[Induced abortion. Legislation, epidemiology, complications].
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Abortion, Legal↗
Biomedical subjects
I Nisand
Publications and source records attributed to I Nisand.
[Prenatal prevention of infant respiratory distress syndrome. 1st part: experimental data and pharmacological treatment].
Pulmonary maturation and growth are two time-related interdependent phenomena. The main regulatory mechanisms of pulmonary maturation are complex and the role of epithelial-mesenchymal interrelationship appear to be determinant in the phenomena leading to morphological growth of the lung and in cellular differentiation of the epithelium during development. At an early stage of morphological development of the fetal lung, endogenous hormones do not directly affect epithelial differentiation but modulate the expression of genes coding for surfactant. Later surfactant production responds to multihormone regulation. Some of these hormones or growth factors (steroids, oestradiol, prolactin, thyroxine, epidermal growth factor, fibroblast pneumocyte factor) are powerful stimulators, favoring biochemical development of the fetal lung. Inversely, other factors (insulin, androgens) limit the production of surfactant. Glucocorticoids play a specific role (stimulation of morphologic and biochemical development of the lung) and potentialize the stimulating effect of other factors. A good understanding of these mechanisms is essential before introducing treatments stimulating natural processes as closely as possible. Experimental results on the use of lung maturation induction, especially with glucocorticoids, have been quite promising. Combining thyroid hormones and thyrotropin-releasing hormone appears to be an interesting proposal, as is the use of growth factors such as epidermal growth factor.
Fetal Organ Maturity↗
[Prenatal prevention of infant respiratory distress syndrome. 2nd part: clinical applications and indications].
Two types of sometimes complementary therapeutic strategies can be developed to prevent infant respiratory distress syndrome antenatally. The first is to administer a treatment aimed at accelerating the maturation process of fetal lung tissue in women at risk of premature birth. This is the only strategy with a goal of antenatal treatment. The second method is to optimize neonatal care, particularly with exogenous surfactants. The use of corticosteroids during the antenatal period has been well studied and is known to be effective with a 50% reduction in the risk of the syndrome before 34 weeks gestation. Prenatal morbidity and mortality are decreased without major adverse effects. Based on a limited number of cases, TRH-corticosteroid combination probably gives better results with no predictable unfavourable neonatal consequences. The synergic action of antenatal treatments, completed with exogenous surfactants at birth, is one of the fundamental aspects of care for very premature infants (< 28 weeks gestation).
Adrenal Cortex Hormones↗
[An unusual etiology of hydramnios: prenatal cerebral vascular accident. Five cases].
Neurological anomalies of the fetus are classically reported as causes of hydramnios, but cerebral vascular events occurring in utero in the fetus are rarely mentioned. We observed five newborns with neurological complications during the neonatal period in which anomalies of cerebral vascularization were identified antenatally. The mothers had hydramnios during pregnancy. Several pathophysiological hypotheses have been proposed to explain the mechanism of hydramnios. Magnetic resonance imaging of the brain in the fetus has made it possible to identify such exceptional events with extremely poor prognosis and major sequelae.
Cerebrovascular Disorders↗
[Contribution of ultrasonography in the assessment of the endometrium and the myometrium].
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Endometrium↗
[Comparative value of transverse abdominal diameter and fetal abdominal perimeter. 3844 biometric examinations].
OBJECTIVE: Assess charts of abdominal size as they are used in a routine ultrasound screening, on a non selected population with 5 operators, to compare the interest of transverse abdominal diameter (TAD) with abdominal circumference (AC). METHOD: Retrospective study, in the department of Antenatal Diagnosis of the Centre Médico-Chirurgical et Obstétrical between September 1991 and August 1994. MAIN OUTCOME MEASURES: Abdominal biometry and gestational age to characterize the prenatal trophicity. Neonatal weight and gestational age at birth to characterize neonatal trophicity. RESULTS: Between 32 and 36 weeks, the TAD charts detected only one SGA (small for gestational age) out of 10. However, the AC sensitivity was 54.5% with a specificity of 94%. In the same period, the TAD charts suspect LGA (large for gestational age) for one exam out of two. The charts of AC have about the same performance to detect LGA and SGA. CONCLUSION: For a routine ultrasound screening between 32 and 36 weeks gestational age, the AC charts have to be preferred to TAD charts.
Abdomen↗
[The practice of ultrasonography in gynecology-obstetrics: standard performance and results].
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Clinical Protocols↗
[Embryo reduction in multiple pregnancies. A French multicenter study].
OBJECTIVE: To study the outcome of multifetal pregnancy embryo reductions (MFPR) in France. STUDY DESIGN: A retrospective questionnaire multicenter survey was conducted in 11 French centers. 262 consecutive MFPR were collected. Miscarriage and prematurity rates were analyzed as a function of the starting number of embryos, the finishing number after MFPR, and the technique of MFPR. RESULTS: There were 41 pregnancy losses before 24 weeks (16%), and 221 deliveries at 25 menstrual weeks or later (84%). Prematurity was significantly correlated to the finishing number of embryos following MFPR. However, even when a single embryo was left, there were 30% of premature deliveries. CONCLUSION: MFPR decreases the risk of prematurity in multifetal pregnancies of high order, and this is best achieved when a single embryo is left.
Abortion, Induced↗
[Isolated fetal tachycardia, a diagnostic event of Basedow's disease. Apropos of a case].
Two of thousand pregnancies are complicated by a Graves' disease. The circumstances of diagnosis are usually maternal disorders (tachycardia, exophthalmia, loss of weight...), also fetal disorders (tachycardia, intra-uterine growth retardation, stillborn...). The discovery of fetal tachycardia (160 beats per minute), and maternal tachycardia (120 beats per minute) associated with high blood pressure, allowed us to suspect, in this case, a Graves' disease, responsible of fetal hyperthyroidism by autoantibodies crossing the placenta. The measuring of T3, T4, TSH and autoantibodies confirmed the diagnosis. The drug of choice is the PTU (propylthiouracil). It prevents synthesis of thyroid hormones and inhibits peripheral deiodination of T4 to T3. It treats simultaneously mother and fetus; the surveillance must allow us to adjust treatment to avoid fetal hypothyroidism, maternal thyrotoxicosis of peripartum and neonatal thyrotoxicosis.
Adult↗
Measurement of limb circumferences with three-dimensional ultrasound for fetal weight estimation.
A large number of formulae have been published for fetal weight estimation. This study examines the possibility of using three-dimensional ultrasound to measure the limb circumference. This technology provides us with the opportunity to visualize two simultaneous, orthogonal planes, allowing the exact determination of the transverse plane at the mid-point of the limb. A total of 157 patients were scanned in the week prior to delivery. The following variables were measured in 154 fetuses: biparietal diameter, head circumference, transverse abdominal diameter, abdominal circumference, femur length, thigh circumference and arm circumference. The whole population was split into three subgroups according to the abdominal circumference centile (< 10th centile, 10-90th centile, and > 90th centile), because this single variable has the strongest correlation with neonatal weight (R = 0.901). With forward stepwise multiple regression analysis, four models were elaborated, one for the whole population and one for each subgroup. The small-for-dates fetuses need a targeted formula including only two variables, thigh circumference and femur length. Our data suggest that the thigh circumference measurement improves the estimation for growth-retarded fetuses and that the arm circumference improves the weight prediction for the others. The measurement of the two variables, made possible with three-dimensional ultrasound, has improved our results in fetal weight estimation.
Journal Article↗
[Management of a short femur discovered via ultrasound in utero. Prenatal diagnosis of Stuve-Wiedemann syndrome].
The authors report a case of familial Stuve-Wiedemann syndrome where the diagnosis was made in utero. Following this case the authors discuss the management of short femur discovered by ultrasound. The analysis of the morphology, the ultrasound appearance and the radiographic appearance (X-ray of the uterine contents) may make it possible sometimes to diagnose the syndrome. An important element is a study of the genealogy to discover the way in which a large number of these bone diseases are transmitted. The prognosis for life is very variable according to the severity of the syndrome.
Adult↗
Embryo reduction in multifetal pregnancies after infertility therapy: obstetrical risks and perinatal benefits are related to operative strategy.
To assess the benefits that can be expected from embryo reduction of multiple pregnancies after infertility therapy, we report 58 consecutive cases of selective termination using either a transcervical or a transabdominal approach. The initial number of embryos was five or more in 13 patients, four in 29 patients, and three in 15 patients. The miscarriage rate after transabdominal procedures (23%) was one half of that after transcervical aspiration. Forty pregnancies resulted in the live birth of one child or more. The rate of prematurity was strongly related to the number of embryos left. Mean gestational age at birth was 35.5 weeks but reached 37.7 weeks when only one embryo was left. A reduction in premature birth after selective termination appeared clear for pregnancies with four or more embryos but was less significant for triplets.
Abortion, Induced↗
Standard curves of cerebral Doppler flow velocity waveforms and predictive values for intrauterine growth retardation and fetal acidosis.
Cerebral Doppler measurements seem to be a future method to evaluate the degree of fetal hypoxemia. The aim of this study was (1) to elaborate standard curves for the different cerebral vessels in our own population, and (2) to describe the predictive value of Doppler measurements for intrauterine growth retardation (IUGR) and fetal acidosis. We recorded cerebral flow velocity waveforms from 71 normal pregnancies to establish standard curves for the following vessels: proximal middle cerebral artery, distal middle cerebral artery and posterior cerebral artery. Finally, we calculated the cerebroplacentar index (CPI) for each case. The predictive values from the different vessels were determined in 24 patients with IUGR and 17 cases with fetal acidosis. The poor sensitivity and the low positive predictive value of each cerebral vessel is probably explained by the rather long interval between the last Doppler assessment and delivery (22 +/- 23 days). Reducing the interval to less than 7 days, the distal middle cerebral artery and the CPI were pathological in 4 cases out of 5 fetuses that underwent cesarean section for fetal distress. These latter results have encouraged us to use cerebral Doppler flow velocity to detect fetal hypoxemia. In conclusion, the middle cerebral artery blood flow in its distal part seems to be the finest parameter to predict fetal acidosis, and this vessel should be used to optimize obstetrical management of high-risk pregnancies.
Acidosis↗
[Resection under echographic control of septate uteri].
Septate uterus can be responsible for such infertility as requires surgical treatment. This series of this kind of uterine malformation in 37 cases makes it possible to evaluate the efficacy of a new technique for correction of the septum. It has the merit of not requiring laparotomy and above all it avoids carrying out hysterotomy which definitely weakens the uterus. The technique assists in correcting the defect through the cervix with scissors under ultrasound control. The morphological results on the uterine cavity are perfect in 19 patients. In 12 patients there was an arcuate fundus left and in 5 cases the section was insufficient and required a repeat procedure. This brings up to 20 the number of perfect corrections and 16 the number left with an arcuate fundus. The simplicity results were assessed in infertile patients and show that the number of abortions per patient dropped from 1.72 on average to 0.38 thanks to the ultrasound correction that was carried out. The simplicity of this method which can be carried out on an outpatient basis makes it possible to spread the indications to a situation where the Bret-Palmer technique could not be carried out and in particular in cases where IVF was being considered.
Congenital Abnormalities↗
[Middle cerebral artery fetal velocimetry: criteria for extraction in severe growth retardation].
Traditional fetal extraction criteria based on the cardiotocogram (group 1) probably occur too late to serve as extraction criteria in cases of severe growth retardation. We suggest that Doppler ultrasound of the middle cerebral artery (M.C.A.) (group 2) would be used to assess the optimal moment for fetal extraction. This method has enabled us to modify perinatal mortality from 37% to 0% (p less than 0.01). The percentage rate of cerebral hemorrhage and/or neurological sequelae was 41% (9/22) in the first group whereas no infant in group 2 or 3 (control group) had these complications. The percentage rate of neonatal complication was 67% in group 1 versus 28% in group 2 (p less than 0.01). Group 1 spent 53 days (+/- 35) in intensive neonatal care unit versus 43 days (+/- 22) for group 2. Neonatal outcome was quite similar between group 2 and the control group. Cerebral Doppler could allowed us to extract severe IUGR fetuses just before cerebral ischemia and irreversible tissue damage.
Cardiotocography↗
[Surveillance of fetal growth].
While clinical methods are sufficient to evaluate normal foetal growth, ultrasonography is indispensable in pathological situations. A knowledge of foetal growth is useful mainly in the 3rd trimestre of pregnancy, when the gestational age can no longer be determined. Growth is evaluated from abdominal parameters, especially perimeters. Disturbance in the development of cranial perimeter means that the brain protection mechanisms are overcome. At the moment, Doppler velocimetry cannot lead to a decision, but it provides valuable information on the perinatal prognosis. Ultrasonography is an accessory decisive factor in matters of stunted foetal growth. Cardiotocography provides instantaneous data to be used in emergencies, but ultrasonography and Doppler ultrasound provide information for long-term use. Despite the accessory position of ultrasonography as a decision-making examination, no one today would consider doing without it when monitoring foetal growth. Hence the necessity to determine exactly when and how should be obtained the data that make ultrasonography so valuable for this purpose.
Embryonic and Fetal Development↗
[The obstetrical ultrasonographer and the law. Toward a medical consensus in prenatal diagnosis].
Ultrasonographers are being held to account more and more often. They are blamed for failures in diagnosis, and in particular "for false negatives". Having been taken off its pedestal, our profession seems now to have been put into the dock by a population that equates the right to treatment (encouraged by our health assurance system) with the right ot a cure and with duty by the medical profession to provide a mean to achieve the cure and good results. All forms of imaging of diagnostic interpretation are particularly vulnerable to the misunderstanding of the rights of the patient. The doctor's responsibility in civil law can be invoked when he has made a mistake, and when that mistake results in injury to the patient or her infant and where there is an obvious causal link between the mistake and the injury. The injuries that can be said to arise in the field of antenatal diagnosis are very broad-ranging, as the cases described in this article show. Comparisons between the state of affairs in France and in North America are made. The following can be involved: death of the fetus or of the newborn, emotional trauma for the parents, loss of opportunity, which is a "new" injury accepted several times since 1965 and now brought up more and more often in civil actions. This loss has not yet appeared in the penal system.(ABSTRACT TRUNCATED AT 250 WORDS)
Diagnostic Errors↗
[Pre-decision algorithms for the induction of ovulation in fertilization in vitro].
The success of medically assisted procreation techniques depends on the influence of numerous parameters and, especially the quality of ovarian hyperstimulation. The need of a homogeneous treatment within the medical team has led us to elaborate a system of assistance in decision making in terms of stimulation of ovulation. A first system was developed for a classical stimulation protocol, type clomiphene-gonadotropin. The limited number of decision making parameters (six) as well as the limited number of therapeutic decisions (six) has enabled us to developed a particularly performing algorithm system.
Algorithms↗