtained and assayed for the presence of fetal fibronectin by means of a monoclonal antibody assay. Results. Out of the 61 patients included, 18 showed a positive swab. The correlation of a positive result with preterm delivery revealed a sensitivity of 56%, a specificity of 81%, and positive and negative predictive values of 56% and 81% respectively. Meta‐analysis of studies published shows that the presence of fibronectin represents a significant relative risk of 3.3 (IC: 2.5–42) of preterm delivery. Conclusion. The presence of fetal fibronectin in cervicovaginal secretions of patients presenting with false labor indicates a major risk of preterm delivery.

Etiology and prevention of pulmonary complications following beta-mimetic mediated tocolysis

OBJECTIVES This study documents biological (haematocrit variations) and therapeutic parameters (salbutamol doses, volumes perfused) in two groups tocolysed with salbutamol, one with and the other without APO in order to define the risk factors linked to APO and to establish a standard protocol of management. STUDY DESIGN This retrospective study includes data from 68 intravenous salbutamol tocolysis with four resulting APOs, carried out between January 1st, 1993 and December 31st, 1995. RESULTS There was an excessive level of salbutamol administered over 48 h in the complicated APO-group (122.5+/-52 mg) opposed to the non-APO group (44.9 21 mg) as well as an overload of perfused solute (3.1+/-1.11) versus (1.9+/-1.11). Blood hemodilution was demonstrated in the APO group with a decrease of haematocrit by over 10% between the admission and the control value. No other risk factor was found. CONCLUSION Tocolysis should be administered at the lowest possible perfusion rate with incremental doses as long as the heart rate stays under 120 beats/min and stopped after 48 h. Administration of maximal 11 of solute perfused/day is recommended. For the patients follow-up we estimate daily input and output fluid to avoid hydric overload, and a daily control of haematocrit whose variation must be less than 10%.

Amniotic fluid embolism: 10-year retrospective study in a level III maternity hospital

OBJECTIVE To provide updated data on amniotic fluid embolism (AFE) based on our population over a 10 year period, and to propose steps for improving current practice. STUDY DESIGN Retrospective study carried out in the Department of Gynaecology and Obstetrics at the Strasbourg University Teaching Hospital between 1 January 2000 and 31 December 2010. Dossiers of patients with AFE were identified using medical information system programme (MISP) coding and cross-checked with the pathology reports (hysterectomy, post-mortem examination). RESULTS Eleven dossiers were found (0.28/1000). Eight cases (73%) of AFE occurred during labour, two (18%) in the post-partum period and one (9%) outside of parturition. Induction was initiated in four patients (45%) and labour sustained with oxytocin in 9 patients (90%). Acute circulatory collapse with cardio-respiratory arrest (CRA) was the herald symptom of AFE in 2 patients, and secondary cardio-respiratory arrest occurred rapidly in 6 patients (55%) following a relatively non-indicative prodromal phase. Disseminated intravascular coagulopathy (DIC) was observed in 10 cases (91%) and massive transfusion was necessary in all patients. Seven haemostatic hysterectomies (63%) were performed, with secondary arterial embolisation in 2 cases (22%). Although all patients presented a clinical picture of AFE, confirmation through histology or laboratory test results was forthcoming in only 7 cases (63%). Three patients died (27%). When AFE occurred during labour, 8 fetuses (75%) received intensive care support. In all, 11 newborns survived (85%). Their pH was less than 7.00 in 3 cases (27%) and 4 fetuses (36%) had an Apgar score of less than 5 at 5 minutes of life. CONCLUSION AFE is a rare but extremely serious disease. Some risk factors for AFE have been identified but they do not allow its occurrence to be predicted. The diagnosis may be supported by specific laboratory test results but only a post-mortem examination provides a pathognomonic diagnosis: unfortunately it is always retrospective. Obstetrical and intensive care management is complex and must be adapted to the situation bearing in mind the significant risk of haemorrhage and DIC. Hysterectomy must be performed if there is the least doubt.

Risk Factors and Clinical Presentation of Uterine Rupture in the UnscarredUterus: A Case Control Study

Purpose: The aim of our study was to determine the risk factors and to describe the clinical presentation of women with uterine rupture without previous caesarean delivery. Methods: Case-control study involving all cases of uterine rupture in the unscarred uterus detected during labour or in the post-partum between January 1, 2004 and April 1, 2016. For the control we included four controls for one case among all the patients with no record of previous caesarean delivery and planned vaginal delivery in the same period. For each woman we collected the maternal and labour characteristics. We evaluate the risk factors of uterine rupture, using Bayesian’s method. Each result is presented as a differential with a 95% credibility interval and the probability that the difference is greater or less than 0 (or 1 for the odds ratio). Results: We identified seven cases of spontaneous rupture. Deep and variable decelerations were the most frequent abnormal fetal rhythm. There was not maternal death but one neonatal death. Multiparity (estimated difference of 1.59 (95% CI=0.55, 2.95) Pr (diff>0)=1); use of oxytocin (OR=26.4 (95% CI=1.79-103) Pr (diff>0)=0.99), induced labour (OR=14 (95% CI=2.5, 122) Pr (diff>0)=1) ultrasound macrosomia (OR 30.0 (95% CI=4.3-327) Pr (diff>0)=0.99), were associated with uterine rupture. Conclusion: Even in developed countries, uterine rupture remains a serious complication with high maternal and fetal morbidity. We identified some risk factors like multiparity, induction of labour and macrosomia. These factors can help us to detect earlier this complication.

Benefits of cord blood collection in the prevention of post-partum hemorrhage: a cohort study

Abstract Objective: The aim of this study was to assess the benefit of umbilical cord drainage through cord blood collection (CBC) for the prevention of post-partum hemorrhage (PPH). Methods: This is a retrospective cohort study based on data collected prospectively including all vaginal delivery of singletons pregnancies after 37 weeks of gestation between July 2011 and May 2013 at the Strasbourg Teaching Hospital. We performed a univariate comparison of PPH risk factors with χ2 tests and then we built multivariate logistic regressions to predict PPH, severe PPH (>1000 cc), retained placenta over 30 min and manual removal of the placenta. Results: A total of 7810 vaginal deliveries were analyzed, among which 1957 benefited from CBC (25%). In the CBC group, 71 PPH (3.6%) were observed versus 260 (4.4%) in the control group (p = 0.12). In multivariate analysis, after adjustment on PPH risk factors, CBC revealed to be a protective factor of PPH: OR = 0.69 (95% CI 0.50–0.97; p = 0.03). CBC is neither a significant predictive factor of severe PPH, time to placental delivery nor rate of manual removal of the placenta. Conclusions: In our study, CBC and thus umbilical cord drainage was a protective factor against PPH but it did reduce neither retained placenta nor the need for artificial placental delivery.

Review Article: Cervico-vaginal fetal fibronectin: Predictive value during false labor

OBJECTIVE The purpose was to determine to what extent fetal fibronectin was a discriminative test of preterm delivery in patients hospitalized for uterine contractions without modification of the cervix. STUDY DESIGN The prospective double-blind study included patients hospitalized between 24 and 34 week for false labor. Cervicovaginal swabs were obtained and assayed for the presence of fetal fibronectin by means of a monoclonal antibody assay. RESULTS Out of the 61 patients included, 18 showed a positive swab. The correlation of a positive result with preterm delivery revealed a sensitivity of 56%, a specificity of 81%, and positive and negative predictive values of 56% and 81% respectively. Meta-analysis of studies published shows that the presence of fibronectin represents a significant relative risk of 3.3 (IC: 2.5-42) of preterm delivery. CONCLUSION The presence of fetal fibronectin in cervicovaginal secretions of patients presenting with false labor indicates a major risk of preterm delivery.