Abstract: BACKGROUND & AIMS: Infants born with severe IUGR are exposed to higher neonatal mortality and morbidity rates, as compared with appropriate-for-gestational-age. They are exposed to a higher risk of developing chronic disease such as hypertension, coronary artery disease, obesity, and type 2 diabetes in adulthood. l-Arginine is a precursor of nitric oxide (NO) and may play a role in placental vascular mediation or local vasodilatation. OBJECTIVE: The current study was designed to determine whether oral supplementation of gravid patients suffering from severe intrauterine growth restriction (IUGR) with l-arginine, would enhance birth weight and/or decrease neonatal morbidity. PATIENTS AND METHODS: Forty-four patients with a singleton pregnancy who had been referred for IUGR detected by ultrasonic examination were included. Vascular IUGR was defined by fetal abdominal circumference less than or equal to the 3rd percentile, associated with abnormal uterine Doppler. After double-blind randomization, patients received either 14g/day of l-arginine, or a placebo. RESULTS: The characteristics of the two groups of patients (IUGR with l-arginine vs IUGR with placebo) were similar upon randomization. There was no significant difference between the two groups concerning birth weight (1042+/-476 vs. 1068+/-452g). At delivery, maternal and neonatal characteristics were similar in the two groups. There was no difference in the Clinical Risk Index for Babies (CRIB) score, the duration of ventilatory assistance, nor the delay between birth and full enteral feeding between the two groups. CONCLUSION: In this study which is, at the best of our knowledge, the first double-bind, multicenter, randomized trial in this condition, l-arginine is not an effective treatment for severe vascular growth restriction.
Abstract: OBJECTIVE: To examine whether a first or second trimester induced abortion with misoprostol influences the risk of late abortion or preterm delivery in subsequent pregnancies. STUDY DESIGN: Case-control study in a teaching hospital from January 2005 to June 2006. The cases had singleton pregnancies delivered at 16-36 weeks of gestation after spontaneous late abortions, preterm labor or preterm premature rupture of membrane, or induction of labor for preterm premature rupture of membrane before 37 weeks. The control group was composed of the two consecutive spontaneous singleton deliveries at >/=37 weeks of gestation after each new case (ratio 2/1). The principal outcome measure was late abortion or preterm delivery. The association between late abortion or preterm delivery and a previous induced abortion with misoprostol was first assessed with the Cochran-Mantel-Haenszel chi-square test. Conditional logistic regression models adapted for clustered data were then further used to quantify the effect size, measured by estimated odds ratios (ORs) with their 95% confidence intervals (95% CI). RESULTS: The study included 245 cases and 490 controls. There was no significant difference in mean maternal age, number of pregnancies, parity, smoking, or history of first trimester miscarriage between cases and controls. However, a history of late abortion or previous preterm delivery was significantly more frequent among cases than controls. Forty (16.3%) cases and 56 (11.5%) controls had a history of cervical ripening with misoprostol before vacuum curettage or evacuation, or of medical abortion by misoprostol alone or with mifepristone (OR 1.51, 95% CI: 0.95-2.39; p=0.08). After adjustment for maternal age and number of pregnancies with a multivariable conditional regression model, the adjusted OR was estimated at 1.33 (95% CI: 0.81-2.17; p=0.25). CONCLUSION: Despite the need for prudence, these results provide some reassurance that induced abortion with misoprostol during the first or second trimester of pregnancy is safe for subsequent pregnancies.
Abstract: OBJECTIVE: The purpose of this study was to assess the incidence and risk factors of limb constriction defects that are related to pseudoamniotic band syndrome (PABS) after selective fetoscopic laser surgery (FLS) in fetofetal transfusion syndrome (FFTS). STUDY DESIGN: All consecutive cases of FFTS that were treated by selective FLS between 1999 and 2006 were examined prospectively for PABS at the time of delivery. Incidence and characteristics of PABS were reported. Univariate analysis was conducted to look for potential risk factors of developing PABS. RESULTS: The 438 consecutive FFTS cases were treated at 15-26 weeks of gestation; PABS developed in 8 cases (1.8 %). The affected twin was always the former recipient. The diagnosis was made prenatally in 2 of 8 cases (25%). All cases survived the perinatal period. PABS affected fetal leg, arm, and foot in 3, 4, and 1 cases, respectively. In 5 (62.5%) and 7 (87.5%) cases, PABS occurred after premature rupture of membranes and intrauterine death of the donor, respectively. In 4 cases (50%), there was both premature rupture of membranes (PROM) and intrauterine fetal death; in 3 cases (37.5%), there was intrauterine fetal death alone, and in 1 case (12.5%), there was PROM alone. In the remaining 430 cases, PROM occurred in 62 cases (14.4%) and 66 cases (15.3%) within and after 3 weeks after surgery, respectively. PROM was significantly more frequent within the group that was complicated with PABS than within the rest of the cohort (P = .05). No maternal, fetal, or perioperative risk factor could be identified. CONCLUSION: Awareness and targeted serial ultrasound evaluation in this high-risk group may improve prenatal diagnosis, counseling, and management of PABS after FLS.
Abstract: We report on a fetus with multiple congenital anomalies including atypical lissencephaly, corpus callosum agenesis, cerebellar hypoplasia, cleft palate, ventricular septal defect, and hypoplastic aortic arch. The initial routine chromosome study failed to detect any abnormality. Subtelomeres analysis by MLPA identified an 18q23 duplication inherited from its healthy father. We describe the anomalies identified and discuss diagnosis and the causability of this telomeric duplication.
Abstract: We report a case of spontaneous rupture of an ovarian artery aneurysm, 5 days after delivery. Severe abdominal pain justified a computed tomography scan, which revealed a massive retroperitoneal hematoma. Arteriography showed the rupture of an ovarian artery aneurysm that was successfully embolized using microcoils.
Abstract: BACKGROUND: Monochorionic twin pregnancies complicated by severe twin-to-twin transfusion syndrome at midgestation can be treated by either serial amnioreduction (removal of large volumes of amniotic fluid) or selective fetoscopic laser coagulation of the communicating vessels on the chorionic plate. We conducted a randomized trial to compare the efficacy and safety of these two treatments. METHODS: Pregnant women with severe twin-to-twin transfusion syndrome before 26 weeks of gestation were randomly assigned to laser therapy or amnioreduction. We assessed perinatal survival of at least one twin (a prespecified primary outcome), survival of at least one twin at six months of age, and survival without neurologic complications at six months of age on the basis of the number of pregnancies or the number of fetuses or infants, as appropriate. RESULTS: The study was concluded early, after 72 women had been assigned to the laser group and 70 to the amnioreduction group, because a planned interim analysis demonstrated a significant benefit in the laser group. As compared with the amnioreduction group, the laser group had a higher likelihood of the survival of at least one twin to 28 days of age (76 percent vs. 56 percent; relative risk of the death of both fetuses, 0.63; 95 percent confidence interval, 0.25 to 0.93; P=0.009) and 6 months of age (P=0.002). Infants in the laser group also had a lower incidence of cystic periventricular leukomalacia (6 percent vs. 14 percent, P=0.02) and were more likely to be free of neurologic complications at six months of age (52 percent vs. 31 percent, P=0.003). CONCLUSIONS: Endoscopic laser coagulation of anastomoses is a more effective first-line treatment than serial amnioreduction for severe twin-to-twin transfusion syndrome diagnosed before 26 weeks of gestation.
Abstract: The purpose is to identify maternal and prenatal risks factors for placental vascular disorders. We excluded biologic and epidemiological data which are discussed in another chapter. Maternal risks factors are pre-existing vascular systemic diseases. Systemic lupus erythematosus (antiphospholipid antibodies are studied in another chapter) is a classical disease associated with unfavorable outcome, particularly when the disease is not quiescent and if the patient has a history of previous poor outcome. Obstetricians' awareness of the influence of inflammatory bowel diseases on pregnancy and fetal outcome is quite poor. These diseases, if they are not quiescent, can induce deleterious perinatal effects. Type 1 or even type 2 diabetes mellitus increases the risk of preeclampsia or hypertension in pregnancy, particularly when there is poor glycemic control early in pregnancy. The duration of type 1 diabetes affects the outcome of pregnancy more than type 2. Smoking during pregnancy is associated with many adverse events including spontaneous abortion, low birth weight and placental abruption. There are data about the dose-response relationship between the number of cigarettes smoked per day and the risk of abortion. Smoking during pregnancy is also protective against preeclampsia and this apparent paradox suggests the complexity of what is called vascular placental pathology. There is a significant relationship between pejorative perinatal vascular outcome and the non quiescence of renal disease. Mid-trimester uterine artery Doppler combining bilateral notches and increased uterine resistance index is the best criterion to predict the placental vascular risk of the pregnancy. Some promising studies suggest the feasibility of uterine Doppler ultrasound screening early in the pregnancy during the first trimester. Large studies are required to confirm this practice. Uterine artery Doppler in combination with other tests (elevated maternal serum hCG or ambulatory 24-hour blood pressure monitoring at 22 weeks gestation) could be a more efficient predictor of vascular complications. A large-scale evaluation is necessary before recommendations can be made. Multiple pregnancies increase the risk of preeclampsia 2- or 3-fold (RR 2.62; 95% CI: 2.03-3.38). A history of preeclampsia is the strongest predictor of unfavorable outcome for the second pregnancy.
Abstract: OBJECTIVE: Primary antiphospholipid syndrome (APS) is by definition associated with high obstetric risk. We performed a retrospective study of pregnancies in women with this syndrome in an attempt to define a common means of caring these patients. STUDY DESIGN: Women with APS followed in Internal Medicine Department and in Gynecology Department since 1989 were studied retrospectively. RESULTS: Fifteen women with primary APS had a total of 51 pregnancies, 39 (76%) of which ended in embryonic (n = 24) or fetal (n = 15) loss. Only 6/39 untreated pregnancies led to a live birth, including 2 cases of intrauterine growth retardation. Among the 12 pregnancies treated preventively for obstetric complications, 6 led to a live birth. The treatments used were dissimilar and included aspirin, corticosteroids and heparin, either alone or in association. Four of these 6 live births were obtained by aspirin alone. Gravidic toxemia was observed in one untreated patient. CONCLUSION: The obstetric prognosis for untreated APS is appalling. The benefit of heparin therapy in association with aspirin remains to be demonstrated, ideally in a protocol comparing aspirin alone with aspirin and heparin.
