Search

We correlated intrarectal pressure parameter recordings during the second phase of labour in primiparous women with postpartum pelvic floor (PF) complaints to try to define a critical pressure threshold for the occurrence of permanent PF injury. Using a microsystem device, the duration of bearing-down efforts, the area under the pressure curve and the peak pressure during bearing-down efforts were continuously recorded in 43 women with spontaneous delivery (group one) and in 17 women with forceps-assisted delivery (group two). PF complaints were assessed using ICS-validated questionnaires established before delivery and 14 ± 6 months after delivery. Postpartum PF complaints were not significantly different between the groups. The first and second phases of labour were longer in women of group two. The three parameters measured were not correlated with the baby’s weight or mode of delivery. The duration of bearing-down efforts was correlated with difficulty voiding and lower abdominal discomfort in women of group one only. The area under the pressure curve was correlated with feeling of urgency to void, urge incontinence, drops escape, decreased frequency of orgasm and difficulties in reaching orgasm in women of group two only. Peak pressure values were not correlated with any PF dysfunction. Intrarectal pressure parameters during second phase of labour show no significant correlations with obstetric parameters, but were significantly correlated with some urinary and sexual PF complaints 14 months after spontaneous and forceps-assisted delivery with a higher incidence of significant correlations in women of group two with forceps-assisted delivery, probably because of the longer first and second phases of labour.

INTRODUCTION AND HYPOTHESIS: This study aims to estimate fecal, urinary incontinence, and sexual function 6 years after an obstetrical anal sphincter tear. METHODS: Among 13,213 women who had a vaginal delivery of a cephalic singleton at term, 196 women sustained an anal sphincter tear. They were matched to 588 controls. Validated questionnaires grading fecal and urinary incontinence, and sexual dysfunction were completed by the participants. RESULTS: Severe fecal incontinence was more frequently reported by women who had sustained an anal sphincter tear compared to the controls. Women with an anal sphincter tear had no increased risk of urinary incontinence, but reported significantly more pain, difficulty with vaginal lubrication, and difficulty achieving orgasm compared to the controls. A fetal occiput posterior position during childbirth was an independent risk factor for both severe urinary incontinence and severe sexual dysfunction. CONCLUSIONS: Fecal incontinence is strongly associated with an anal sphincter tear. A fetal occiput posterior position represents a risk factor for urinary incontinence and sexual dysfunction.

INTRODUCTION: Fetal brain injury is an essential cause of lifelong morbidity. Infection appears as a cause of brain damage. Apart from chorioamnionitis, screening for infectious diseases must be considered in pregnancies with a risk of congenital infection or cases with abnormal cerebral ultrasound findings. DISCUSSION: Congenital infections include most of the major components of the TORCH complex: toxoplasmosis, rubella, cytomegalovirus, herpes, and varicella. Seronegative mothers can develop primary infection, which carries a risk of vertical transmission. The timing of the infection is a critical point, because fetal damage often depends on the gestational age at which acute maternal infection took place and occurs more likely in the first half of pregnancy. Antenatal ultrasound can detect brain abnormalities, like hydrocephalus, periventricular leukomalacia, calcifications or hemorrhage. Maternal serologic tests must be performed to look for an infectious etiology; the most frequent agents are the components of the TORCH complex. But additional serology must include parvovirus B19, HIV, and coxsackieviruses.

To compare the adverse neonatal and maternal outcomes after medically indicated and elective labor induction. Both induction groups were also compared to women with spontaneous onset of labor.Retrospective cohort study of 13 971 women with live, cephalic singleton pregnancies who delivered at term (from 1997 to 2007). Adverse maternal and neonatal outcomes were compared between women who underwent an induction of labor in the presence and absence of standard medical indications.Among 5090 patients with induced labor, 2059 (40.5%) underwent elective labor inductions, defined as inductions without any medical or obstetrical indication. Risks of cesarean or instrumental delivery, postpartum hemorrhage500 ml, prolonged maternal hospitalization6 days, Apgar7 at 5 min of life, arterial umbilical cord pH7.1, admission in neonatal intensive care unit (NICU) and prolonged NICU hospitalization7 days were similar between nulliparous who underwent elective and medical labor induction. Similar results were obtained for multiparous. All the above mentioned risks, but the Apgar7 at 5 min of life, were significantly increased after induction in comparison to spontaneous labor.Elective induction of labor carries similar obstetrical and neonatal risks as a medically indicated labor induction. Thus, elective induction of labor should be strongly discouraged.

Objective A single course of antenatal corticosteroids (ACS) is associated with a reduction in respiratory distress syndrome and neonatal death. Multiple Courses of Antenatal Corticosteroids Study (MACS), a study involving 1858 women, was a multicentre randomized placebo-controlled trial of multiple courses of ACS, given every 14 days until 33+6 weeks or birth, whichever came first. The primary outcome of the study, a composite of neonatal mortality and morbidity, was similar for the multiple ACS and placebo groups (12.9% vs. 12.5%), but infants exposed to multiple courses of ACS weighed less, were shorter, and had smaller head circumferences. Thus for women who remain at increased risk of preterm birth, multiple courses of ACS (every 14 days) are not recommended. Chronic use of corticosteroids is associated with numerous side effects including weight gain and depression The aim of this postpartum assessment was to ascertain if multiple courses of ACS were associated with maternal side effects. Methods Three months postpartum, women who participated in MACS were asked to complete a structured questionnaire that asked about maternal side effects of corticosteroid use during MACS and included the Edinburgh Postnatal Depression Scale Women were also asked to evaluate their study participation Results Of the 1858 women randomized, 1712 (92.1%) completed the postpartum questionnaire. There were no significant differences in the risk of maternal side effects between the two groups. Large numbers of women met the criteria for postpartum depression (14.1% in the ACS vs. 16.0% in the placebo group). Most women (94.1%) responded that they would participate in the trial again. Conclusion In pregnancy, corticosteroids are given to women for fetal lung maturation and for the treatment of various maternal diseases. In this international multicentre randomized controlled trial, multiple courses of ACS (every 14 days) were not associated with maternal side effects, and the majority of women responded that they would participate in such a study again.

TOC Summary: Women experiencing miscarriage should be screened for C. trachomatis., To determine the role of Chlamydia trachomatis in miscarriage, we prospectively collected serum, cervicovaginal swab specimens, and placental samples from 386 women with and without miscarriage. Prevalence of immunoglobulin G against C. trachomatis was higher in the miscarriage group than in the control group (15.2% vs. 7.3%; p = 0.018). Association between C. trachomatis–positive serologic results and miscarriage remained significant after adjustment for age, origin, education, and number of sex partners (odds ratio 2.3, 95% confidence interval 1.1–4.9). C. trachomatis DNA was more frequently amplified from products of conception or placenta from women who had a miscarriage (4%) than from controls (0.7%; p = 0.026). Immunohistochemical analysis confirmed C. trachomatis in placenta from 5 of 7 patients with positive PCR results, whereas results of immunohistochemical analysis were negative in placenta samples from all 8 negative controls tested. Associations between miscarriage and serologic/molecular evidence of C. trachomatis infection support its role in miscarriage.

Objective Insulin-like growth factor-I (IGF-I) is an important regulator of fetal growth and its bioavailability depends on insulin-like growth factor binding proteins (IGFBPs). Genes coding for IGF-I and IGFBP3 are polymorphic. We hypothesized that either amniotic fluid protein concentration at the beginning of the second trimester or genotype of one of these two genes could be predictive of abnormal fetal growth. Study design Amniotic fluid samples (14–18 weeks of pregnancy) from 123 patients with appropriate for gestational age (AGA) fetuses, 39 patients with small for gestational age (SGA) fetuses and 34 patients with large for gestational age (LGA) were analyzed. Protein concentrations were evaluated by ELISA and gene polymorphisms by PCR. Results Amniotic fluid IGFBP3 concentrations were significantly higher in SGA compared to AGA group (P = 0.030), and this was even more significant when adjusted to gestational age at the time of amniocentesis and other covariates (ANCOVA analysis: P = 0.009). Genotypic distribution of IGF-I variable number of tandem repeats (VNTR) polymorphism was significantly different in SGA compared to AGA group (P = 0.029). 19CA/20CA genotype frequency was threefold decreased in SGA compared to AGA group and the risk of SGA occurrence of this genotype was decreased accordingly: OR = 0.289, 95%CI = 0.1–0.9, P = 0.032. Genotype distribution of IGFBP3(A-202C) polymorphism was similar in all three groups. Conclusions High IGFBP3 concentrations in amniotic fluid at the beginning of the second trimester are associated with increased risks of SGA while 19CA/20CA genotype at IGF-I VNTR polymorphism is associated with reduced risks of SGA. Neither IGFBP3 concentrations, nor IGF-I/IGFBP3 polymorphisms are associated with modified risks of LGA.

Resume Objectifs Evaluer l’interet des examens para-cliniques prescrits dans les morts du fœtus in utero pour aboutir a l’etablissement d’un nouvel algorithme de prise en charge du bilan des morts in utero. Materiel et methodes Analyse retrospective d’une serie de 106 morts in utero recensees entre septembre 1989 et decembre 1998 dans le departement de gynecologie-obstetrique du CHUV (maternite de type 3) a Lausanne. Nous avons defini la mort in utero a partir de la date limite de viabilite fœtale. Seules les grossesses de 24 semaines ou plus ont ete inclues dans cette serie. Nous avons exclu les morts in utero survenues en cours d’interruption therapeutique de grossesse ainsi que les cas presentant un dossier incomplet. La classification etiologique utilisee est celle decrite par Fretts. L’analyse a porte sur les differents examens demandes, ainsi que sur l’evaluation de leur pertinence dans l’etablissement du diagnostic etiologique de chaque cas. La recherche de facteurs de risque significatifs a egalement ete prise en consideration. Nous avons compare notre prise en charge aux donnees de la litterature, afin de proposer un nouvel algorithme. Resultats L’etiologie de la mort fœtale a pu etre definie dans 90 % des cas. Les causes principales en etaient les retards de croissance in utero (19,8 %), les anomalies congenitales et chromosomiques fœtales (18,9 %), les infections (15,1 %), le decollement placentaire (7,5 %), la pre-eclampsie (5,6 %), le diabete maternel (3,8 %). Le 18,9 % restant se repartissant par petits nombres entre diverses autres causes. Dans 10,4 % des cas, nous n’avons pas trouve d’explication a la mort in utero. Les examens les plus profitables dans le bilan de la mort in utero etaient l’autopsie fœtale, qui etait anormale dans 92,7 % des cas examines, l’anatomo-pathologie placentaire, anormale dans 93 % des cas et le babygramme (radiographie du squelette fœtal), pathologique dans 53 % des cas. La serologie maternelle infectieuse etait informative dans 6,6 % des cas. Conclusion Nous presentons un protocole de prise en charge du bilan de la mort in utero differencie en fonction des circonstances entourant l’evenement, afin de limiter les examens superflus.

Background The aim of this longitudinal study was to determine the short-term and long-term effects of spontaneous and forceps delivery on bladder neck (BN) support. Methods One hundred twenty-seven primiparae women underwent repeated clinical and perineosonography examinations during pregnancy and at 10 weeks and 10 months after delivery. Eighty-two had a spontaneous delivery, 25 a forceps delivery, and 20 cesarean section. The parameters measured by perineosonography were BN position measured in a two-axis system in the supine and standing positions, BN mobility, and BN elevation during pelvic floor squeezing. Results At 10 weeks and 10 months after delivery, a significant posterior, but not inferior, displacement of the BN at rest in the supine and standing positions was observed only after spontaneous delivery. In spontaneous and forceps-delivered women, but not in cesarean-delivered women, BN mobility stayed significantly increased and the ability to elevate the BN during voluntary pelvic floor contraction significantly decreased 10 weeks and 10 months after delivery. Results Women with cystocoeles grade 1 and 2 had significant higher bladder neck mobility compared with women without cystocoele. Conclusions Vaginal delivery is responsible for a significant and persistent impairment of BN support. Forceps delivery does not seem to have a more deleterious effect than spontaneous delivery.

BACKGROUND: The development of medical-led care in obstetrics over the past decades has contributed to improving outcomes for both mother and child. Although efficiency has improved in complex situations, unnecessary interventions are still practiced in low-risk pregnancies, contrary to international recommendations. A shift to a less interventionist model of care has encouraged many countries to review their policies on maternal health care and develop models such as the "midwife-led unit" (MLU) where the midwife plays a predominant role with a minimum of routine intervention. Existing research has provided convincing evidence that MLUs lead to better maternal and neonatal outcomes when compared to traditional models. They not only improve the level of satisfaction amongst women, but are also associated with reduced healthcare costs. This study aimed to explore the perceptions of women and healthcare providers regarding the creation of an MLU in a Swiss university hospital. METHODS: A descriptive research study using qualitative methods was conducted among pregnant women and new mothers in a Swiss maternity unit, including also midwives and medical staff. Data collection was carried out through one-to-one interviews, focus groups, and telephone interviews (n = 63). After transcription, thematic analysis was performed. RESULTS: The triangulation of perceptions of women and healthcare providers indicated support for the implementation of an MLU to promote physiological delivery. Most women welcomed the idea of an MLU, in particular how it could help in offering continuity of care. Healthcare providers were optimistic about the implementation of an MLU and recognised the need for some women to have access to a less interventionist approach. From the women's perspective, barriers concerned the lack of awareness of midwives' full scope of practice, while barriers for midwives and obstetricians were related to the challenge to develop a good interprofessional collaboration. CONCLUSION: Alternative models to provide maternity care for low-risk women have been developed and evaluated widely in several countries outside Switzerland. This study showed that women and healthcare providers were favourable towards the development of a new care model, while taking into account the specific expectations and barriers raised by participants.

Objective: To assess the effect of pelvic floor education after vaginal delivery on pelvic floor characteristics in nulliparous women. Methods: We examined 107 nulliparas during pregnancy and at 9 weeks and 10 months after vaginal delivery. Methods used included a questionnaire, clinical examination, perineosonography, urethral pressure profiles, and intravaginal and intra-anal pressure recordings during pelvic floor contraction. After the second examination, the women were assigned in alternating manner to either 12 sessions of pelvic floor exercises with biofeedback and electrostimulation (n = 51) or no training (n = 56). The two groups were compared at the third examination. Results: Stress urinary incontinence incidence decreased in 2% of control subjects compared with 19% of women who underwent pelvic floor education (P = .002), whereas the incidence of fecal incontinence (5% versus 4%, P = 1) and the percentage of women who recovered predelivery pelvic floor contraction strength (33% versus 41%, P = .4) were no different. We observed no significant differences in bladder neck position and mobility, urethral functional length, maximal urethral closure pressure, pressure transmission ratio, residual area of continence at stress standing, or intravaginal or intra-anal pressures during pelvic floor contraction between groups at the third examination. Conclusion: Pelvic floor education, begun 2 months postpartum, significantly reduced the incidence of stress urinary incontinence, but not fecal incontinence or weak pelvic floor. Similarly, bladder neck behavior, urodynamic characteristics, intravaginal or intra-anal pressures during pelvic floor squeezing also were not modified.

Objective: To assess prospectively the diagnostic reliability and prognostic significance of prenatal diagnosis of cytomegalovirus (CMV) infection. Methods: One hundred ten pregnant women (four with twin pregnancies) with a risk of congenital CMV infection were investigated. Prenatal diagnosis was carried out by amniocentesis and fetal blood sampling (n = 75) or amniocentesis alone (n = 35). Serial ultrasonographic examinations were performed from time of referral until pregnancy end. All infected neonates were given long-term follow-up. Autopsy was performed in all cases of termination of pregnancy. Results: Nearly 23% (26 of 114) of fetuses were infected and prenatal diagnosis was positive in 20 cases. Sensitivity of prenatal diagnosis was 77% and specificity 100%. In eight cases, parents requested termination of pregnancy on the basis of abnormal ultrasonographic findings and/or biologic abnormalities in fetal blood. In 12 cases, parents decided to proceed with the pregnancy. In this group, one intrauterine and one neonatal death were observed. In one case, prenatal diagnosis revealed an abnormal cerebral sonography and the infant had bilateral hearing loss at birth. In 15 cases (nine positive and six false-negative prenatal diagnoses), no apparent lesion was present at birth, nor did it develop during the follow-up period (mean 31 months). In 88 (77.2%) of 114 infants, no evidence of vertical transmission was found during the pre- or postnatal period. Conclusion: Prenatal diagnosis provides the optimal means for both diagnosing fetal infection (amniocentesis) and identifying fetuses at risk of severe sequelae (ultrasound examination, fetal blood sampling), thus allowing proper counseling.

In severe forms of Diamond-Blackfan anemia, preimplantation genetic diagnosis (PGD) of histocompatibility leukocyte antigen-compatible embryos for enabling the next sibling in the family to be a stem-cell transplantation donor constitutes the sole lasting cure capable of terminating the enduring need for iterative transfusions. We report here an open collaboration between two renowned institutions to provide a family desiring this treatment even though they resided where the preimplantation genetic diagnosis procedure is banned.

Objective: To compare published guidelines concerning screening for gestational diabetes. Study design: Systematic search and comparative analysis of published guidelines. Appraisal of guidelines quality. Simulation analysis. Results: Ten published guidelines proposed either universal screening (5), selective screening (3) or screening when clinically indicated (2). Variations of testing schedules and blood glucose thresholds were observed. The quality of the published guidelines was low, on average 22 (8–51) percentage points on the assessment scale. These differences would have led to large variations in the number of patients to be screened. Conclusions: Large variations between guidelines have been observed which would translate in large practice variations, if the guidelines were systematically applied. These variations are partially explained by the absence of definite evidence that universal or selective screening for gestational diabetes do more good than harm on infant and maternal health. The methodology of developing guidelines should be more evidence based, systematic and explicit.

Background The transplacental transfer of specific maternal IgG antibodies makes the diagnosis of congenital Toxoplasma infection quite difficult in the neonate. The enzyme-linked immunofiltration assay (ELIFA), comparing at delivery the immunologic profile of the mother's antibody response and that of her child, allows discrimination between IgG antibodies of maternal origin and IgGs synthesized by the fetus. Objective To evaluate the diagnostic reliability of the comparative ELIFA for diagnosing congenital Toxoplasma infection as well as the reliability of testing for IgM- and IgA-specific antibodies in cord blood. Methods From November, 1991, to December, 1995, an ELIFA was prospectively performed at delivery on blood samples obtained from 227 women with primary Toxoplasma infection during pregnancy and from their infants. For each child the ELIFA result was evaluated in relation to the serologic follow-up: disappearance of specific anti-Toxoplasma gondii IgG antibodies in the absence of treatment before 12 months of age indicating an uninfected child, as opposed to persistence beyond 12 months of age indicative of a congenital infection. Results Of 227 children 139 were lost to follow-up. Among the 88 children available for follow up, the ELIFA was negative in 70 infants, 69 of whom were confirmed to be uninfected. Thirteen of these 69 cord blood ELIFA-negative samples were positive for anti-T. gondii IgM and/or IgA detected by means of a conventional immunosorbent agglutination assay. Of the remaining 18 children (representing 75% of all new cases of congenital toxoplasmosis diagnosed during the study period at our institution), the ELIFA was positive in 16, negative in 1 and inconclusive in 1. Conclusions The ELIFA test is a valuable tool for diagnosing congenital T. gondii infection and in differentiating between true neonatal infection and cord blood contamination. In our experience the diagnostic sensitivity of the ELIFA test was 94.1% and the specificity was 98.6%. The cord blood was contaminated by specific maternal anti-T. gondii IgA and/or IgM in as many as 20% of the cases.

Objective: To investigate the effects of neonatal hypoglycemia on physical growth and neurocognitive function. Study design: A systematic detection of hypoglycemia (

Objective: To determine the effects of delivery on bladder and anorectal functions. Methods: One hundred forty-nine nulliparas were studied once during pregnancy and again about 9 weeks after delivery by means of questionnaire, clinical examination, perineal sonography, urethral pressure profiles, and recording of intravaginal and intra-anal pressures during pelvic-floor contraction. Results: Stress urinary incontinence was present in 46 patients (31%) during pregnancy and persisted in ten of them after delivery. After vaginal delivery, urinary and fecal incontinence were present in 36% and 4% of forceps-delivered women, respectively, and in 21% and 5.5% of spontaneously delivered women. Bladder neck mobility was increased significantly after all vaginal births, whereas bladder neck position at rest was lowered only in forceps-delivered women. Functional urethral length was decreased in the supine and standing positions after spontaneous and forceps deliveries. Otherwise, indices of urethral sphincter function were unchanged or improved after vaginal delivery. A significant decrease in intravaginal pressure and in intra-anal pressure was observed in all vaginally delivered women. The intra-anal pressure decrease correlated significantly with infant weight (r = 0.24, P = .01). Women who underwent cesarean had no specific complaints and only slight modifications of these measurements. Conclusion: After spontaneous and instrumental deliveries, 21% and 34% of women complained of stress urinary incontinence and 5.5% and 4% reported fecal incontinence, respectively. Substantial bladder neck hypermobility was present together with diminished functional urethral length and intravaginal and intra-anal pressures. Only 22% of patients with stress urinary incontinence during pregnancy had such incontinence after delivery.

Summary Autologous skin-grafting is the gold standard for treatment of deep second and third degree burns. Available bioengineered skin products also necessitate this two-step surgical procedure. Therefore, we developed fetal skin constructs to improve healing of such degree burns. A bank of fetal skin cells was developed from one organ donation (4 cm 2 of skin allowing the preparation of several million three-dimensional skin constructs, 9×12 cm, on native horse collagen). Successive fetal constructs were applied to eight patients at every change of dressing during 1–3 weeks in an outpatient setting. Complete closure was rapid (mean 15·3 days [SD 5·5]) with little hypertrophy of new skin and no retraction seen. This simple technique provided complete treatment without auto-grafting, showing that fetal skin cells might have great potential to treat burns and eventually acute and chronic wounds of other types.

PRINCIPLES: Interstitial pregnancy represents 2% of ectopic pregnancies, but it is a highly morbid condition with a 2.5% of maternal mortality. Its diagnostic and therapeutic management remains controversial. The aim of this review is to describe the management of interstitial pregnancy in our institution between 2001 and 2011 and to define some general rules for the clinical practice. METHODS: Single institution retrospective study. RESULTS: Eleven women were treated for interstitial pregnancy. The median age was 33 years and the median gestity was 4. Seven patients had a history of gynaecological surgery and four interstitial pregnancies followed in vitro fertilisation. The diagnosis was made at a median gestational age of seven weeks with a median beta-HCG level of 5,838 U/l. Six of the eleven patients received an initial treatment with intracornual methotrexate, three with intramuscular methotrexate and two with surgery. The median time to beta-HCG resolution was 58 days. Three of the eleven patients needed a second line treatment: two after intramuscular methotrexate and one after intracornual methotrexate. Six patients had further pregnancies and delivered by caesarean section. CONCLUSIONS: A high prevalence of previous ectopic pregnancies, gynaecological surgery and of pregnancies resulting from in vitro fertilisation was observed. The earliness of the diagnosis was the factor that allowed a conservative treatment in most cases. Beta-HCG level follow up was fundamental in allowing a second line therapy but beta-HCG can persist over a long period of time and this must be taken into account due to its possible psychological impact. Intracornual methotrexate seems to be more efficacious than intramuscular methotrexate in our series.

Introduction: A standardized three-dimensional ultrasonographic (3DUS) protocol is described that allows fetal face reconstruction. Ability to identify cleft lip with 3DUS using this protocol was assessed by operators with minimal 3DUS experience. Material and Methods: 260 stored volumes of fetal face were analyzed using a standardized protocol by operators with different levels of competence in 3DUS. The outcomes studied were: (1) the performance of post-processing 3D face volumes for the detection of facial clefts; (2) the ability of a resident with minimal 3DUS experience to reconstruct the acquired facial volumes, and (3) the time needed to reconstruct each plane to allow proper diagnosis of a cleft. Results: The three orthogonal planes of the fetal face (axial, sagittal and coronal) were adequately reconstructed with similar performance when acquired by a maternal-fetal medicine specialist or by residents with minimal experience (72 vs. 76%, p = 0.629). The learning curve for manipulation of 3DUS volumes of the fetal face corresponds to 30 cases and is independent of the operator's level of experience. Discussion: The learning curve for the standardized protocol we describe is short, even for inexperienced sonographers. This technique might decrease the length of anatomy ultrasounds and improve the ability to visualize fetal face anomalies.

OBJECTIVE: To evaluate the impact of body position on the arterial stiffness indices provided by radial applanation tonometry in pregnant and nonpregnant women. METHODS: Twenty-four young women (18-30 years) in the third trimester of a normal pregnancy and 20 healthy nonpregnant women of the same age were enrolled. In each, applanation tonometry was carried out in the sitting and supine position. The following stiffness indices were analyzed: systolic augmentation index (sAix), sAix adjusted for heart rate (sAix@75) and diastolic augmentation index (dAix), all expressed in % of central aortic pulse pressure. RESULTS: The sAix was apparently not influenced by body position, but the transition from seated to supine was associated with a substantial decrease in heart rate. When correcting for this confounder by calculating the sAix@75, systolic augmentation was substantially lower when individuals were supine (mean ± SD: nonpregnant 3.0 ± 14.4%, pregnant 8.8 ± 9.7%) than when they were sitting (nonpregnant 5.7 ± 13.0%, pregnant 11.1 ± 83%, P = 0.005 supine vs. seated in both study groups, P > 0.2 for pregnant vs. nonpregnant). The influence of body position on the dAix went in the opposite direction (supine: nonpregnant 9.7 ± 6.6%, pregnant 4.4 ± 3.5%; seated: nonpregnant 7.7 ± 5.8%, pregnant 3.3 ± 2.4%, P

Summary Parameters of intrarectal pressure (surface area under pressure curve and peak pressure) recorded with a microsystem device during the second phase of labor showed no significant correlations with baby's weight or mode of delivery. Aim of the study Was to assess the biomechanical pressures delivered against pelvic floor structures during the second phase of labor in nulliparae women, and to correlate them with obstetrics parameters, i.e. baby'sweight and mode of delivery. Material Using a microsystem device placed into the rectum at the beginning of the second phase of labor, two parameters were assessed during the bearing efforts in 59 nulliparae women: the surface area under the pressure curve and the peak pressure. Results During 11.5 ± 9 bearing efforts of 99.1 ± 16 s duration, the mean value of surface area under the pressure curve was 32677 ± 26058 cm/s and the mean value of the peak pressure was 60.7 ± 24 cmH2O, exceeding 100 cmH2O in 10% of women. These two parameters were not correlated with baby's weight (R: 0.19, P: 0.15 and R: 0.05, P: 0.71). In the same way, these two parameters were not correlated with the mode of delivery (spontaneous or forceps/vacuum-assisted). Furthermore, the individual values of these two parameters showed great variation from one woman to another. Conclusion This study has showed that parameters of biomechanical pressures recorded into the rectum during second phase of labor had no significant correlations with obstetricals parameters, explaining why these latter have poor predicitive value of further pelvic floor problems.

Fetal platelet counts were retrospectively studied in a series of 5,194 consecutive fetal blood samplings (FBS). The mean value was 245 +/- 65 x 10(9)/L, without significant variation between 17 and 41 weeks' gestation. After exclusion of false thrombocytopenia due to contamination with amniotic fluid, 247 fetuses had platelet counts less than 150 x 10(9)/L. In 70 cases, thrombocytopenia was due to congenital infectious diseases (toxoplasmosis, rubella, and cytomegalovirus). It was related to immune causes in 45 cases: anti-HPA-1a (n = 23), anti- HPA-5b (n = 2) or possible anti-HLA (n = 2) alloimmunizations, and immune thrombocytopenic purpura (n = 18). Chromosomal abnormality was the etiology in 43 cases (trisomy 13, 18, and 21, Turner's syndrome, triploidy), and other disorders (multiple birth defects, intrauterine growth retardation, rhesus disease, and gestational thrombocytopenia) in 62 cases. No specific cause for the low platelet count could be established in 27 fetuses (range, 115 to 149 x 10(9)/L). Severe thrombocytopenia (< or = 50 x 10(9)/L) occurred mainly in immune cases (16%), congenital infectious diseases (7%), and chromosomal abnormalities (1%). Diagnosis, prognosis, and management of fetal thrombocytopenia are presented in the different clinical situations. In this series, FBS was never associated with serious bleeding, and no fetal exsanguination was observed.

Considering the patient’s right to autonomy and the trend towards more involvement of the patient in the decision making, it is our belief that obstetricians should consider the woman’s request for cesarean section without medical indication. The procedure can only be carried out after obtaining proper consent of the patient with careful information including a detailed description of the possible risks and benefits of both modes of delivery. In order to decrease the risk of respiratory distress syndrome, cesarean section under these circumstances should not be performed prior to 39 weeks’ gestation. Debating over whether or not to charge women who request a cesarean section that is not medically indicated is fruitless, since rigorous cost studies are lacking and since any implementation of such a system would be extremely difficult.

Although the general trend for delaying childbearing is generally viewed as causing infertility, its consequences on the interpregnancy interval have been unknown. A study of birth records for Swiss married women from 1969 to 2006 revealed that the woman's age at first birth has increased from 25.0 to 30.1 years, whereas calculated theoretical interpregnancy intervals after the first and second child decreased from 23.2 to 13 and from 22.4 to 7.9 months, respectively.

Female genital mutilation (FGM) is defined as an injury of the external female genitalia for cultural or non-therapeutic reasons. FGM is mainly performed in sub-Saharan and Eastern Africa. The western health care systems are confronted with migrants from this cultural background. The aim is to offer information on how to approach this subject. The degree of FGM can vary from excision of the prepuce and clitoris to infibulation. Infections, urinary retention, pain, lesions of neighbouring organs, bleeding, psychological trauma and even death are possible acute complications. The different long-term complications include the risk of reduced fertility and difficulties during labour, which are key arguments against FGM in the migrant community. Paediatricians often have questions on how to approach the subject. With an open, neutral approach and basic knowledge, discussions with parents are constructive. Talking about the newborn, delivery or traditions may be a good starting point. Once they feel accepted, they speak surprisingly openly. FGM is performed out of love for their daughters. We have to be aware of their arguments and fears, but we should also stress the parents’ responsibility in taking a health risk for their daughters. It is important to know the family’s opinion on FGM. Some may need support, especially against community pressure. As FGM is often performed on newborns or at 4–9 years of age, paediatricians should have an active role in the prevention of FGM, especially as they have repeated close contact with those concerned and medical consequences are the main arguments against FGM.

Eighty-nine cases of proven Toxoplasma gondii fetal infection were studied in order to describe the morphological lesions which could be demonstrated on ultrasound examination; these were present in 32 of the infected cases. Cerebral ventricular dilatation was the most common sign and was generally bilateral and symmetrical. Its evolution was always very rapid over a period of a few days. Other signs observed included intracranial and intrahepatic densities, increased thickness and hyperdensity of the placenta, ascites and rarely pericardial and pleural effusions. Thirteen fetuses demonstrated two or more ultrasound features. Intrauterine growth retardation and microcephaly were not observed. Ultrasonographic assessment of the fetus injected with Toxoplasma gondii is important. It improves the reliability of prenatal diagnosis and is of important prognostic value in cases with severe brain lesions, but is of little value in detecting brain necrosis without ventricular dilatation.

Thirteen cases of fetal parvovirus B19 infection with hydrops foetalis are reported. Viral DNA was identified by polymerase chain reaction (PCR) of amniotic fluid sampled between the 19th and the 29th week of gestation. Haematological examination revealed severe anaemia in all cases and thrombocytopenia in 11/13 cases, which was severe in two cases. Six fetuses died in utero; two after intrauterine transfusion. Complete recovery was observed in seven fetuses; five cases were treated by intrauterine transfusions, and in two cases spontaneous recovery occurred. Upon follow-up, no case of congenital anaemia was observed.

Using a specific myofibroblast contraction test, we try to predict future utero-vaginal prolapse development in young primiparae women. We compare myofibroblast cultures of the vaginal wall in primiparae women (group 1), young multiparae women (group 2) and older multiparae women (group 3) who were operated on for severe utero-vaginal prolapse. A myofibroblast-mediated collagen gel contraction assay determined a contraction factor that was compared in the three groups of women. The myofibroblasts contraction factor after 24 and 48 hours was significantly higher in group 1 women (2.4 +/- 0.6/4.4 +/- 1.9) compared to group 2 (1.6 +/- 0.3/ 1.8 +/- 0.1) andgroup 3 (1.6 +/- 0.3/1.8 +/- 0.3), but showed no differences in group 1 women without (2.1 +/- 0.5/3.5 +/- 1.9) and with (2.7 +/- 0.6/5.1 +/- 1.7) cystocoele. Vaginal myofibroblasts of young women show better contraction forces than young women with severe utero-vaginal prolapse. The latter have a myofibroblast contraction factor similar to those of older post-menopausal women operated for the same condition.

Wound healing in fetal skin is characterized by the absence of scar tissue formation, which is not dependent on the intrauterine environment and amniotic fluid. Fetal cells have the capacity of extraordinary expansion and we describe herein the development of a fetal skin cell bank where from one organ donation (2–4 cm2) it is possible to produce several hundred million fetal skin constructs of 9 × 12 cm2. Fetal cells grow three to four times more rapidly than older skin cells cultured in the same manner and these banked fetal cells are very resistant against physical and oxidative stress when compared to adult skin cells under the same culture conditions. They are up to three times more resistant to UVA radiation and two times more resistant towards hydrogen peroxide treatment. This mechanism may be of major importance for fetal cells when they are delivered to hostile wound environments. For fetal cell delivery to patients, cells were associated with a collagen matrix to form a three-dimensional construct in order to analyze the capacity of these cells for treating various wounds. We have seen that fetal cells can modify the repair response of skin wounds by accelerating the repair process and reducing scarring in severe burns and wounds of various nature in children. Hundreds of thousands of patients could potentially be treated for acute and chronic wounds from one standardized and controlled cell bank.

OBJECTIVE: To evaluate the impact of uncomplicated pregnancy on the pulse contour of central aortic pressure. METHODS: A total of 66 women with singleton pregnancy were grouped according to pregnancy duration: first trimester (T1, n = 22), second trimester (T2, n = 20), and third trimester (T3, n = 24). Non-pregnant healthy women, who took combined oral contraception, were included as controls (C, n = 21). The pulse contour of aortic pressure was obtained with radial applanation tonometry, using a commercial device (SphygmoCor). The influence of reflected waves on the contour was evaluated not only in systole, as usual with pulse contour analysis (systolic augmentation), but also in diastole (diastolic augmentation). RESULTS: Throughout pregnancy, central systolic and diastolic blood pressure remained unchanged and comparable to values in the non-pregnant state. Systolic augmentation amounted to 8.1 +/- 7.5% of pulse pressure in the control group (mean +/- SD), and there was no statistically significant deviation from this value at any stage of pregnancy (T1, 4.6 +/- 11.4%; T2, 5.0 +/- 9.3%; T3, 4.7 +/- 8.1%). In contrast, the amplitude of the diastolic augmentation wave progressively declined with advancing pregnancy (C, 6.5 +/- 2.4%; T1, 5.2 +/- 3.1%; T2, 3.8 +/- 2.6%; P = 0.002 versus C, T3, 2.3 +/- 2.0%; P < 0.0001 versus C and P = 0.0004 versus T1). CONCLUSION: The systolic shape of the central aortic pressure contour is left unaltered by pregnancy, implying a finely tuned adaptation of the cardiovascular system to the increased demand for blood flow at all stages of the gravid state. In contrast, the amplitude of reflection waves reaching the aortic root in diastole progressively decreases with advancing pregnancy.

Heparin is the drug of choice for the treatment or the prevention of thromboembolic disease during pregnancy. However, treatment options are limited when heparin cannot be used because of hypersensitivity skin reactions. Despite the recent availability of new anticoagulant agents, data relating to their use during pregnancy are lacking. This report describes the successful management with fondaparinux, during 150 days, of a pregnant patient with protein S deficiency and prior deep vein thrombosis (DVT) who developed heparin and danaparoid hypersensitivity.

Objective Absent or reverse end-diastolic flow (Doppler II/III) in umbilical artery is correlated with poor perinatal outcome, particularly in intrauterine growth restricted (IUGR) fetuses. The optimal timing of delivery is still controversial. We studied the short- and long-term morbidity and mortality among these children associated with our defined management. Study design Sixty-nine IUGR fetuses with umbilical Doppler II/III were divided into three groups; Group 1, severe early IUGR, no therapeutic intervention ( n = 7); Group 2, fetuses with pathological biophysical profile, immediate delivery ( n = 35); Group 3, fetuses for which expectant management had been decided ( n = 27). Results In Group 1, stillbirth was observed after a mean delay of 6.3 days. Group 2 delivered at an average of 31.6 weeks and two died in the neonatal period (6%). In Group 3 after a mean delay of 8 days, average gestational age at delivery was 31.7 weeks; two intra uterine and four perinatal deaths were observed (22%). Long-term follow-up revealed no sequelae in 25/31 (81%) and 15/18 (83%), and major handicap occurred in 1 (3%) and 2 patients (11%), respectively, for Groups 2 and 3. Conclusion Fetal mortality was observed in 22% of this high risk group. After a mean period of follow-up of 5 years, 82% of infants showed no sequelae. According to our management, IUGR associated with umbilical Doppler II or III does not show any benefit from an expectant management in term of long-term morbidity.

Fetal blood sampling is a widely used technique for both diagnostic and therapeutic purposes. However, despite the fact that examination of blood smears is a critical step in the study of a large variety of disorders, the place of fetal blood smears analysis has been overshadowed by more sophisticated diagnostic tools such as those offered by molecular biology. Nevertheless, as highlighted by four cases presented in this paper, the role of fetal blood smears examination must be re-emphasized. The recognition of abnormal cytological findings limits the number of possible aetiologies, thus elegantly contributing to the diagnosis without multiplying unnecessary test techniques.

In spite of extensive clinical examinations or autopsies, as many as 15% to 40% of stillbirths remain unexplained. A systemic fetal inflammatory response is an independent risk factor for severe neonatal morbidity, mediated by proinflammatory cytokines. As a major anti-inflammatory cytokine, interleukin-1 receptor antagonist (IL-1ra) plays a crucial role modulating the proinflammatory response. The gene coding for IL-1ra (IL1RN) is polymorphic. We hypothesized that fetal possession of a specific allele, IL-1RN*2, associated with increased proinflammatory responses, may increase susceptibility to intrauterine fetal death.Fetal kidney cells were obtained from paraffin blocks of 27 unexplained stillbirths. DNA was isolated and tested for IL-1RN genotypes by polymerase chain reaction. As a control group, DNA from 302 live births was also tested.There was an enhanced rate of IL-1RN*2 homozygocity, 41%, among unexplained stillbirths compared with the control group, 8.6% (P.001). Histologic analysis of fetal tissues demonstrated a predominant proinflammatory response in IL-1RN*2 homozygote fetuses. Extensive screening (microbiology, maternal serology, placenta histology) did not identify any specific trigger agent.There is an association between unexplained stillbirth and fetal homozygous IL1RN*2 carriage.

Objective: The relationship between detection of Mycoplasma hominis in mid-trimester amniotic fluid and subsequent pregnancy outcome was investigated. Study design: Amniotic fluids from 456 women of European background who underwent a transabdominal amniocentesis at weeks 15-17 of pregnancy were tested for M. hominis by polymerase chain reaction (PCR). The amplicons were hybridized to an internal probe and detected by ELISA. Pregnancy outcomes and clinical data were subsequently obtained. Results: M. hominis were identified in 29 (6.4%) of the amniotic fluids. The rate of preterm labor in women positive for M. hominis (14.3%) was higher than in the negative women (3.3%) (p=0.01). Similarly, a spontaneous preterm birth with intact membranes occurred in 10.7% of the M. hominis-positive women as opposed to only 1.9% of the negative women (p=0.02). The presence of this mycoplasma was not correlated with fetal chromosomal aberrations, intrauterine growth restriction or preeclampsia. Conclusions: Detection of M. hominis in second-trimester amniotic fluids can identify women at increased risk for subsequent preterm labor and delivery.

To compare the efficacy and safety of misoprostol (prostaglandin E(1) (PGE(1))) with dinoprostone (prostaglandin E(2) (PGE(2))) for third trimester cervical ripening and labor induction.Patients requiring induction of labor were randomly assigned to receive either 50 microg of intravaginal misoprostol every 4 h or 0.5 mg of intracervical dinoprostone gel every 6 h. Eligibility criteria included gestation = 36 weeks. Primary outcome was the time interval from induction to delivery; secondary outcomes were mode of delivery, perinatal outcome, and interpretation of cardiotocogram (CTG) records.Two hundred women were randomly enrolled to receive either misoprostol (n = 100) or dinoprostone (n = 100). Time induction-to-delivery at 12, 24 and 48 h and the need for oxytocin were reduced with misoprostol (P0.05). Pathological CTG tracing according to FIGO and Melchior scores were more frequent in the misoprostol-treated group (P0.001).Misoprostol shortened the induction-to-delivery interval, but is associated with a higher incidence of abnormal CTG than prostaglandin E(2).

The aim of the study was to assess the effects of epidural analgesia on pelvic floor function. Eighty-two primiparous women (group 1, consisting of 41 given an epidural, and group 2 of 41 not given an epidural) were investigated during pregnancy and at 2 and 10 months after delivery by a questionnaire, clinical examination, and assessment of bladder neck behavior, urethral sphincter function and intravaginal/intra-anal pressures. The prevalence of stress urinary incontinence was similar in both groups at 2 months (24% vs. 17%, P = 0.6) and 10 months (22% vs. 7%, P = 0.1), as was the prevalence of decreased sexual vaginal response at 10 months (27% vs. 10%, P = 0.08). Bladder neck behavior, urethral sphincter function and intravaginal and intra-anal pressures showed no significant differences between the two groups. Ten months after spontaneous delivery, there were no significant differences in the prevalence of stress urinary incontinence and decreased sexual vaginal response, or in bladder neck behavior, urethral sphincter function and pelvic floor muscle strength between women who had or had not had epidural analgesia.

QUESTION UNDER STUDY: To evaluate the situation of Female Genital Mutilation (FGM) in Switzerland. METHODS: Through a questionnaire, Swiss gynaecologists were asked if they have been confronted to FGMs, if they have been asked to perform infibulations and FGMs. The health representatives (Kantonsarzte/medecins cantonaux) were interviewed on FGM activity at the Canton level. Swiss Medical Schools were asked if FGM was included in the pregraduate curriculum, and an estimated prevalence rate for FGMs in Switzerland was gathered. RESULTS: Among Swiss gynaecologists, 20% reported having been confronted with patients presenting with FGM and among them 40% had been asked about reinfibulation. Gynaecologists are occasionally asked about the possibility of performing FGMs in Switzerland. No activity concerning FGM is reported by health authorities in the Cantons. Teaching about FGM is not included in the curriculum of any of the Swiss medical schools. Approximately 6,700 girls at risk and women who have undergone FGM live in Switzerland. CONCLUSION: The extent to which gynaecologists are confronted to women with FGM may justify further action to try to better understand the situation in Switzerland. Improvement of care by better education of health care providers (guidelines) and prevention of new cases by women's education should also be considered.

We report a case of an intrauterine fetal infection by the varicella-herpes zoster virus following maternal varicella at 17 weeks' amenorrhea. Prenatal diagnosis of fetal infection was confirmed by serology and fetal damage by ultrasonography. Autopsy of the fetus showed multiorgan manifestation with disseminated foci of necrosis and microcalcifications, encephalitis and unilateral segmental skin scarring with an underlying hypoplastic fixed lower limb. The placenta showed a multifocal chronic villitis with multinucleated giant cells. The lesions included segmental anomalies and multiorgan damage.

OBJECTIVE: To evaluate the pertinence of prenatal diagnosis in cases of congenital uropathy. STUDY DESIGN: Retrospective evaluation over a period of 6.5 years. METHOD: 93 cases were involved in the comparison of prenatal ultrasonographic diagnosis with neonatal findings, autopsy results, and follow-up data. RESULTS: 33 fetuses had renal parenchymal lesions, 44 had excretory system lesions, and 6 had bladder and/or urethral lesions. Seventy-three pregnancies lead to live births. Eighteen terminations of pregnancy were performed on the parents' request for extremely severe malformations. Two intrauterine deaths were observed, and two infants died in the postnatal period. Prenatal diagnosis was obtained at an average of 27 weeks gestation. Diagnostic concordance was excellent in 82% and partial in 12% of cases with renal parenchymal lesions; the false-positive rate was 6%. For excretory system lesions, concordance was excellent in 87% and partial in 7.4% of cases, with a false-positive rate of 5.6%. Finally, concordance was excellent in 100% of cases of bladder and/or urethral lesions. The overall rate of total concordance was 86%. Partial concordance cases consisted of malformations different from those previously diagnosed, but prenatal diagnosis nevertheless lead to further investigations in the neonatal period and to proper management. The false-positive diagnoses (5.4%) never lead to termination of pregnancy. CONCLUSION: Prenatal diagnosis of congenital uropathy is effective. A third-trimester ultrasonographic examination is necessary to ensure proper neonatal management, considering that the majority of cases are diagnosed at this gestational age.

Objective To compare the effects of forceps delivery and spontaneous delivery on pelvic floor functions in nulliparous women. Design A longitudinal prospective study with investigations during the first pregnancy, 10 weeks and 10 months after delivery. Setting Antenatal clinic in a teaching hospital. Population One hundred and seven patients aged 28.4 years, divided into those with forceps (n= 25) or spontaneous (n= 82) delivery. Methods Investigations with a questionnaire, clinical examination, assessment of bladder neck behaviour, urethral sphincter function, intra-vaginal/intra-anal pressures during pelvic floor contractions. Results The incidence of stress urinary incontinence was similar in both groups at 9 weeks (32%vs 21%, P= 0.3) and 10 months (20%vs 15%, P= 0.6) after delivery, as was the incidence of faecal incontinence (9 weeks: 8%vs 4%, P= 0.9; 10 months: 4%vs 5%, P= 1) and the decreased sexual response at 10 months (12%vs 18%, P= 0.6). Bladder neck behaviour, urethral sphincter function and intra-vaginal and intra-anal pressures were also similar in the two groups. However, 10 months after delivery, the incidence of a weak pelvic floor (20%vs 6%, P= 0.05) and the decrease in intra-anal pressure between the pre- and post-delivery values (−17±28 cm H2O vs 3±31 cm H2O, P= 0.04) were significantly greater in the forceps-delivered women. Conclusions Forceps delivery is not responsible for a higher incidence of pelvic floor complaints or greater changes in bladder neck behaviour or urethral sphincter functions. However, patients with forceps delivery have a significantly greater decrease in intra-anal pressure and a greater incidence of a weak pelvic floor.

Polychemotherapy including idarubicin was administered during the second trimester to treat acute lymphoblastic leukemia. The infant delivered at 28 weeks' gestation had acute cardiac failure attributed to the cardiotoxic effect of idarubicin. Cardiotoxicity may be caused by idarubicin's biophysical properties that facilitate its transplacental passage. Idarubicin should be used with extreme caution during pregnancy.

Using fetal blood sampling, the diagnosis of triploidy can be strongly suspected on the basis of the peculiar hematological picture. Triploid fetuses present with anemia, marked anisopoikilocytosis, and grossly increased mean corpuscular volume, associated with thrombocytopenia and significant platelet anisocytosis. These findings are of considerable immediate diagnostic value. They allow physicians to immediately counsel parents about the prognosis of the fetus. In case of fetal or neonatal distress, this information could orientate decisions about obstetrical and pediatric management while waiting for the definitive diagnosis.

A simple generalized linear model of toxoplasmosis incidence has been applied to serologic data from more than 9,000 women who delivered babies in Switzerland. This model, based on an assumption of constant incidence of toxoplasmosis throughout time and ages, yields estimates of incidence rates that show marked contrasts between subgroups of women categorized on the basis of their geographic origin and duration of residence in Switzerland. The patterns observed are in agreement with previously reported data from specific areas. When applied to Swiss resident women of different age groups, the average incidence rate estimates obtained were remarkably similar. This was not the case among the subgroup of Portuguese immigrant women, nor when the model was applied to previously published data from Sweden where toxoplasmosis incidence has clearly decreased in the last 20 years. Although models for the analysis of cross-sectional data involve major simplifying assumptions, it appears that they can yield useful epidemiologic information and that departures from the assumed simplified structure of the data can sometimes be identified.

Normal levels of cancer-associated antigen (CA) 19-9, neurone-specific enolase (NSE), cancer-associated antigen (CA) 125, and mucin-like carcinoma-associated antigen (MCA) during pregnancy were determined in 87 mothers and fetuses, using a solid-phase sandwich enzyme immunoassay. CA 19-9 concentrations were higher in the fetuses, whereas the other three tumour-associated antigen levels were higher in the mothers. Only fetal NSE and MCA levels were positively correlated with those in maternal serum. Contrary to adult samples, no difference was demonstrated between male and female fetal levels of CA 125. MCA was the only maternal marker that increased significantly with gestational age between 20 and 34 weeks' pregnancy.