Origine fœtale des maladies de l'adulte : quelle importance pour la pratique obstétricale ?

The Developmental Origins of Human Adult Disease are thought to be secondary to a perturbation of the embryonic or fetal development, which leads to metabolic disorders such as diabetes or hypertension at adulthood. Maternal undernutrition or overnutrition, repeated glucocorticosteroids administered to the mother, or placental dysfunction are the most frequently considered causal factors. Therefore, it is necessary that the obstetrician is aware of these phenomena, as this knowledge may contribute to the prevention of adult diseases. Little is known yet, on the pathophysiological or epigenetic mechanisms that lead to theses observations, and more studies are needed both in humans and animal models.     

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.     

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.     

Abdominal radical trachelectomy: Is it safe for IB1 cervical cancer with tumors ≥ 2 cm?

Objectives

As abdominal radical trachelectomy (ART) has become a favored fertility-sparing procedure, the relative contraindication of a tumor ≥ 2 cm in size has been questioned. The aim of the study was to report the surgical and oncological safety of ART for selected patients with cervical cancer ≥ 2 cm in size.

Methods

We conducted a retrospective review of a prospectively maintained database of patients undergoing ART at our institution from 04/2004 to 01/2013. The largest tumor dimension was determined by physical exam, MRI or final pathology. Clinical and pathological data were tabulated. All patients were followed postoperatively.

Results

Of the 133 patients who underwent planned ART, 62 (46.6%) had tumors ≥ 2 cm in size (2–4 cm). Forty-six patients were documented by exam or MRI, while 16 were documented by pathology reports. The mean age was 30.4 years, and 42 patients (67.7%) were nulliparous. Fifty (80.7%) had squamous carcinoma, 7 (11.3%) had adenocarcinoma and 5 (8%) had adenosquamous carcinoma. Due to frozen-section results, 6 patients (9.7%) underwent an immediate hysterectomy. Due to high-risk features on final pathology, 27 patients (43.5%) were treated with adjuvant chemotherapy (n = 20) or chemoradiation (n = 7). In total, 55 (88.7%) of 62 patients with a tumor ≥ 2 cm in size preserved their fertility potential. Among these patients, 35 underwent ART without further adjuvant treatment. At a median follow-up of 30.2 months, there were no recurrences.

Conclusions

Expanding the ART inclusion criteria to cervical cancers ≥ 2 cm in size allows a fertility-sparing procedure in young women who would have otherwise been denied the option with no apparent compromise in oncological outcome. However, this may result in higher rates of conversion to hysterectomy or the need for adjuvant chemotherapy/or chemoradiation.     

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.     

In vivo and in vitro postovulatory aging: when time works against oocyte quality?

In mammalian species an optimal fertilization window during which successful fertilization occurs. In the majority of mammals estrus marks ovulation time and coincident with mating, thereby allowing the synchronized meeting in the fallopian tubes, between freshly ejaculated sperm and freshly ovulated oocytes. Conversely, women do not show natural visual signs of ovulation such that fertilization can occur hours later involving an aged oocyte and freshly ejaculated spermatozoa. During this time, the oocyte undergoes a rapid degradation known as “postovulatory aging” (POA). POA may become particularly important in the human-assisted reproductive technologies, as the fertilization of retrieved mature oocytes can be delayed due to increased laboratory workload or because of unforeseeable circumstances, like the delayed availability of semen samples. This paper is an updated review of the consequences of POA, either in vivo or in vitro, on oocyte quality with particular attention to modifications caused by POA on oocyte nuclear, cytoplasmic, genomic, and epigenetic maturation, and embryo development.     

Ensayo clínico aleatorizado para evaluar la eficacia y seguridad de la administración de 25 μg de misoprostol por vía vaginal frente a 50 μg por vía sublingual para la inducción del trabajo del parto en gestantes con diabetes

Objective

To evaluate the safety and efficacy of misoprostol 50 μg administered sublingually versus 25 μg administered vaginally for labor induction at term in pregnant women with diabetes.

Methods

Three hundred pregnant women with diabetes were randomly allocated to receive misoprostol 25 μg vaginally or 50 μg sublingually every 4 hours up to 4 doses. The main variable assessed was the rate of vaginal deliveries in 24 hours.

Results

Vaginal delivery in 24 hours was achieved in 109/150 (72.7%) women in the sublingual group and in 104/150 (69.3%) in the vaginal group, with no statistically significant differences (p = 0.611; RR = 1.176; 95% CI for RR, 0.714-1.938). Tachysystole was significantly more frequent in the sublingual misoprostol group (RR = 0.474; 95% CI for RR, 0.233-0.968). The indications for cesarean section were similar in both groups. Uterine rupture occurred in one patient in the sublingual group who was administered the third misoprostol dose in the active phase of labor.

Conclusions

No statistically significant differences were found in the vaginal delivery rates between sublingual and vaginal misoprostol, although adverse effects were more frequent with the sublingual route.     

Ethinyl estradiol 20 μg/drospirenone 3 mg 24/4 oral contraceptive for the treatment of functional impairment in women with premenstrual dysphoric disorder

Objective

To determine the effects of ethinyl estradiol (EE)/drospirenone in a 24/4 regimen (24 days of active and 4 days of inactive pills) on functional impairment (affecting work, partnership, and social activities) in women with premenstrual dysphoric disorder (PMDD).

Methods

The present study was a secondary analysis of a double-blind, randomized, parallel-design multicenter trial. Women received EE 20 μg/drospirenone 3 mg (n = 232) or placebo (n = 218) and completed the Daily Record of Severity of Problems (DRSP) scale daily.

Results

The decrease in mean scores for all 3 DRSP functional impairment items (work, partnership, and social activities) from baseline to cycle 3 mirrored changes in the total DRSP symptom score; the greatest decreases were observed in cycle 1 with further small reductions through to cycle 3. The proportional mean decreases from baseline to cycle 1 for the 3 functional items ranged from 47% to 48%. For all 3 functional items, the mean reductions from baseline to cycle 1 (but not from cycle 1 to cycles 2 and 3) were significantly greater with EE/drospirenone than with placebo (P < 0.05).

Conclusion

Ethinyl estradiol 20 μg/drospirenone 3 mg in a 24/4 regimen significantly improved functional impairment in women with PMDD. Symptoms improved in parallel.     

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.