Jacky Nizard

Depression During Pregnancy: Is the Developmental Impact Earlier in Boys? A Prospective Case-Control Study

OBJECTIVE Animal studies have shown sex differences in the impact of prenatal maternal stress on the offspring. The aim of this prospective case-control study was to assess the effect of prenatal depression on newborn and 1-year-old infant characteristics as related to gender, controlling for confounding variables. METHOD We screened 205 pregnant women from April 2004 to November 2006 for depressive symptoms. Inclusion in the prenatal depression group (n = 34) was based on meeting DSM-IV criteria for major depressive episode. We excluded postnatal depression from the control group (n = 79) by routine screening at 2 and 6 months. Newborn and 1-year-old infant characteristics were evaluated with the Neonatal Behavioral Assessment Scale (NBAS) and the Infant-Toddler Social and Emotional Assessment, respectively. RESULTS Despite our use of numerous exclusion criteria (eg, at-risk pregnancy, preterm delivery), prenatal depression highly correlated with anxiety and stress scores. Male newborns of mothers with prenatal depression had lower scores than controls on the motor skills and regulation of states NBAS clusters (P = .03 and P = .026, respectively). At 1 year, infants of prenatally depressed mothers presented higher scores on generalized anxiety (P = .002), particularly in males (P = .009); activity/impulsivity (P = .042); and sleep problems (P = .023) than controls. CONCLUSIONS As in animal studies, depression during pregnancy may affect infant development in a way that is related to gender. Early gender differences observed to be associated with depression, stress, and anxiety during pregnancy may be a key to understanding the higher prevalence in males of child psychiatric disorders.

Maternal and fetal outcomes of pregnancy with Fontan circulation: A multicentric observational study

BACKGROUND Despite serious long-term sequel, women with Fontan palliation have reached childbearing age. However there is paucity of data on the pregnancy outcomes and management of this condition. We aimed to determine the maternal and fetal outcomes of pregnancy in women with Fontan palliation. METHODS This multicentric, retrospective study included women with Fontan circulation followed in 13 French specialized centers from January 2000 to June 2014. All pregnancies were reviewed, including miscarriages, abortions, premature and term births. We reviewed maternal and fetal outcomes. RESULTS Thirty-seven patients had 59 pregnancies. Mean age was 27 ± 5 years at first pregnancy. There were 16 miscarriages (27%) and 36 live births with 1 twin pregnancy. Cardiac events occurred in 6 (10%) pregnancies, with no maternal death. The most common cardiac complication was atrial arrhythmia, which occurred in 3 patients. Hematological complications including thromboembolic/hemorrhagic events (n=3/7) occurred in 5 women antepartum (n=2/3), and 4 women postpartum (n=1/4). Two of the 3 thromboembolic events occurred in patients without anticoagulation. There was a high incidence of prematurity (n=25/36, 69%). Anticoagulation was associated with adverse neonatal outcome (OR=10.0, 95% CI [1.5-91.4], p<0.01). After a median follow-up of 24 months, there was no significant worsening of clinical status and thromboembolic disease noted. CONCLUSIONS Pre-selected women can successfully complete pregnancy with Fontan circulation. There is an increase in cardiac and neonatal morbidity during pregnancy. Because thromboembolism could have a severe consequence on Fontan circulation, anticoagulation should be indicated during pregnancy and postpartum period.

Catastrophic antiphospholipid syndrome and pregnancy: an experience of 13 cases

OBJECTIVE Catastrophic antiphospholipid syndrome (CAPS) is a life-threatening disease caused by the onset of rapidly progressive and widespread small-vessel thromboses in the presence of aPLs. The aim of this study was to examine pregnancy-related CAPS. METHODS Retrospective series of 13 patients with pregnancy-related CAPS with special focus on the follow-up. RESULTS; Eleven patients had known APS and had been treated with low-molecular-weight heparin (n = 10), aspirin (n = 8), oral anticoagulants (n = 1), HCQ (n = 3) and/or steroids (n = 1) during pregnancy. The most frequent manifestations of CAPS were cutaneous (n = 11), hepatic (n = 11), renal (n = 10), cardiac (n = 8) and neurological (n = 5). CAPS usually followed haemolysis, elevated liver enzymes and low platelet count (HELLP) syndrome (n = 12), which was associated with pre-eclampsia (n = 6) or with eclampsia (n = 3). No maternal death was observed. The perinatal mortality of 54% was related to prematurity with a mean gestational age of 26.6 weeks at onset of CAPS or HELLP syndrome. During a mean follow-up of 4.8 years (range 2-8 years), seven new pregnancies occurred in five patients and led to one miscarriage, four successful pregnancies and two HELLP syndrome with pre-eclampsia or eclampsia that occurred at 28 weeks gestation in both cases despite optimal treatment. No relapse of CAPS was observed. Two mothers suddenly died 2.5 and 6 years after CAPS. CONCLUSION The occurrence of HELLP syndrome in a patient with APS should raise the suspicion of CAPS in the following days, and anticoagulation should be maintained post-partum or post-abortum. Subsequent pregnancies are at very high risk.

Behçet's Disease and Pregnancy

OBJECTIVE To describe the interplay between Behçets disease (BD) and pregnancy. METHODS This retrospective study included 76 pregnancies in 46 patients fulfilling the international criteria for BD. The median age of the patients at the time of entry into the study was 28.4 years (interquartile range 22.8-30.9 years). Patients were used as their own historical controls to assess the incidence of BD flares during pregnancy and before or after pregnancy. Factors associated with the occurrence of complications during pregnancy were assessed. RESULTS Among the 76 pregnancies with BD analyzed, 27 (35.5%) were associated with worsening of the symptoms of BD flare; oral and genital ulcerations (78.4% and 67.6%, respectively) as well as ocular complications (32.4%) were the most frequent. The mean ± SD annual rates of BD flares were 0.49 ± 0.72 during pregnancy and 1.46 ± 2.42 during the nonobstetric period (P = 0.018). The proportion of BD flares tended to be lower in patients treated with colchicine (27.9% versus 45.4% of patients not treated with colchicine; P = 0.11). The overall rate of complications during pregnancy was 15.8%. The complications included miscarriage (5 patients), cesarean delivery (3 patients), medical termination of pregnancy (2 patients), hemolysis, elevated liver enzymes, and low platelets syndrome (1 patient), and immune thrombocytopenia (1 patient). There was a statistically significant association between a history of deep vein thrombosis in BD and the risk of obstetric complications (odds ratio 7.25, 95% confidence interval 1.21-43.46, P = 0.029). Neither gestational age at delivery nor neonatal outcome was influenced by BD. CONCLUSION The disease course in BD seems to improve during pregnancy, mostly in patients who are treated with colchicine. Pregnancy in patients with BD appears not to be associated with an increased rate of pregnancy-related complications.

Pregnancy in a Woman with a Leptin-Receptor Mutation

This case report describes a spontaneously conceived pregnancy in a woman with a leptin receptor mutation, an observation that calls into question the belief that leptin is necessary for normal reproductive function.

Determination of fetal head station and position during labor : a new technique that combines ultrasound and a position-tracking system

OBJECTIVE The purpose of this study was to compare the ultrasound-based LaborPro (Trig Medical Ltd, Yokneam, Israel) system determination of fetal head station and position with routine vaginal examination. STUDY DESIGN This prospective study, which was conducted in 3 centers included 311 measurements that were performed in 166 singleton term pregnancies during the active phase of vertex, uncomplicated labor. Ultrasound-based position-tracking system calculations of fetal head station and position were compared with routine vaginal examination measurements. RESULTS Comparison of vaginal examination with the system head station results revealed a mean absolute difference of 5.5 +/- 6.1 mm (n = 311). Vaginal examination head-position evaluation, within a 45 degrees interval, complied with the system in 35 of 87 cases (40.2%). CONCLUSION Our data show that an ultrasound-based system can determine fetal head station and position during labor, when compared with vaginal examination, and requires minimal ultrasound skills. The limits of vaginal examination assessment of the head position are in agreement with published data.

Grossesse et syndrome des antiphospholipides

Antiphospholipid syndrome (APS) is associated with a risk of obstetrical complications, affecting both the mother and the fetus. Obstetrical APS is defined by a history of three consecutive spontaneous miscarriages before 10 weeks of gestation (WG), an intra-uterine fetal death after 10 WG, or a premature birth before 34 WG because of severe pre-eclampsia, eclampsia or placental adverse outcomes (intrauterine growth retardation, oligohydramnios). Pregnancy in women with a diagnosis of obstetric APS is at increased risk for placental abruption, HELLP (Hemolysis, Elevated Liver enzymes, Low Platelet count) syndrome and thrombosis that may be part of a catastrophic antiphospholipid syndrome (CAPS). A previous thrombosis and the presence of a lupus anticoagulant are risk factors for pregnancy failure. A multidisciplinary approach, associating the internist, the anesthesiologist and the obstetrician, is recommended for these high-risk pregnancies. Preconception counseling is proposed to identify pregnancy contraindications, and to define and adapt the treatment prior and during the upcoming pregnancy. Heparin and low-dose aspirin are the main treatments. The choice between therapeutic or prophylactic doses of heparin will depend on the patients medical history. The anticoagulant therapeutic window for delivery should be as narrow as possible and adapted to maternal thrombotic risk. There is a persistent maternal risk in the postpartum period (thrombosis, HELLP syndrome, CAPS) justifying an antithrombotic coverage during this period. We suggest a monthly clinical and biological monitoring which can be more frequent towards the end of pregnancy. The persistence of notches at the Doppler-ultrasound evaluation seems to be the best predictor for a higher risk of placental vascular complications. Treatment optimization and multidisciplinary antenatal care improve the prognosis of pregnancies in women with obstetric APS, leading to a favorable outcome most of the time.

Takayasu Arteritis and Pregnancy

To assess the relationship between Takayasu arteritis (TAK) and pregnancy outcome.

Office Hysteroscopy for Infertility: A Series of 557 Consecutive Cases

Objective. To study incidence of abnormal hysteroscopic findings according to age. Methods. We retrospectively studied 557 consecutive office hysteroscopies in patients referred for incapacity to conceive lasting at least 1 year or prior to in vitro fertilization. Rates of abnormal findings were reviewed according to age. Results. In 219 cases, hysteroscopy showed an abnormality and more than a third of our population had abnormal findings that could be related to infertility. Rates of abnormal findings ranged from 30% at 30 years to more than 60% after 42 years. Risk of abnormal finding was multiplied by a factor of 1.5 every 5 years. Conclusion. Our data are an additional argument to propose office hysteroscopy as part of first-line exams in infertile woman, regardless of age.

Amniocentesis: technique and education

Purpose of review To review available data on the technique and education of amniocentesis. Recent findings Literature shows many tools facilitating training for amniocentesis. These models can be either bought or hand made. Initial teaching should ideally be part of a specific curriculum. Reports of fetal loss due to amniocentesis differ greatly among authors, varying from 0.13 to 2.2%. Summary Developing an adapted curriculum for amniocentesis training is important and emphasizes the usefulness of a standardize technique. Available data on the risks of amniocentesis should help counseling women/couples.