F. Pierre

Maternal Outcome After Conservative Treatment of Placenta Accreta

OBJECTIVE: To estimate maternal outcome after conservative management of placenta accreta. METHODS: This retrospective multicenter study sought to include all women treated conservatively for placenta accreta in tertiary university hospital centers in France from 1993 to 2007. Conservative management was defined by the obstetricians decision to leave the placenta in situ, partially or totally, with no attempt to remove it forcibly. The primary outcome was success of conservative treatment, defined by uterine preservation. The secondary outcome was a composite measure of severe maternal morbidity including sepsis, septic shock, peritonitis, uterine necrosis, fistula, injury to adjacent organs, acute pulmonary edema, acute renal failure, deep vein thrombophlebitis or pulmonary embolism, or death. RESULTS: Of the 40 university hospitals that agreed to participate in this study, 25 institutions had used conservative treatment at least once (range 1–46) and had treated a total of 167 women. Conservative treatment was successful for 131 of the women (78.4%, 95% confidence interval [CI] 71.4–84.4%); of the remaining 36 women, 18 had primary hysterectomy and 18 had delayed hysterectomy (10.8% each, 95% CI 6.5–16.5%). Severe maternal morbidity occurred in 10 cases (6.0%, 95% CI 2.9–10.7%). One woman died of myelosuppression and nephrotoxicity related to intraumbilical methotrexate administration. Spontaneous placental resorption occurred in 87 of 116 cases (75.0%, 95% CI 66.1–82.6%), with a median delay from delivery of 13.5 weeks (range 4–60 weeks). CONCLUSION: Conservative treatment for placenta accreta can help women avoid hysterectomy and involves a low rate of severe maternal morbidity in centers with adequate equipment and resources. LEVEL OF EVIDENCE: II

Major vascular injuries during gynecologic laparoscopy

BACKGROUND This study was undertaken to report our experience with major vascular injuries in gynecologic laparoscopy in order to specify the circumstances under which they occurred, the means of diagnosis, the risk factors, and the means for prevention. STUDY DESIGN Retrospective case review study. RESULTS Seventeen patients with 21 major vascular injuries were identified. The average age of the patients was 33.8 +/- 11.6 years, and the mean body index mass was 21.6 +/- 3.08 kg/m2. Three of four of the accidents occurred during the set-up phase of laparoscopy (13 cases; 76.5%), and in 4 cases (23.5%) the accident occurred during the laparoscopic surgery procedure. Eleven (84.6%) of the complications occurring during the set-up phase were secondary to insertion of the umbilical trocar and 2 (15.4%) to insertion of the needle used to create the pneumoperitoneum (P-needle). Half (6 cases; 54.5%) of the major vascular injuries secondary to insertion of the umbilical trocar were observed when reusable trocars were used. In every case, the diagnosis was made during the operation. Two patients died, and two others presented a serious complication (phlebitis; acute ischemia requiring reoperation). CONCLUSIONS Major vascular injuries are rare but serious complications of laparoscopic surgery. Prevention of these accidents relies on the surgeons experience and scrupulous respect of the safety rules. In the vast majority of cases, it is necessary to convert to laparotomy immediately, calling in a vascular surgeon.

European registry of babies born to mothers with antiphospholipid syndrome

Objectives This study aimed to describe the long-term outcome and immunological status of children born to mothers with antiphospholipid syndrome, to determine the factors responsible for childhood abnormalities, and to correlate the childs immunological profile with their mothers. Methods A prospective follow-up of a European multicentre cohort was conducted. The follow-up consisted of clinical examination, growth data, neurodevelopmental milestones and antiphospholipid antibodies (APL) screening. Children were examined at 3, 9, 24 months and 5 years. Results 134 children were analysed (female sex in 65 cases, birth weight 3000±500 g, height 48±3 cm). Sixteen per cent had a preterm birth (<37 weeks; n=22), and 14% weighted less than 2500 g at birth (n=19). Neonatal complications were noted in 18 cases (13%), with five infections (4%). During the 5-year follow-up, no thrombosis or systemic lupus erythematosus (SLE) was noted. Four children displayed behavioural abnormalities, which consisted of autism, hyperactive behaviour, feeding disorder with language delay and axial hypotony with psychomotor delay. At birth lupus anticoagulant was present in four (4%), anticardiolipin antibodies (ACL) IgG in 18 (16%), anti-β2 glycoprotein-I (anti-β2GPI) IgG/M in 16 (15%) and three (3%), respectively. ACL IgG and anti-β2GPI disappeared at 6 months in nine (17%) and nine (18%), whereas APL persisted in 10% of children. ACL and anti-β2GPI IgG were correlated with the same mothers antibodies before 6 months of age (p<0.05). Conclusion Despite the presence of APL in children, thrombosis or SLE were not observed. The presence of neurodevelopmental abnormalities seems to be more important in these children, and could justify long-term follow-up.

Risk factors for severe neonatal acidosis.

OBJECTIVE: Neonatal asphyxia may have severe consequences in term newborns. Our purpose was to identify possible risk factors of severe acidosis during pregnancy and labor. METHODS: In a case–control study from January 2003 to December 2008 in three university perinatal centers (two French and one Canadian hospitals), we analyzed 226 women with term pregnancies complicated by severe neonatal acidosis (umbilical artery pH less than 7.00). Cases were individually matched with controls with a normal acid-base status (pH 7.15 or greater) paired by parity. Groups were compared for differences in maternal, obstetric, and fetal characteristics. Univariable and logistic conditional regression were used to identify possible risk factors. RESULTS: Among 46,722 births after 22 weeks, 6,572 preterm births and 829 stillbirths or terminations of pregnancy were excluded. From the 39,321 live term births, 5.30% of pH values were unavailable. Severe acidosis complicated 0.63% of 37,235 term structurally normal pregnancies. By using multivariate conditional regression, maternal age 35 years or older (35.0% compared with 15.5%; odds ratio [OR] 5.58, 95% confidence interval [CI] 2.51–12.40), prior neonatal death (3.5% compared with 0%), prior cesarean delivery (24.7% compared with 6.6%; OR 4.08, 95% CI 1.71–9.72) even after excluding cases of uterine rupture, general anesthesia (8.4 compared with 0.9%; OR 8.04, 95% CI 1.26–50.60), thick meconium (6.4% compared with 2.8%; OR 5.81, 95% CI 1.72–19.66), uterine rupture (4.4% compared with 0%), and abnormal fetal heart rate (66.1% compared with 19.8%; OR 8.77, 95% CI 3.72–20.78) were independent risk factors of severe neonatal acidosis. CONCLUSION: Prior cesarean delivery, maternal age 35 years or older, prior neonatal death, general anesthesia, thick meconium, uterine rupture, and abnormal fetal heart rate are independent risk factors of severe neonatal acidosis. LEVEL OF EVIDENCE: II

Differentiation between severe HELLP syndrome and thrombotic microangiopathy, thrombotic thrombocytopenic purpura and other imitators

Pre-eclampsia complicated by severe HELLP (hemolysis, elevated liver enzymes and low platelet count) syndrome is a multi-organ disease, and can be difficult to differentiate from thrombotic microangiopathy (appearing as thrombotic thrombocytopenic purpura or hemolytic uremic syndrome), acute fatty liver, systemic erythematous lupus, antiphospholipid syndrome and severe sepsis. Many papers have highlighted the risks of misdiagnosis resulting in severe consequences for maternal health, and this can be fatal when thrombotic thrombocytopenic purpura is misdiagnosed as severe HELLP syndrome. The aim of this paper is to propose relevant markers to differentiate pre-eclampsia complicated by severe HELLP syndrome from its imitators, even in the worrying situation of apparently indistinguishable conditions, and thereby assist clinical decision-making regarding whether or not to commence plasma exchange. Relevant identifiers to establish the most accurate diagnosis include the frequency of each disease and anamnestic data. Frank hemolysis, need for dialysis, neurological involvement and absence of disseminated intravascular coagulation are indicative of thrombotic microangiopathy. The definitive marker for thrombotic thrombocytopenic purpura is undetectable ADAMTS 13 activity.

Complications vasculaires majeures de la cœlioscopie gynécologique

OBJECTIVE: To specify the circumstances of occurence, the means of diagnosis, the risk factors and the means of prevention for major vascular injuries (MVI) during gynecologic laparoscopic procedure. STUDY DESIGN: Retrospective case review study of 24 patients. RESULTS: Twenty-four patients with 31 MVI were identified. The average age of the patients was 32.8 +/- 10.6 years and the mean body index mass was 22.4 +/- 4.0 kg/m2. Three of four of the MVI occurred during the setting-up phase of laparoscopy (19 cases; 79.2%). In five cases (20.8%) MVI occurred during the laparoscopic surgical procedure. Fifteen of the MVI occurring during the set up phase were secondary to insertion of the umbilical trocar and four to insertion of the needle used to create the pneumoperitoneum. A minimum of six MVI secondary to insertion of the umbilical trocar were observed with disposable trocars. In every case diagnosis was performed during the laparoscopic procedure. Five patients (20.8%) died and three others (12.5%) presented serious complications (phlebitis (one case); ischemia (two cases) with a reoperation for one patient). CONCLUSION: MVI are rare but serious complications of gynecologic laparoscopy. Prevention relies on the surgeons experience and strict respect of the safety rules. In the vast majority of cases, it is necessary to convert to laparotomy immediately, calling in a vascular surgeon.

Complications of laparoscopy: a prospective multicentre observational study

Sir, We were grateful to Professor Barlow for highlighting our research on women’s health during the menopause (Vol 104, August 1997)’ in his recent commentary (Vol 104, August 1997)2 and support his request for multidisciplinary co-operation in this area. As he rightly says, the psychological symptoms experienced by women study members aged 47 years in the MRC National Survey of Health and Development appear in part to reflect underlying factors which were detectable a decade earlier and suggest there is continuity of health in adult life. Professor Barlow also suggests that our study found that the increased problems among women taking hormone replacement therapy could be accounted for by predisposing factors noticeable at 36 years of age. So far we have no evidence that this is so, as we report in the discussion: “One hypothesis is that the relationship between psychological symptoms and HRT use may not be related to the experience of menopause per se but occur because HRT users have been more susceptible to these symptoms, or more inclined to report symptoms, at each life stage. However this hypothesis was not supported in this study which found no evidence that eventual HRT users had been more anxious and depressed at 36 years (data not shown), although both factors were important and independent predictors of psychological symptoms at 47 years.” As we are still following these women up and taking a full HRT history we plan to examine in detail the pattern of HRT use in this cohort, its relationship to current symptomatology, and whether long term users differ from the rest of the cohort, either in terms of earlier psychological difficulties or in ways which may have an effect on their future disease risk. This cohort are already heavy users of HRT by the age of 50 years two-fifths of women have tried taking HRT and over one-fifth have taken it for two years or more.

ADAMTS13 deficiency in severe postpartum HELLP syndrome.

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Endocervical infection in a pregnant woman caused by Neisseria meningitidis: evidence of associated oropharyngeal colonization of the male partner

A case of premature birth associated with an endocervical infection caused by Neisseria meningitidis is reported. Treatment of the mother with amoxycillin eradicated the bacteria from the endocervix and avoided newborn colonization or infection. Epidemiological investigation identified meningococcal oropharyngeal colonization of the male partner. The two strains were of the same antigenic formula B:4:P1.14 and exhibited identical rDNA restriction fragment patterns and outer membrane protein profiles. This phenotypic and genomic identity of strains is the first clear evidence for cross-colonization between sexual partners.

Using middle cerebral artery peak systolic velocity to time in utero transfusions in fetomaternal hemorrhage.

BACKGROUND: Fetomaternal hemorrhage is a rare cause of fetal anemia and hydrops fetalis. Early and severe fetomaternal hemorrhage may benefit from in utero transfusion(s); however, hemorrhage rate is unpredictable, and reliable criteria are needed to identify recurrent anemia. CASE: Fetal hydrops due to massive fetomaternal hemorrhage was diagnosed at 29 weeks. After the first in utero transfusion, daily monitoring of middle cerebral artery peak systolic velocity suggested recurrent fetal anemia, requiring two additional in utero transfusions at 1-week intervals. One day after the third in utero transfusion, a sudden increase in fetomaternal hemorrhage rate was suspected on a rapid elevation of middle cerebral artery peak systolic velocity, leading to immediate delivery at 32 weeks. CONCLUSION: Middle cerebral artery peak systolic velocity is a relevant, noninvasive tool for the timing of repeated in utero transfusions and of fetal delivery in case of chronic fetomaternal hemorrhage.