Pierre-François Ceccaldi

Risk of synechiae following uterine compression sutures in the management of major postpartum haemorrhage

Please cite this paper as: Poujade O, Grossetti A, Mougel L, Ceccaldi P, Ducarme G, Luton D. Risk of synechiae following uterine compression sutures in the management of major postpartum haemorrhage. BJOG 2011;118:433–439.

Placental transfer of enfuvirtide in the ex vivo human placenta perfusion model

OBJECTIVE The objective of the study was to determine the placental transfer of the antiretroviral fusion inhibitor, enfuvirtide (Fuzeon). STUDY DESIGN Human cotyledons were perfused for 90 minutes in an open dual circuit with enfuvirtide, and fetal venous samples were collected every 5 minutes. Three perfusion experiments were validated using antipyrine. RESULTS Enfuvirtide was not detected in the fetal compartment in any of the 3 experiments. The mean concentration of the drug measured in the maternal compartment was 12,400 ng/mL (range, 6500-16,200 ng/mL), which is 2.5 times the maximum concentration recommended for patients treated with enfuvirtide. CONCLUSION Even at maternal concentrations twice above therapeutic levels, no placental transfer of enfuvirtide was observed. The high molecular weight of the molecule (4492 kDa) and its ionized state may account for the lack of placental transfer. This result suggests that enfuvirtide could be used in HIV-infected pregnant women without causing fetal exposure.

Anti-TPO antibodies diffusion through the placental barrier during pregnancy.

Background Hashimoto’s thyroiditis is the principal aetiology of hypothyroidism with presence of anti-thyroperoxidase antibodies (anti-TPO). The association between anti-TPO and foeto-placental complications has been observed in previous studies. To go further in the understanding, the current study compares the level of anti-TPO in maternal blood and in the cord blood of her fetus at the moment of childbirth to demonstrate the passage of anti-TPO through the placenta barrier. Methods and Findings This study was realised in a maternity ward located in the Northern district of Paris, France from 2006 to 2007. Women with normal pregnancy were included in a first study and only women with no abnormal thyroid dosage at baseline and tested positive with anti-TPO were prospectively enrolled. Maternal blood samples were collected in the third trimester and at the arrival to the ward when patients came to deliver. After delivery, cord blood sample was collected. Pearson’s correlation coefficient was computed. 5941 patients delivered in the ward during the study, 33 pregnant women were included. We found a correlation between the anti-TPO levels in maternal and in the cord blood of their fetus with a correlation coefficient of 0.98 and a p-value<0.001. Conclusions This is the first demonstration of the free passage through the placental barrier of anti-TPO from the mother to the fetus at the moment of childbirth. These findings can be extrapolated all along pregnancy and open the door to a direct action of the anti-TPO on fetus and to a possible action on the fetal thyroid.

Preconception care in France

Preconception care is advocated throughout the world as a tool for improving perinatal outcomes. However, the proportion of women in France who attend a dedicated medical preconception visit is unknown.

Amniocentèse et risque viral (hépatites virales B, C et VIH)

Very few studies have properly addressed to the risk of fetal hepatitis B (HBV), hepatitis C (HCV) or human immunodeficiency virus (HIV) infection through amniocentesis. For HBV, this risk is low. However, knowledge of the maternal hepatitis B e antigen status is valuable in the counselling of risks associated with amniocentesis. For HCV, the risk is not well known but cannot be excluded. For HIV, it seems rational to propose a viral test before amniocentesis for patients with contaminations risk and to postpone the sampling in cases with positive results in order to obtain an undetectable HIV-1 RNA viral load. For these reasons, it can be useful to analyse for each virus the benefit of amniocentesis and the risk of mother-to-infant transmission, and to inform the patient.

Intérêt de l’instillation pariétale unique de ropivacaïne dans la prévention des douleurs après césarienne

OBJECTIVE To assess the efficiency of single-shot ropivacaine wound infiltration during cesarean section for postoperative pain relief, using a prospective, randomized, double-blinded study. PATIENTS AND METHODS One hundred consecutive patients with planned cesarean section were enrolled between September 2007 and May 2008 and randomized into two groups: single-shot wound infiltration of 20mL of ropivacaine 7.5mg/mL (Group R; n=56) or single-shot wound infiltration of 20mL of saline solution (group T; n=44). The primary goal of this study was the double-blinded evaluation of the postoperative pain after coughing and leg raise using the 100-mm visual analog scales (VAS) during the first 48 postoperative hours after cesarean delivery. The secondary goals were the occurrence of nausea and vomiting and the morphine consumption. RESULTS Numerical pain rating scale for pain evaluation was significantly lower (P<0.05) in the ropivacaine group than in the control group at M0, M20, M40, M60, H2 and H4. But, at H8, H12 and H24, no significant difference for VAS was noted between the two groups. The occurrence of nausea and vomiting and the total morphine consumption were not significantly different between the two groups during the first 48 postoperative hours. DISCUSSION AND CONCLUSION Single-shot ropivacaine wound infiltration during planned cesarean section is a simple and safe procedure that provides effective reduction of post-partum pain within the first 4hours.

Persistent vegetative state with encephalitis in a pregnant woman with successful fetal outcome

Case report A 28 year old woman, gravida 3, para 2, consulted her physician at 22 weeks of gestation for a flulike syndrome. Pharyngitis was suspected and antibiotics were given. Vomiting, vertigo, left sided paraesthesia and dysarthria developed over the next few days. The patient was referred to our centre in December 2001. At the first examination, she was conscious, with confusion and fever. She had an internuclear ophthalmoplegia with monocular nystagmus; her gait was ataxic, without dysmetria. She presented left hemiparesis, dysphagia and false passage. During the next week, the neurological status worsened: the patient was able to open her eyes but unable to respond to simple commands; she became unconscious with finally a persistent vegetative status. The patient was admitted to the Department of Neurosurgery, which is located immediately beside the obstetric unit at our institution. Her neurological status remained unchanged for 10 weeks. The brain magnetic resonance imaging (MRI) showed numerous hypersignals in the cerebral trunk, corpus callosum and basal hemispheric brain (Fig. 1). Routine biochemical tests were normal. The analysis of the cerebrospinal fluid showed a non-specific reaction (normal glucose, 1.5 g/L protein, 11–30 leucocytes/mm 3 ). The immunologic tests found high concentrations of IgM against Epstein–Barr virus and cytomegalovirus and an antiprothrombin-like circulating anticoagulant. The direct viral and bacteriological cultures were negative. The diagnosis was therefore encephalitis of unknown origin. The patient was separated and not married to the father of the fetus. Her parents were the legal decision makers in this case. They received complete information on medical findings and data of the literature, and we told them that in our opinion, the pregnancy should be continued. However, the parents wrote to political and medical authorities to request for the pregnancy to be terminated. We asked a judge to appoint an independent arbiter. We also asked for an opinion from the National Academy of Medicine and National Committee of Ethics. All these authorities agreed

Modulation of free corticotrophin-releasing hormone, adrenal and placental steroid hormone levels induced by mifepristone during pregnancy.

Mifepristone is a progesterone receptor antagonist widely used in obstetrics. The aim of the study was to focus on free corticotrophin-releasing hormone (CRH) and also describe modulation of adrenal and placental steroid hormone concentrations induced by mifepristone. Methods: Twenty-six women were enrolled in the study. They received mifepristone for termination of pregnancy. Maternal blood samples were retrieved before administration of mifepristone (600 mg) and 48 h after, just before induction of labor. Bound and free CRH levels were determined in maternal blood concomitantly with cortisol, estriol, progesterone and SDHEA levels. Also paired fetal cord blood samples were collected. Results: Maternal plasmatic CRH level did not change after mifepristone absorption but free CRH increased significantly (0.500 ± 0.326 vs. 0.388 ± 0.303 ng/ml, p = 0.040). A significant decrease of progesterone was observed (83.6 ± 49.3 vs. 95.6 ± 54.9 ng/ml, p = 0.001) with a lower progesterone/estriol ratio (26.9 ± 15.7 vs. 40.7 ± 31.1, p = 0.004). There was a strong association between maternal and fetal free CRH (r2 = 0.675, p = 0.001), cortisol (r2 = 0.570, p = 0.019), and positive but modest correlation for progesterone (r2 = 0.341, p = 0.046) and estriol (r2 = 0.379, p = 0.025) levels. Conclusion: Mifepristone has an effect on free CRH level and changes the estriol-progesterone balance.

Apports de la perfusion ex vivo du cotylédon humain dans l’étude du passage placentaire des médicaments

Perfused human placental lobule was developed during the 1970s. Only this model respects the anatomical features of the human placenta. This approach allows different technical conditions (concentrations of drugs…) without ethical problems. Limitations of this ex vivo model are detailed in this review, also its recent contributions in better understanding of placental passage of drugs.

Dysplasies cervicales chez les patientes ménopausées infectées par le VIH

INTRODUCTION An increasing number of HIV-1-infected women reaches the age of menopause. This infection is associated with a higher incidence of cervical squamous intraepithelial lesions (low-grade or LSIL, high grade or HSIL). The aim of our study was to describe the cervical disease in these patients during menopause. PATIENTS AND METHODS Retrospective study, identifying all Pap smears and colposcopy in HIV-1-infected postmenopausal women between 1995 and 2008, in our hospital. RESULTS Eighteen postmenopausal women, aged of 54 years (43-63), have HIV-1 infection since 7.5 years (2-25). Fifty-one pathological exams were reviewed in which 27 (50.98%) abnormal, including four (7.84%) ASC-US, 15 (29.41%) LSIL lesions, and seven (13.73%) HSIL. Ten patients had surgery (laser, conisation, hysterectomy) during the period. The evolution of cervical lesions was: stability in 40.48%, regression in 35.71% and progression in 23.81%. The median time to develop an HSIL at menopause was 5 years. CONCLUSION In our study, postmenopausal HIV-1-infected women have most frequently LSIL and persistent. Monitoring of these postmenopausal women should be continued, the attitude to realise an initial HPV typing and confirmation of an abnormal annually Pap smear with colposcopic exam should be confirmed by larger study.