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Antigen HLA-A, B sharing couples have been previously observed in abnormal pregnancies of unknown etiology. We have determined the HLA-A, B, C and DR antigens of 20 couples with recurrent spontaneous abortions (RSAs), 32 control couples and 100 normal controls. The results showed that in couples with more than two idiopathic repeated abortions, there is no significant increase in the HLA antigen sharing couples. But we were able to observe, in the affected couples, a significant increase in HLA-DR antigen sharing as regards the control couples. We also find a significant increase in the DR5 antigen, in both wives and husbands, in couples with repeated abortions of unknown etiology as previously described for the Dw5 antigen.

In this 8th statement of the ESHRE Taskforce on Ethics and Law, the focus is on the ethical issues raised by (assisted) reproduction for HIV positive men and women. Due to treatment improvements, their life expectancy has increased substantially. This, in combination with the reduction of perinatal transmission to the child, makes the creation of a family more acceptable. Recommendations are made concerning methods of avoiding HIV transmission in the couple and to their offspring. It is concluded that, if certain precautions are taken, medical assistance to reproduction of HIV positive people is ethically acceptable. For the time being, only cases of serodiscordant couples should be considered.

In the field of human procreation, the problems raised by bioethics are multiple and complex. First, there is the request from couples and individuals with regards to the management of procreation, not only the negative requests, be it contraception or abortion, but also the positive requests concerning medically assisted procreation. Then there is the practitioner's response to the request, particularly for assisted procreation. The practitioner is at the heart of conflicting interests between the needs or desires of the patients and the reluctance, legitimate or not, of society, with the implication of a third person, embryo, fetus or newborn. And here again we are confronted with the aims of researchers wishing to obtain information concerning the efficacy, possibilities of application and potential dangers. The legists and magistrates are concerned with the legal status of the embryo and the fetus. However, if the fact of giving a legal status can solve many legal problems, it does not solve the problem of the eventual use of an embryo, and of its interpretation by philosophers and moralists. Moreover, public opinion should not be forgotten, including the attraction of rapid anathema, without recourse. Finally, there is also the role of the legislator who, here again, is confronted with several controversial conceptions.

This lecture deals with the difficult problem of so called "wrongful life". Two Court decisions have been issued recently in France and lead to a very ambiguous situation since they differ dramatically. In the "Perruche affair" where a diagnosis of rubella was not done, the parents prevented to get an interruption of pregnancy, and the child severely affected, the Court (Cour de Cassation, i.e. Supreme Court in charge of civil affairs) decided to compensate the child for "not having be aborted". In the "Quarez affair" where a diagnosis of Down syndrome was not done, the parents prevented to get an interruption of pregnancy, the Court (Conseil d'Etat, i.e. Supreme Court in charge of "administrative" affairs, affairs opposing individuals to state administration since the hospital in cause was belonging to the public sector) decided not to compensate directly the affected child. The consequences of these opposite decisions are analysed according to medical, legal, ethical and economic considerations.

Flat heart rate recordings may be observed in different fetal states such as chronic distress and sleep. Their visual analysis do not allow the distinction between these two states. We used spectral analysis to study the heart rate patterns in 25 fetuses. Two significant ( P -5 ) groups were apparent from the determination of the position of the maximum energy peak (PMEP) in the high-frequency band (0.20–0.50 Hz): a PMEP at about 0.20 Hz (group 1), and another around 0.30 Hz (group 2). The two groups did not differ in spectral density (SD). The outcome of neonates showed that group 1 fetuses made good progress and produced healthy neonates; whereas group 2 comprised cases of chronic fetal distress, or even death in utero, and neonatal distress. The significance of this difference in PMEP between fetal heart rate patterns in chronic distress and sleep is unclear. Studies combining the assessment of fetal movements and the determination of PMEP are planned.

Our objectives were to increase the discrimination between fetal distress and fetal well-being, using fetal heart rate spectral analysis. Monitoring of the heart rate from 259 fetuses was done between 26 and 42 weeks, interpreted with classical criteria, and analysed with the spectral analysis method we developed. The fetal heart rate spectrum analysis performed on these recordings allow discrimination of fetal distress from the normal state using the energy value and frequency of the maximal energy in the high frequency band. We can conclude that the spectral analysis produces two significant parameters which could contribute to a multivariate approach to assessments of the physiological mechanisms of heart rate variability.

Quite a few medical situations are as difficult as the ones where the desire of procreation and the risks associated to it are in conflict. The practitioner's opinion is grounded on his experience, on statistical data, but also on his own sensitivity and subjectivity. His role is not to give the patient the medical data and to leave her deciding alone. He must involve himself in the process of reflexion and decision, recognize and appreciate the depth of the motivations and finally respect them. He must remember that the female intuition bears sometimes more value than the so called scientific knowledge.

A multicentric randomized double-blind trial was realized in order to determine whether a treatment with a low-dose aspirin (150 mg/day) with or without dipyridamole (225 mg/day) was able to prevent the perinatal consequences of pre-eclampsia. This study demonstrated a significant difference in birthweight and incidence of fetal growth retardation between treatment and placebo groups. No difference was demonstrated between aspirin and aspirin + dipyridamole patients.

Findings of routine vaginal examinations during pregnancy were compared in two teaching hospitals located in the same area of Paris. We selected 2943 women who had had at least one antenatal visit between 29 and 31 weeks of gestation. Large differences in the frequency of maturation signs were observed between the two hospitals for mid-position, soft consistency and expanded lower uterine segment, although the higher frequency of each sign was not found in the same hospital. No difference was observed for dilatation of the internal os. A better reliability in assessing dilatation than other signs of maturation may explain our results and the role of dilatation in the prediction of preterm delivery.

Summary The ability of routine vaginal examinations to improve the prediction of preterm delivery was assessed in a group of 6909 women who were registered at each prenatal visit and on whom this examination had been carried out. We compared two risk scores, one including known risk factors (maternal characteristics and symptoms reported by women), and the other including these factors and the findings of vaginal examination. These risk scores were computed by multiplying the adjusted odds ratio estimations obtained by logistic regressions. The prediction of preterm delivery was improved significantly by vaginal examination at 25 to 28 weeks' and 29 to 31 weeks' gestation. However, the improvement was not very large: when 30% of nulliparous women were classified as high risk at 29 to 31 weeks, the sensitivity was 55% when considering only the risk factors and 63% when adding the findings of vaginal examination; the percentages were 52% and 55%, respectively, for parous women. These results partially explain why the medical practice of routine vaginal examinations varies from country to country. (Am J Obstet Gynecol 1990;162:1042-8.)

The authors studied 165 patients, 161 of them having been examined at least once for their umbilical diastolic index, uterine diastolic index and carotid diastolic index (CDI) during pregnancy. Four patients have been examined only for the umbilical and carotid indexes. These patients presented either a pathological pregnancy (37% of arterial hypertension; 34% of intrauterine growth retardation; 8% other causes) or previous pathological gestations (21%). Particular emphasis was given to the study of the prediction of CDI with respect to fetal heart rate (FHR) abnormalities or an intrauterine fetal death (IUFD). A mean of 1.4 measurements of CDI per patient were performed, ranging from 1 to 5. The average time lag of the first CDI measurement was of 30 weeks of pregnancy, ranging from 21 to 36.5 weeks. The mean time lag of the children's deliveries was of 35 weeks, ranging from 27 to 40 weeks of pregnancy. The mean time lag of the last CDI measurement with respect to delivery was of 15 days (1 day to 15 weeks). The CDI (CDI = D/S; D = residual diastolic velocity; S = maximal systolic velocity) was considered as pathological when exceeding 22% up to 30 weeks of pregnancy and when exceeding 26% after 30 weeks. 50% of the children born in this series were hypotrophic. When presenting identical umbilical and uterine indexes, the percentage of hypotrophic offspring was the same, whether the carotid index was normal or pathological.(ABSTRACT TRUNCATED AT 250 WORDS)

To evaluate the effects of gestational hypertension on fetal growth, we studied the standardized records of 2996 single live-birth pregnancies. Mothers all had documented diastolic blood pressure of less than 85 mmHg before the 16th wk of amenorrhea and no history of pre-pregnancy hypertension or kidney disease. Diastolic blood pressure readings exceeding 84 mmHg were found later in pregnancy in 38.4% of the mothers, and were associated with an increased number of small-for gestational-age infants: 3.2% in mothers whose diastolic blood pressure had never reached 85 mmHg, 6.3% when peak diastolic blood pressure had been in the 85-94 mmHg range, and 8.5% when it had exceeded 94 mmHg (p less than 0.01). In mothers who had had one or more diastolic readings of more than 84 mmHg, and for all peak diastolic pressures, the rate of small-for-gestational-age infants was higher when hypertension had begun early in third trimester (between the 27th and 36th wk), than in the second trimester or later than the 35th wk (10.2% compared to 5.6 and 6.1% respectively, p = 0.02). This temporal reinforcement of the adverse fetal effects of hypertension when it began in the early third trimester was not explained by differences in the incidence of proteinuria or in maternal age, parity, obstetric history or smoking habits.

Fetal heart rate (FHR) deceleration areas were studied to obtain by objective measurement of the FHR, their prognostic value of the new-born state. 1. There is a reasonably good correlation between FHR deceleration areas and UApH (Tab. II). Such a correlation was found by SHELLEY and TIPTON [6] for the whole deceleration area, and by TOURNAIRE et al. [10] for areas divided in a slightly different way. The correlation coefficients between FHR deceleration areas and Apgar score at 1 minute are within a close range of those of the FHR deceleration area and UApH (Tab. I and II). 2. According to the time relationship between deceleration areas and uterine contractions the best correlation coefficient was obtained surprisingly for total, followed by residual and then simultaneous areas. These results agree with those of SHELLEY and TIPTON [6] suggesting that in practice a simple measurement of the whole deceleration area, regardless of the uterine contractions is a sufficient method in evaluating FHR patterns. 3. The special purpose computer built by the BAUDELOCQUE research group can be used on-line, thus in clinical practice. It was not the case for the manual method [4] or the method using a large programmed computer [10]. 4 The evaluation of deceleration areas appears to have several advantages: 1. It provides objective measurements. 2. The unit used is independant of factors such as display speed or scale of the strip-chart. 3. The data is reduced: A few numbers replace the long descriptions of the usual clinical classifications.

The performance of 2 maternity units is compared. In comparable groups of average risk the prematurity rate was significantly lower in the unit practising intensive supervision during pregnancy.

In a first study, 28 pregnant women received a fast intravenous injection of atropine sulphate 12.5 microgram/kg, as in a classical atropine test. Fetal tachycardia resulted. The maternal venous blood concentration of atropine, determined by bioassay on guinea pig ileum, decreased rapidly in the first 3--5 min and very slowly therafter. In a second study, 45 women in labour received the same dose i.v., and at birth atropine was measured both in maternal and cord blood. Placental transfer of atropine had occurred in every case and was highly variable, depending on the maternal blood concentration of the drug. This suggests that the atropine test is not mainly dependent on placental function.

The efficacy of caproate of hydroxyprogesterone and acetate of chlormadinone in preventing premature labore was compared in a controlled trial. The survey was based on 211 pregnant women with a high risk of premature delivery discovered during clinical examination. There are no significant differences between the two groups in either length of gestation, delay between the beginning of treatment and delivery or other parameters related to prematurity. The absence of evidence suggesting any significant difference between the two treatments can have three possible causes (which are discussed): the methodology, the inefficacy of the two products or the equivalent efficacy of the two products.

Unbound cortisol was assayed in maternal and cord plasma. A method was used in which experimental conditions are carefully selected to approach as closely as possible the in vivo situation. ∗ ∗Robin, P., Predine, J., and Milgrom, E.: J. Clin. Endocrinol. Metab. 46:277, 1978. In maternal plasma at term, the proportion of unbound cortisol (9.7 ± 1.5%) (mean ± SE) was identical to that of normal nonpregnant women (9.7 ± 0.4%). However, the concentration of unbound cortisol was 3-fold higher at term (46.0 ± 5.9 ng/ml) than that in nonpregnant women (14.2 ± 1.0 ng/ml). During labor an increase was observed, and at birth the proportion (and concentration) of unbound cortisol was extremely high varying between 17.0 ± 0.8% (92.3 ± 7.4 ng/ml) and 20.9 ± 1.4% (130.4 ± 17.9 ng/ml) (spontaneous and induced vaginal deliveries, respectively). In cord plasma at term and before labor (fetuses delivered by elective cesarean section), the proportion of unbound cortisol was high (29.1 ± 1.3 %) but its concentration (9.6 ± 1.1 ng/ml) was only slightly lower than that observed in normal adults. Labor had an important stimulatory effect as observed in cases of vaginal delivery after spontaneous labor (proportion of unbound cortisol 35.1 ± 1.2%, concentration of unbound cortisol 15.4 ± 1.35 ng/ml, respectively). No difference was observed between spontaneous and provoked labor since similarly high values of unbound cortisol were found in cord plasma after oxytocin-induced labor followed by vaginal delivery (36.2 ± 1.4% and 23.0 ± 5.2 ng/ml).

We investigated the variations in the distribution of glycosaminoglycans (GAG) in the cervical, isthmic and corporeal stroma of the pregnant and non-pregnant human uterus. The GAG were measured in non-pregnant (n = 9) and pregnant (n = 14) cervices, in non-pregnant (n = 8) and pregnant (n = 6) uterine isthmus, and in non-pregnant (n = 12) and pregnant (n = 5) uterine corpus. Heparan sulfate is abundant in the isthmic and corporeal stroma. This has to be related to a larger content in blood vessels and muscular cells at this level than in the cervix. The distribution of hyaluronic acid and dermatan sulfate is the same in the cervix as in the corpus, but the amount of these GAGs is lower in the former, which could be due to a lower connective tissue content. Two of the main features of cervical maturation, increased hydration, and decreased dermatan sulfate concentration, were found also in the pregnant corporeal stroma. These results suggest that connective tissue maturation is not only a cervical phenomenon and could play a role in active and/or passive mechanical properties of the myometrium during late pregnancy and labor.

A study was made of the modifications of glycosaminoglycans in the uterine cervix and the relationship to gestation. These substances are essential constituents of connective tissue, and a modification of their concentration could affect the physical and chemical characteristics of the cervix. Glycosaminoglycans were extracted from cervical biopsies obtained from pregnant and non-pregnant women. This study showed dermatan sulfate to be quantitatively the most important glycosaminoglycan in the cervix of both the groups studied, and that a significant decrease in the concentration of both dermatan sulfate and chondroitin sulfates occurred in the biopsies obtained just after delivery. This was related to a decrease of collagen in the cervix at the end of gestation, as the proteoglycans containing dermatan sulfate are principally associated with collagen.

Sometimes the relationship between peripartum events and neonatal CNS injury is obvious: for example, following complete abruptio placentae or umbilical cord prolapse and occlusion with a delay of many minutes before delivery of the baby. These circumstances are, of course, rare in modern obstetrics. Usually, when a neonate develops neurological injury, a host of various potentially adverse peripartum factors are assumed to be the aetiology, but without definitive evidence. Among these latter factors are those we have focused on in this paper: the mechanical forces exerted on the fetal head during labour when the full-term fetus is in cephalic presentation. The mechanical events during the first stage of labour are reviewed, showing how uterine contractions result in cervical dilatation and descent and rotation of the fetal head. The consequences of these forces on the fetal intracranial pressure and blood flow are discussed: FHR remains normal up to a certain pressure threshold, above which decelerations occur. In other words, excessive pressures applied to the fetal head, either spontaneously (e.g. uterine tetany) or iatrogenically (e.g. traumatic forceps delivery or excessive fundal pressure) can increase fetal intracranial pressure to such a degree as to result in significant decreases in cerebral blood flow that are associated with fetal heart rate decelerations. Even when decelerations are simultaneous to contractions, decelerations cannot be considered as reflex and innocuous, as they are indeed associated with a decreasing cerebral blood flow. They must therefore be considered and evaluated in the management of labour. Cord compression and functional modifications of intervillous space by mechanical forces may further compromise the biological status of the fetus, leading to severe asphyxia. Neurological evaluation of the neonate within the first few days after delivery is currently the only way to provide the obstetricians with information on the possible consequences of an abnormal labour. The assessment of normality of the CNS in the neonate born at term, and its value in predicting late outcome are discussed. When abnormalities are detected after one or repeated assessments, abnormal neurological signs and symptoms are classified into three grades at the end of the first week. According to our data, a good correlation exists between this neonatal grading of cerebral dysfunction and late outcome. A careful evaluation of fetal head deformation, extensive caput succedaneum, and extensive retinal haemorrhages can help to interpret an abnormal labour retrospectively.(ABSTRACT TRUNCATED AT 400 WORDS)

The role of nonstressed monitoring of the fetal heart rate (HR) in determining fetal well-being during the antepartum period was assessed in 125 high-risk patients. Observations on HR, variability, and HR response to fetal movement (FM) and uterine contractions (UC) over a 30 minute period were made with an external microphone and tocotransducer. A total of 625 tests were performed; the earliest gestation tested was 28 weeks, and the latest was 46 weeks. A reactive pattern (variability greater than 6 b.p.m. and accelerations with FM) appears to be a reliable indicator of fetal well-being. All the 51 fetuses exhibiting this pattern survived. This group also had the lowest incidence of neonatal complications. On the other hand, of the babies who failed to show variability greater than 6 b.p.m. or accelerations with FM (nonreactive pattern), 40% died in the perinatal period. Thirty-five patients showed features of both a reactive and nonreactive pattern (combined pattern). Poor outcome in this group was confined to those in whom the majority of the pattern was nonreactive. An undulating HR pattern with virtually absent variability (sinusoidal pattern) was found in 20 Rh-sensitized fetuses, 50% of whom died in the perinatal period. Bradycardia and tachycardia were not found to be reliable signs of fetal distress antepartum. Of the 12 fetuses who died during observation, six showed late decelerations with spontaneous UC but all showed diminished variability. The close correlation between nonstressed patterns and neonatal outcome demonstrated by this preliminary study warrants further use of this technique for fetal evaluation.

A case is reported where a sinusoidal fetal heart rate pattern was found in a fetus at 34 weeks. This pattern, at first isolated and later persistent for several hours, during a normal pregnancy became progressively transformed into a silent pattern. Cesarean delivery then performed resulted in the birth of an infant affected by a severe anemia due to a major feto-maternal transfusion and it died aged 36 h. The authors enquire into the significance of this pattern when found in apparently normal pregnancies, not involving rhesus iso-immunization, and they suggest a possible management when confronted with a sinusoidal fetal heart pattern.

Fetal heart rate was studied during the antepartum period in 246 patients, yielding a total of 1964 recordings. The following parameters were evaluated and correlated: • the semi-quantitative assessment of fetal heart rate instability (as expressed by the percentage of duration of flat traces); • the presence of decelerations and their relationship to the presence or absence of uterine contractions; • the neonatal condition. Overall, 50% of the patients exhibited uterine contractions while 30% contained decelerations patterns either occurring spontaneously or in association with uterine contractions. A definite relationship was observed between the presence of severe decelerations (irrespective of the time relationship with any uterine contraction) and poor neonatal outcome. A relationship does exist between the presence of severe decelerations and flattening in the recording, which, as demonstrated in the previous part of the paper also exhibited a strong positive relationship with the neonatal outcome. When one considers the different degrees of flattening, it appears that a further correlation between decelerations and neonatal state is demonstrable only in the case of a 10–50% flat recording. Here the probability of a distressed baby is 20% in the absence of decelerations, but 43.4% in the presence of decelerations. In other cases (i.e., less than a 10% or more than a 50% flat recording) the pronostic significance of the instability of the record is not significantly modified by the presence or absence of decelerations. These results indicate that consideration of decelerations is only advisable in these cases where instability is moderately affected (flattening in 10–50% of the record) and that the use of the oxytocin challenge test OCT may be reserved for such cases, when these are neither spontaneous contractions nor decelerations and no contraindications present.

A single dose of micronized oral progesterone was administered to 15 pregnant women immediately prior to elective cesarean section. Levels of progesterone, 17β-estradiol, and estrone were measured in the plasma, in the placenta, and at different sites in myometrium obtained during the surgical procedure. Results were compared to those observed in a control group of women who did not receive progesterone. Progesterone levels demonstrated a marked increase in plasma and in the whole myometrium 150 minutes after administration. The levels then decreased rapidly to control values in 1 hour. The concentrations of progesterone in the placenta did not show any changes. No difference appeared in 17β-estradiol levels in the plasma or the myometrium, whereas an increase was observed in the placenta. Estrone levels did not change in the plasma, but they decreased in the myometrium and in the placenta.

This report concerns 20 patients with intrauterine fetal death. Blood samples for coagulation studies were obtained before, during and after delivery. No clinical defibrination or bleeding was noted. Coagulation defects were observed as follows: 2 biological defibrinations: The first case was a pregnancy of 32 wk with retention for more than 12 wk; hypofibrinogenemia was noted in all 6 samples, between 180 and 280 mg/100 ml. The second was a pregnancy of 32 wk with retention for more than 8 wk; fibrinogenemia was between 170 mg/100 ml and 140 mg/100 ml. 2 intravascular coagulations with normal fibrinogenemia, increase of fibrin degradation products and positive ethanol tests. 3 cases with slight coagulation defects that were difficult to explain. The coagulation defects appeared to be transient, and sometimes resolved themselves spontaneously. Induction of labour was made in 19 cases; quinine sulfate, used in 17 cases, was remarkably successful (1 intolerance, 1 failure). Study of the half-life of [125I]fibrinogen was made in 18 of the 20 cases. On average, it was reduced by half in comparison with the half-life of healthy men. The decrease was noted even in cases of fetal deaths without the coagulation defects detected by classical tests. The half-life of [125I]fibrinogen in 6 pregnant women before therapeutic abortion was also studied. The decrease of half-life was noted. Changes of metabolism of fibrinogen during pregnancy are discussed.

Among the various autoantibodies commonly found in women with systemic lupus erythematosus, the so-called lupus anticoagulant has been described in association with fetal losses. Recently, women with repeated spontaneous abortions and lupus anticoagulant, but no apparent systemic lupus erythematosus have been described. We have studied prospectively the possible connections between fetal losses and autoimmunity in a large control study of 130 idiopathic habitual aborters. These non-pregnant patients without any antecedent autoimmune disease were explored for the presence for autoantibodies especially lupus anticoagulant. Ten percent of the patients exhibit an antithromboplastin antibody (lupus anticoagulant) and half of this group possesses a striking association of biological manifestations of autoimmunity. In conclusion, two points appear: firstly, statistical correlation is demonstrated between antithromboplastin antibody and habitual abortion; secondly, doubt remains about the significance of the association between autoimmunity, fetal losses and antithromboplastin: beginning of systemic lupus erythematosus or new autoimmune entity with gynaeco-obstetrical expression.

This was a parallel of the rate of caesarean section and neurological morbidity of the term newborn. This study was performed on all infants born at a gestational age of 37 weeks or greater in 1981 and 1982 at the Baudelocque Maternity Hospital. The results show a stable caesarean section rate during these two years: 21% in 1981, 20% in 1982; as for the safety of term birth there was only one case of perinatal insult during a vaginal birth responsible for cerebral dysfunction of moderate degree. There was a 18% operative maternal morbidity and there were no deaths. We concluded that a caesarean section rate of 20% in a University Hospital is justified by the virtual absence of neonatal morbidity with an acceptable maternal risk. This rate should not increase. The possible ways of decreasing this rate, while maintaining neonatal safety, must be studied. The original aspect of this work concerns the monitoring of the caesarean section rate by the incidence of neurological complications of all term births during a fixed period of time.

A method for reading the foetal heart rate tracings and a guide of management advise in each case have been established from a review of the literature and the study of 500 records. The tracings are schematically divided into three categories according to the presumed risk of foetal distress: normal or "tolerable" tracings, alarm symptoms and danger symptoms. For each categorie, and according to the duration of the variations, a type of management is proposed. Other diagnostic means, such as capillary blood pH measurement are desirable to improve the foetal state diagnostic and make the treatment more precise.

A newly developed tissue pH electrode designed for continuous pH monitoring was evaluated in 61 fetuses during labor. The results obtained in this series confirm the reliability of this method. The correlation coefficient between tissular pH and capillary blood pH is 0.94. The correlation coefficient between the last intrapartum tissue pH and the umbilical arterial blood pH is 0.84.

Sometimes the relationship between peripartum events and neonatal CNS injury is obvious: for example, following complete abruptio placentae or umbilical cord prolapse and occlusion with a delay of many minutes before delivery of the baby. These circumstances are, of course, rare in modern obstetrics. Usually, when a neonate develops neurological injury, a host of various potentially adverse peripartum factors are assumed to be the aetiology, but without definitive evidence. Among these latter factors are those we have focused on in this paper: the mechanical forces exerted on the fetal head during labour when the full-term fetus is in cephalic presentation. The mechanical events during the first stage of labour are reviewed, showing how uterine contractions result in cervical dilatation and descent and rotation of the fetal head. The consequences of these forces on the fetal intracranial pressure and blood flow are discussed: FHR remains normal up to a certain pressure threshold, above which decelerations occur. In other words, excessive pressures applied to the fetal head, either spontaneously (e.g. uterine tetany) or iatrogenically (e.g. traumatic forceps delivery or excessive fundal pressure) can increase fetal intracranial pressure to such a degree as to result in significant decreases in cerebral blood flow that are associated with fetal heart rate decelerations. Even when decelerations are simultaneous to contractions, decelerations cannot be considered as reflex and innocuous, as they are indeed associated with a decreasing cerebral blood flow. They must therefore be considered and evaluated in the management of labour. Cord compression and functional modifications of intervillous space by mechanical forces may further compromise the biological status of the fetus, leading to severe asphyxia. Neurological evaluation of the neonate within the first few days after delivery is currently the only way to provide the obstetricians with information on the possible consequences of an abnormal labour. The assessment of normality of the CNS in the neonate born at term, and its value in predicting late outcome are discussed. When abnormalities are detected after one or repeated assessments, abnormal neurological signs and symptoms are classified into three grades at the end of the first week. According to our data, a good correlation exists between this neonatal grading of cerebral dysfunction and late outcome. A careful evaluation of fetal head deformation, extensive caput succedaneum, and extensive retinal haemorrhages can help to interpret an abnormal labour retrospectively.(ABSTRACT TRUNCATED AT 400 WORDS)

Polyhydramnios, which is caused by an excess of amniotic fluid, was diagnosed uniformly in eight patients by ultrasound examination and clinical symptoms, namely, premature uterine contraction, abdominal pain, and respiratory discomfort that resulted from excessive pressure on the diaphragm. Fetal anomalies incompatible with extrauterine existence were excluded by serum alpha-fetoprotein levels, repeated sonography, amniocentesis, and chromosomal analyses. Patients were treated with 2.2 to 3.0 mg of indomethacin/kg body weight/day. The treatment was started at an average gestational age of 24 +/- 0.5 weeks and continued for 2 to 11 weeks. All patients had significant improvement with a simultaneous reduction in amniotic fluid volume, fundal height, and umbilical perimeter. All patients were delivered satisfactorily at an average of 39 weeks' gestation. The fetuses were within the normal body weight range of 2750 to 3600 gm and showed normal development during the neonatal period of 2 to 6 months. Before delivery without indomethacin, the polyhydramnios reformed. Adverse effects or intolerance to the drug was avoided by either a reduction in the dose or cessation of indomethacin therapy. Our studies suggest that indomethacin therapy is an effective way to manage pregnancy complicated by polyhydramnios.

In vivo recordings of electrophysiological activity of the muscular tissue in the cervix, in both the pregnant human female and Macaca monkey, showed that most of the cervix did not present a measureable electrical activity. Only muscular tissue located in the peripheral, supra vaginal portion of the cervix, exhibited a noticeable propagated E.M.G. activity, which always originated in the fundus. This accords well with histological studies which demonstrate that this portion of the cervix is the richest in muscular tissue. It is however possible that the other muscular cells of the cervix have a role other than a contractile one, and may be responsible for synthetizing or catabolizing constituant parts of the cervical connective tissue.

The authors report three years of experience with the use of the Doppler in Obstetrics. Certain notions may be integrated to the principles of clinical decision. The diastolic index D at the umbilical artery increases regularly during a normal pregnancy. It is significantly decreased in case of intra-uterine growth delay (IUGD). When this index reaches zero, it may be considered as a reliable criteria for fetal extraction. Certain notions must be verified: the index seems frequently altered in case of chromosomal abnormality. Some results still depend on research. The index measured at the uterine arteries could predict IUGD and at the level of the fetus' internal carotids, its elevation could be one of the first signs of fetal hypoxia. Finally, the index was measured during normal labor. In case of deceleration it is markedly altered. Thus, this could be an additional element of fetal monitoring.

The physiopathological role of antithromboplastin-type circulating anticoagulants in habitual abortion may be envisaged since the presence of antithromboplastin has been reported in most studies on women at high risk of abortion. To avoid a possible statistical bias, we conducted a prospective study in a sufficiently large group of women with habitual abortion (n = 99) compared with a control group of women with normal fecundity (n = 50). In addition, all women were investigated for lupus symptoms. The circulating antibody was detected by the diluted thromboplastin time and activated cephalin time methods. The results were considered positive when the patient/control diluted thromboplastin time ratio was 1.2 and/or when the increase in activated cephalin time was not corrected by a control plasma. In the patients' group, 10 women (10%) had an anti-thromboplastin type circulating anticoagulant, whereas no circulating anticoagulant could be detected in the control group. Three women with circulating anticoagulant had signs of systemic lupus erythematosus. None of the patients presented with Soulier-Boffa syndrome. These data have established a significant correlation between habitual abortion and circulating anticoagulant whilst avoiding statistical bias. Our results suggest that women with idiopathic habitual abortion should be subjected to systematic immunological exploration and that a small number of them should be followed attentively.

The relationship between abortive disease and systemic lupus erythematosus is complex as shown by data from the literature and by our 9 patients selected for presenting with abortive disease, circulating anticoagulant and biological signs of autoimmunity. The risk of transformation into a systemic disease is real, although difficult to evaluate in the absence of prospective studies, but the major problem with these patients is the severity of the obstetrical pathology. The sombre foetal prognosis, already reported in the literature, requires close supervision and sustained treatment during pregnancy. For these reasons we suggest calling autoimmune abortive disease the disease which affects women with signs of autoimmunity who have had several, often late foetal deaths associated with the presence of circulatory anticoagulant thought to interfere with placental blood flow.