Peut-on encore réaliser des rotations instrumentales par spatules de Thierry ? Étude préliminaire chez la primipare

Objectives

To study immediate perineal and neonatal outcomes after instrumental rotational performed with Thierry's spatula among primiparous, and compare subsequent perineal tear with occiput posterior position delivery.

Materials and methods

The study was performed from December 2005 to June 2006 at Paule-de-Viguier hospital (Toulouse university hospital) including all persistent occiput posterior vaginal deliveries among primiparous (49 patients). Mode of delivery was: 1) seven patients with spontaneous occiput anterior vaginal delivery (14.3%); 2) seven patients with rotational extraction using spatula with occiput anterior delivery (30.6%); 3) twenty-seven patients with instrumental extraction and occiput posterior delivery (55.1%). Maternal and fetal parameters were studied prospectively.

Results

Spatula was performed for failure of progress in 71.4% of cases (n = 30) and for no reassuring fetal status in 28.6% of cases (n = 12). In “rotational group”, only one perineal tear was observed (Third degree) (6.6%) versus seven in “occiput posterior extraction group” (26%) with three severe perineal lacerations. Neonatal superficial lesions are frequent (26,6% after rotation versus 11.6% after occiput posterior extraction). None severe traumatic tears were observed.

Conclusion

Instrumental rotation using Thierry's spatula seems to be less deleterious for maternal perineum than occiput posterior extraction, without increasing neonatal complications. Theses preliminary results have to be confirmed by more important prospective works.     

Quelle place pour la radiopelvimétrie au XXIe siècle ?

The purpose of this article was to perform a critical analysis of publications having estimated the utility of X-ray pelvimetry, in order to allow tangible and useful conclusions for the clinical practice. X-ray pelvimetry was proposed in 3 indications: trial of labour among patients with a history of caesarean section, breech presentation, suspicion of cephalopelvic disproportion. The large majority of these publications are retrospective studies, studying a low number of patients and especially without control groups or randomisation. Their contradictory results and their methodological weaknesses do not allow any conclusion. Published randomised trials are exceptional. Among patients with a history of caesarean section, there is only one randomised trial; it demonstrates that ante-partum X-ray pelvimetry is not necessary prior to a trial labour in women with one previous caesarean section. It increases the caesarean section rate and is a poor predictor of the outcome of labour. There is also only one randomised trial which evaluated the interest of X-ray pelvimetry in patients with a breech presentation: the use of pelvimetry in breech presentation at term does not significantly reduce the overall caesarean-section rate, and does not improve the neonatal issues. However, it allows better selection of the delivery route, with a significantly lower emergency Caesarean-section rate. Finally, the only one randomised trial having studied the utility of X-ray pelvimetry for the prediction of cephalopelvic disproportion shows that pelvimetry is a poor predictor of the outcome of labour, has no influence on the neonatal issues and increases the caesarean sections rate. Furthermore, although radiation exposure during a X-ray pelvimetry is very weak, diagnostic X-ray studies during any stage of gestation have been shown to increase the risk of childhood cancer in the irradiated fetus. In the rare cases where pelvimetry is useful (trial of labour with a breech presentation), it is thus careful to perform a MRI pelvimetry.     

Anonymat du don de gamètes : protection d'un modèle social ou atteinte aux droits de l'homme ?

The French legislation about gamete donation imposes anonymity between the donor and the demanders, in reference to the principles of protection of the human dignity that are applied in other fields of biomedicine. We are here wondering about this choice: does this obligation really protect the human rights that are one of the ethical bases of law? At the time the French law was written, anonymity in gamete donation was inherited from the practice of the French CECOS but it has now become controversial. Many European countries have opened the access to the genetic origins. There is no evidence for this practice to be an efficient protection of the respect of human body and the disinterested nature of donation. Concerning gametes, it seems that it protects a social object, the parental project, but that it has no influence on the protection of parenthood, filiation, and the concept that humankind is not only biological. At last, we analyse the most important human rights documents to assume the hypothesis that anonymous gamete donation, although not violating the human rights, is an implement for Foucault's biopower, far from protecting the ethical foundations of human dignity.     

Le kit prothétique dans la cure des prolapsus génitaux : est-ce un gadget ?

ObjectiveTo search if the prosthetic kits bring an interest, other that financier.Materials and methodAuthors have counted 5 firms presenting the varied kits. The Prolift™ kit with synthetic pre- cut mesh made of polypropylene, standardized needle, cannulas and protective devices of recovery of mesh arms in 3 versions, anterior, posterior and total. Perigee™ and Apogee™ systems in a synthetic version (IntePro™) and a biological version (InteXen ++LP™) matched of specific needles for the different obturator passages and infra coccygeus. The Avaulta™ kit declines in a biosynthetic version and a hybrid version with a specific needle for its anterior kit and an other for its posterior kit. The Biomesh^® Soft system presents a polypropylène mesh posed on a multi pattern sheet to carve following dots with a share of 3 needles according to the type of arm passage ended by a recuperator thread. The Nazca POP Repair System, in its anterior version claims to be able to correct in the same time a urinary incontinence by pre-pubic arms. The polypropylene mesh is perforated and is had with the help a needle for its anterior and posterior kit. Authors have been interested in the research of studies on prosthesis with and without kit.ResultsThe Prolift™ kit contains the alone prosthesis having been evaluated without (TVM) and with kit. Authors remind results of two studies, understanding 684 cases without kit and 110 cases with kit. The rate of early per and postoperative complications has been decreased half, the rate of mesh exposure decreased from 11,3 to 4,7%. Studies on Perigee and Apogee IntePro™ kits, whose meshe and the procedure are similar to the Prolift™ seem to obtain from results equal. The Biological version has not made the object of study. For the Avauta™ kit, alone the mesh in plate not pre-cut has been well studied as for its tolerance for the biosynthetic version. Nothing on the hybrid version. No study is found for the Biomesh^® Soft kit and Nazca POP repair system.DiscussionThe cost of these kits, varying 1 to 4, is to take in consideration and to put in scale with the returned service. Alone TVM/Prolift™ allows to advance in a reply. The utilization of needles, presents in all the kits, but especially devices facilitating the passage and the recovery of prosthesis arms, presents solely in the Prolift™ kit, reduce the utilization of valves and the risk of tear tissues during their job. The improvement of techniques by elements of the kit make that the surgical procedure become mini invasive.ConclusionThe full kits allow a best security of procedures, facilitate the surgical gesture and limit complications. It is necessary to remain vigilant in the evaluation of these new materials "ready to wear" and to require pre clinic and clinic studies before their distribution.     

Intervalle de naissance entre les jumeaux : une limite de temps est-elle justifiée ?

OBJECTIVES: To assess the effect of the twin-to-twin delivery interval on the umbilical cord blood gas status and the neonatal outcome of the second twin following vaginal delivery. PATIENTS AND METHODS: Retrospective study of twin deliveries at or beyond 34 weeks of gestation over a period of five years. The correlation between the twin-to-twin delivery interval, and the umbilical arterial blood gas parameters of the second twin, including pH, PO(2), PCO(2), HCO(3-) and base excess, was studied. A second analysis was performed after exclusion of non-vertex presentation, need for general anesthesia, growth restriction and weight difference between the twin>30%. RESULTS: Two hundred and thirty-nine patients were studied. The mean twin-to-twin delivery interval was 11.3+/-6.4 minutes (between 6 and 14 minutes in 56.1% of cases). The second twin had more Apgar score<7 at 1 minute (P<0.02) and more arterial ombilical pH<7.20 (P<0.01) than the first twin. Over 15 minutes, the mean arterial pH was lower (P<0.01) and the number of arterial pH<7.20 increased (P<0.03). In contrast, the mean Apgar score and the rate of neonatal transfer did not differ significantly. There were significant negative correlations between arterial pH, base excess and bicarbonates and the twin-to-twin delivery interval (P<0.05). Similar results were found in the homogenised population. The reduction in the second twin arterial pH was expressed as pH=7.282-0.003 x time. DISCUSSION AND CONCLUSION: Umbilical cord arterial blood gas parameters deteriorate with increasing twin-to-twin delivery interval. Our results suggest that this interval should be less than 15 minutes, but obstetrician should adapt to every clinic situation.     

L'œdème aigu du poumon chez des patientes en menace d'accouchement prématuré traitées par inhibiteurs calciques : place de facteurs prédisposants ou pharmacologiques spécifiques ?

Calcium channel blockers of the dihydropyridin's family have been associated with the onset of an acute pulmonary edema when they are used as a treatment of preterm labor. We report here four cases of pulmonary edema in pregnant women treated with nicardipine (Loxen) for preterm labor. The physiopathology of pulmonary edema, the pharmacology of calcium channel blockers of dihydropyridin's family and the detailed analysis of our cases and those of the literature make us discuss of the role of these agents and associated population and risk factors in such complication.     

Femmes psychotiques et maternité : quels risques pour l'enfant ?

Desire for child in psychotic patients: what risks for the child? Here are two very different questions. When mentally ill patients express the desire to have a child, professionals are apprehensive regarding the child's future and express eugenics temptation. Nevertheless, it is a topical question as neuroleptic drugs efficiency as well as mental health policy encourage them to live as close to normality as possible. Therefore, they have sexual relations, they have children. Since 1975, children born from psychotic mothers have been considered by the World Health Organisation (WHO) to be at high risk. This means they justify close support measures and prevention. The child runs 3 risks: a risk to develop a mental illness partly hereditary, a risk regarding his or her development, risks related to suffering, as these children are confronted with the illness of their parents. The major role played by environmental factors guide prevention behaviours; in particular towards parents-to-be psychotic adult patients and during the pregnancy, a privileged moment for preventive strategies consistent with the Perinatal Plan 2005–2007. A clinical label will provide an example of the difficulty to establish a mother-child link observed with a psychotic woman, because the imaginary child overrides the real baby. To conclude the emphasis should be put on multidisciplinary and evolutionary strategies. These imply some optimism.     

Grossesse des patientes obèses : quels risques faut-il craindre ?

OBJECTIVE: To evaluate the deleterious effects of maternal obesity on obstetrical complications and neonatal outcomes. PATIENTS AND METHODS: Historical cohort study including all patients delivered in our maternity between 1st January 2002 and 31st December 2004. Intra uterine death and fetal loss before 22 weeks were excluded. Women were categorized by the Body Mass Index: less than 25, between 25 and 30, and more than 30. Maternal data, obstetrical complications, labor and its complications, and neonatal outcomes were studied. RESULTS: During these 3 years, 23.5% (1336/5686) of patients were overweight and 7.5% (425/5686) were obese. Obstetrical pathologies (gestational diabetes mellitus, hypertension, preeclampsia and fetal macrosomia) and labour induction were more significantly frequent in obese patients (P < 0.01). We noted twice more caesarean sections during labour in obese patients. The rate of artificial placental delivery was significantly higher in obese patients (P < 0.01). Obese patients with prior caesarean sections had a rate of vaginal delivery significantly lower than non obese patients with prior C-sections (23.6 vs 43.8%; P < 0.01). Mean children birth weight was significantly higher in obese patients (3305 vs 3181 g; P < 0.01) with no impact on Apgar score. DISCUSSION AND CONCLUSION: Our study confirms that obesity is responsible for major obstetrical complications, for what should no doubt be considered as high risk pregnancies. Our practices must take these complications into account by ensuring an adapted and early management in order to improve maternal and neonatal issues.