Ph. Dufour

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.

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.

Immunological aspects of ovarian function : role of the cytokines

Interaction between the immune system and reproduction is multiple. Either directly or indirectly through their products, immune cells are associated with the regulation of every level of the hypothalamus-pituitary-ovarian axis. Immune cells are present in the ovaries and their numbers increase during the cycle. During the follicular development cytokines assist granulosa cell growth while inhibiting their differentiation. During the LH peak, an influx of immune cells occurs and several cytokines are released. The rupture of the follicle is considered as an inflammatory reaction. IL-1, TNF-alpha are the main cytokines involved in this process. During the luteal phase, the installation of the corpus luteum needs the setting up of neovascularization. Cytokines are probable candidates for this function, but they also promote cellular differentiation resulting in steroid synthesis. In the absence of pregnancy T lymphocytes and eosinophils are involved in corpus luteum regression. Their products are directly cytotoxic for the luteal cells. They attract macrophages which are locally activated to phagocytose the damaged luteal cells. They can induce apoptosis of endothelial and luteal cells through gene expression. Cytokines are members of a larger regulatory network residing in the ovary and involving hormones and growth factors. The various stages of ovarian cycle will be shown from an immunological point of view. Understanding the role of the cytokines should enable us to go beyond a purely descriptive stage, and allow us to envisage new ovulation induction therapy and treatment in certain cases of premature menopause.

The use of intravenous nitroglycerin for cervico-uterine relaxation: a review of the literature

Abstract. The safety, predictability, and ease of intravenous administration of nitroglycerin (NTG) have been firmly documented. In recent years, intravenous NTG has come to the attention of the obstetrician as a potent uterine relaxant. Intravenous nitroglycerin has been used to relax the uterus during manual extraction of retained placenta and to permit replacement of a contracted, completely prolapsed, inverted uterus. The use of this agent as a tocolytic has previously been reported in cesarean delivery of twins, in cases of intra partum external cephalic version, and for internal intrapartum podalic version of the second twin. This new procedure was also used for fetal head entrapment after vaginal breech delivery. The authors report a review of the literature about this subject.

Monoamniotic twin pregnancies. Review of the literature, and a case report with vaginal delivery

OBJECTIVE To specify the process of the sometimes difficult diagnosis of monoamniotic twin pregnancies, as well as the best practise for delivery of this type of pregnancy. METHOD Using their personal observation (a patient with a monoamniotic twin pregnancy, which presented a vaginal delivery at 35 weeks of gestation, two girls, in cephalic presentation, without particular problem, despite an entanglement of the cord and the existence of a knot), the authors established a review of the literature on this subject. RESULTS Monoamniotic twin pregnancies represent a rare possibility. The prognosis is traditionally somber: 40-60% mortality, mainly due to pathologies of the cord. The review of the recent literature shows that most authors remain in favour of weekly ultrasound supervision from the 23rd week and of caesarean section in principle at 34 weeks (or from fetal pulmonary maturation). CONCLUSION In the absence of funicular compression signs by colour-doppler, and under the cover of flawless obstetrical conditions, vaginal delivery can only be authorized for cases when both presentations are cephalic.

Intravenous nitroglycerin for internal podalic version of the second twin in transverse lie

Objective To report our experience with high doses (0.1–0.2 mg per 10 kg pregnant weight) of intravenous (IV) nitroglycerin as a uterine relaxing agent for managing internal podalic version of the second twin in transverse lie with unruptured membranes. Methods Between August 1994 and December 1997, we managed 22 cases of internal podalic version of the second twin with the administration of high doses of IV nitroglycerin. Results Twenty internal podalic versions were completed successfully, and two cases failed. One failure was considered not related to IV nitroglycerin because the patient had a panic attack, requiring general anesthesia for sedation. The internal podalic version then succeeded. The patient with true failure of IV nitroglycerin required emergency cesarean because of acute fetal bradycardia and a nonrelaxed uterus. This was the only nontransverse lie, but with a very high face presentation. One internal podalic version was complicated by hemorrhage (2000 mL). Conclusion Intravenous nitroglycerin to induce uterine atonia, with epidural analgesia, avoids general anesthesia and makes internal podalic version easier. In 22 cases (with success in 20) of internal podalic version of the second twin in transverse lie with unruptured membranes, IV nitroglycerin induced transient and prompt uterine relaxation without affecting maternal and fetal outcomes.

Varicella and pregnancy

OBJECTIVE To appreciate the risk of embryo-foetopathy in case of maternal varicella occurring before 20 weeks of gestation, as well as the maternal complication risk (notably pulmonary) in case of maternal varicella occurring the third trimester of pregnancy. METHOD Over the period from January 1987 to February 1995, 20 patients were managed for maternal varicella confirmed during the pregnancy. From these observations, the authors, by studying the literature, attempt to better specify the real fetal and/or maternal complication risk in case of maternal varicella. RESULTS In their personal series of 20 cases, including 17 before 20 weeks of gestation, the authors have noted no embryo-foetopathy. Similarly, no maternal complication (notably pulmonary complication), has been found. Careful study of the literature allows to specify some points. In case of varicella before 20 weeks, one observes an identical frequency of spontaneous abortions, as compared to the general population and a moderated increase of the frequency of premature delivery. The risk of congenital varicella syndrome reaches about 1.3%. Finally the risk of neonatal varicella consists in a maternal infection which occurs during the perinatal period and which is source of a high perinatal morbidity. The prenatal diagnosis is based essentially and currently, on the amniocentesis with viral research by polymerase chain reaction (PCR) in the amniotic fluid, completed by a ultrasound supervision. CONCLUSION The occurrence of maternal varicella during the pregnancy is rare (0.7/1000) because more than 90% of women are immunized. The risk of congenital varicella syndrome is limited to the 20 first weeks and seems very weak, authorizing therapists to reassure patients presenting a varicella during their pregnancy. Nevertheless, the risk of pulmonary complications for the mother, in case of varicella during the third trimester, does exist and requires appropriated treatment.

Pregnancy after myocardial infarction

Abstract The occurence of pregnancy in a patient after myocardial infarction remains a dilemma for both the cardiologist and the obstetrician. The majority of obstetrians and cardiologists are very reticent about pregnancy in a woman suffering from coronary disease. Aims: The aims of this study are to evaluate the risks, the prognosis of pregnancy for women who had suffered from myocardial infarction and to propose guidelines for pre-pregnancy counselling and medical supervision of the pregnancy and delivery. Methods: A review of literature has revealed 30 cases, 14 of which are sufficiently documented. Only one of these patients requested pre-pregnancy counselling. We add to this experience the case of a patient who, having had an infarction, was authorized to begin pregnancy. Results: Most of the pregnancies in these patients evolve satisfactorily if the more frequent cardiovascular complications are diagnosed and treated rapidly. During the pregnancy, rest is the rule and any situation which risks to increase the myocardial work-load should be avoided. Normal vaginal delivery with epidural anesthesia is the preferred method. Conclusion: The maternal and fetal prognosis is good on condition of performing a pre-pregnancy examination and of setting up a multi-discipline surveillance of the pregnancy. The review of the literature does not confirm the surrounding pessimism concerning the patients becoming pregnant after myocardial infarction.

Intravenous nitroglycerin for intrapartum internal podalic version of the second non-vertex twin

OBJECTIVE Authors report their experience of intravenous nitroglycerin as uterine relaxing agent for managing successfully internal podalic version of the second twin. METHODS From a retrospective study including nine observations of internal podalic version of the second non vertex twin performed with administration of intravenous nitroglycerin, between August 1994 and February 1996, authors compare their results with those reported elsewhere. RESULTS Two failures of internal podalic version with nitroglycerin have been observed. But one failure is not considered to be due to the NTG: it was a patient, who had a panic attack necessitating a general anesthesia for sedative purpose. The internal podalic version succeeded. The true failure of NTG needed an emergency cesarean due to acute fetal distress and a non relaxing uterus. One internal podalic version was complicated by hemorrhage. The intravenous NTG used to induce uterine atonia associated with epidural-analgesia to relief pain avoiding general anesthesia makes internal podalic version easier. CONCLUSION Our results confirmed those already reported. That intravenous nitroglycerin (NTG) injection induces a transient and prompt uterine relaxation required for internal podalic version without affecting maternal and fetal prognosis.

Pregnancy after myocardial infarction and a coronary artery bypass graft

The authors report a pregnancy in a 34 year old patient who previously experienced a myocardial infarction. The pregnancy ended at 39 weeks in the birth of a healthy girl weigthing 3040 g, by cesarean section under epidural anesthesia. A review of the literature revealed 33 similar cases, 16 of which were adequately documented.