Crise sanitaire et transgression

Le parcours en périnatalité a subi une réorganisation complète pendant la crise sanitaire. Le suivi de grossesse a été assuré en totalité, mais pas toujours la préparation à la naissance et à la parentalité. Cette situation, associée à l’absence de l’accompagnant en salle de naissance, a provoqué des incertitudes fortes et, chez certains couples, des angoisses majeures. Pour prévenir les risques de fragilisation des liens conjugaux et parents-enfant, une écoute attentive de la part des soignants s’est avérée nécessaire.

La téléconsultation, un nouvel outil pour la pratique sage-femme

L’épidémie due au coronavirus, qui a contraint la population au confinement pendant deux mois, a eu un impact sur la pratique des professionnels de santé, et notamment sur celle des sages-femmes. Les grossesses n’ont pas attendu la fin de la crise sanitaire pour se mettre en route ou arriver à leur terme, et la santé génésique des patientes a dû être préservée. La téléconsultation a permis de maintenir le contact avec les femmes désireuses d’obtenir une grossesse, de la poursuivre ou non, et d’assurer leur surveillance et leur prise en charge, malgré les distances.

Conséquences de l’infection à Sars-CoV-2 chez les femmes enceintes et les nouveau-nés

L’épidémie de Covid-19 survenue au premier semestre 2020 a fait naître de nombreuses craintes vis-à-vis des conséquences de l’infection virale chez les femmes enceintes et leurs nouveau-nés. À la fin de l’été, les données disponibles ne mettaient pas en évidence de surrisque d’infection et de complications chez les femmes enceintes par rapport à la population générale. En l’absence d’atteinte maternelle sévère, celles concernant le fœtus et le nouveau-né étaient également rassurantes.

[Materno-Fetal Prognosis Of Anemia In Bougouni]

GOAL

The goal was to assess the maternal-fetal prognosis of anemia in pregnant women in the Bougouni reference health center.

METHODS

We carried out a prospective descriptive and analytical cross-sectional study from January 1 to December 31, 2013 at the Bougouni reference health center. It covered all pregnant women with a hemoglobin level below 11g/dl regardless of the outcome of the pregnancy.

RESULTS

The prevalence of anemia in pregnant women was 33.2%. They were women married to peasants in 88.6% of cases, unschooled in 93.2% of cases, having not done antenal care in 56.8% of cases. Malaria was the most common etiology in 75% of cases. Anemia was severe in 61.4% of cases. The maternal-fetal prognosis was dominated by 3.3% of maternal death, 12.5% of abortion, 7.6% of prematurity and 6.8% of fetal death in utero.

CONCLUSION

Anemia in pregnant women is the source of many maternal-fetal complications.

[Pregnancy And Delivery In The Large Multiparous In The Reference Health Center Of Commune II Of Bamako, Mali]

AIM

The aim was to compare the maternal-fetal prognosis of pregnancies in large multiparous with that of other parities.

MATERIALS AND METHODS

We conducted a case-control study from March 1st, 2014 to February 1st, 2015. It concerned all parturients admitted in our service during the study period. We have chosen 1 case for 2 witnesses. All the large multiparous were included as cases and as witnesses the primiparous, the pauciparous and the multiparous who gave birth just before and after the case. The statistical test was the Chi2 with a significance level at 5%.

RESULTS

The frequency of pregnancy in the large multiparous was 4.93%. They were housewives in 84% of cases, unschooled in 74.7% of cases. The maternal-fetal outcome was dominated by uterine rupture in 0.6% of cases, immediate postpartum hemorrhage in 9.8% of cases, vicious presentations in 5.5% of cases and cord prolapse in 6.8% of cases.

CONCLUSION

Large multiparity is common in our practice. It is a high-risk pregnancy because of its many maternal-fetal complications.

Prévention de la propagation de la Covid-19 en Polynésie française

La Polynésie française est une collectivité d’outre-mer de la République française regroupant 118 îles. Située en plein océan Pacifique, elle a dû relever un défi majeur pour freiner l’entrée du virus Sars-CoV-2, tout en assurant la continuité des soins auprès de sa population répartie sur ses cinq archipels. Le risque d’infection à Covid-19 chez la femme enceinte a constitué une forte préoccupation, notamment en raison du taux élevé d’obésité sur le territoire.

Twice-Daily vs 4-Times-Daily Glucose Testing in Women With Gestational Diabetes Mellitus: A Pilot Study

OBJECTIVES

In women with gestational diabetes mellitus (GDM), glycemic control is typically assessed by capillary blood glucose (BG) self-monitoring. Currently, the standard method of monitoring is by 4-times-daily self-measurements. The goal of our study was to determine whether twice-daily capillary BG testing is comparable with 4-times-daily testing in women with GDM.

METHODS

Thirty-two women with GDM completed initial dietary counselling and recorded consecutive fasting and 2-h postprandial BG over a 14-day period. We randomly selected 2 of 4 BG measurements on each given day and compared mean (95% confidence interval [CI]) twice-daily vs 4-times-daily BG measurements using paired t tests and Bland-Altman plots. The proportion of 14-day BG measurements above glycemic targets was also compared between twice-daily vs 4-times-daily testing for fasting and postprandial readings.

RESULTS

Comparing twice-daily vs 4-times-daily mean BG, there was a small difference for fasting BG (0.09 mmol/L; 95% CI, 0.03 to 0.14), but not for 2-h postbreakfast (-0.05 mmol/L; 95% CI, -0.17 to 0.06), 2-h postlunch (-0.03 mmol/L; 95% CI, -0.13 to 0.08) or 2-h postdinner (0.05 mmol/L; 95% CI, -0.09 to 0.19) BG. Bland-Altman plots showed general agreement and minimal bias between twice-daily vs 4-times-daily BG, whether fasting or postprandial. There was no significant difference in the proportion of 14-day BG measurements above glycemic targets comparing twice-daily vs 4-times-daily testing in the fasting or postprandial states.

CONCLUSIONS

Twice-daily BG testing appears to generate 14-day average values similar to 4-times-daily BG testing. In women with GDM, whose BG is in target range, twice-daily BG monitoring may reduce inconvenience and cost.

Greater energy demand of exercise during pregnancy does not impact mechanical efficiency

Pregnant women are recommended to engage in 150 min of moderate-intensity physical activity per week to reduce pregnancy complications. Many women struggle to remain physically active throughout pregnancy, and there is no consensus about whether women adopt a less efficient movement pattern as they progress through pregnancy and experience gestational weight gain. This study assessed the change in energy expenditure and mechanical efficiency in pregnant women (PREG; n = 10) when performing a walking treadmill task in early, mid, and late pregnancy and also compared with an age- and body mass index-matched, nonpregnant (CON; n = 10) group. On average, the PREG group gained within the Institute of Medicine's gestational weight gain guidelines (11.6 ± 3.6 kg) and were all inactive (measured using accelerometry), except for 1 participant, by the third trimester, as per the 2019 Canadian physical activity guidelines for pregnant women. Energy expended to complete the walking task increased throughout pregnancy and was higher than the controls (111.5 ± 24.6 kcal) in mid and late pregnancy (139.0 ± 22.2 kcal, p = 0.02, and 147.3 ± 24.6 kcal, p = 0.005, respectively), but not early pregnancy (129.9 ± 18.9 kcal, p = 0.08). Walking mechanical efficiency was similar within pregnant women at each time point and compared to nonpregnant controls. Our findings add to the growing body of evidence demonstrating that pregnant women can safely perform physical activity by showing that walking mechanical efficiency is unchanged at low to moderate intensities. Novelty Energy demand during exercise increases proportionally to weight gain across pregnancy trimesters. However, mechanical efficiency remains unchanged during low- to moderate-intensity walking.

Risks of Dysglycemia Over the First 4 Years After a Hypertensive Disorder of Pregnancy

BACKGROUND

Women with the hypertensive disorders of pregnancy (HDP) (preeclampsia [PE] and gestational hypertension [GHTN]) have increased risks of future diabetes. Postpartum glycemic testing offers early identification and treatment of dysglycemia, but evidence-based recommendations for this high-risk population are lacking. The objective of this study was to describe the risks of developing dysglycemia in women with normotensive and hypertensive pregnancies over the first 4 years postpartum.

METHODS

The Discharge Abstract Database was used to identify women who delivered singleton live-born infants in Calgary, Alberta, Canada, between January 2010 and December 2012 (N=27,300). This was linked with Calgary Laboratory Services (for glycemic tests) and the Pharmaceutical Information Network databases (for antidiabetes medication prescriptions) over the first 4 years postpartum. Logistic regression analyses compared glycemic testing and results were adjusted for maternal age, gestational age, parity and the Pampalon deprivation index.

RESULTS

Women with HDP had more glycemic testing (GHTN 67.8% and PE 69.9% vs normotensive 60.9%; p<0.001) and significantly higher results for fasting plasma glucose (GHTN 4.82±0.51 mmol/L and PE 4.84±0.54 mmol/L vs normotensive 4.73±0.49 mmol/L; p<0.001), random plasma glucose (GHTN 5.20±0.96 mmol/L and PE 5.39±1.71 mmol/L vs normotensive 5.00±0.87 mmol/L; p<0.001) and glycated hemoglobin levels (PE 5.62±0.53% vs normotensive 5.49±0.32%; p<0.001). Women with HDP had a higher adjusted odds (95% confidence interval) of developing type 2 diabetes compared with normotensive women (GHTN: 2.26, 1.50 to 13.4; PE: 2.02, 0.91 to 4.46).

CONCLUSIONS

The high prevalence of early dysglycemia highlights the importance of targeted postpartum glycemic testing in women after HDP. Further research on optimal glycemic testing (specific tests and timing) in these high-risk women is needed.

Predictors of Large-for-Gestational-Age Birthweight Among Pregnant Women With Type 1 and Type 2 Diabetes: A Retrospective Cohort Study

OBJECTIVE

Our aim in this study was to compare the effects of risk factors for large-for-gestational-age (LGA) birthweight between women with type 1 and type 2 diabetes mellitus (TIDM and T2DM, respectively).

METHODS

A retrospective cohort study was conducted for women with T1DM (n=152) and T2DM (n=255) attending a diabetes/pregnancy clinic during the period from 2009 to 2016. Multiple logistic regression analysis was used to identify variables associated with LGA birthweight.

RESULTS

LGA was significantly higher in those with T1DM (39%) than T2DM (17%) (p<0.001). Among those with T1DM, there was a nonsignificant association between LGA and continuous subcutaneous insulin infusion (odds ratio, 1.17; 95% confidence interval, 0.99 to 1.39; p=0.06) and excess maternal weight gain (T1DM odds ratio, 1.19; 95% confidence interval, 0.99 to 1.43; p=0.069). In those with T2DM, there was an association between LGA and glycated hemoglobin at delivery (T2DM odds ratio, 1.10; 95% confidence interval, 1.02 to 1.19; p=0.01).

CONCLUSIONS

In the study population, glycemic control at delivery was predictive of LGA in women with T2DM, and there was a trend toward an association of maternal weight gain and continuous subcutaneous insulin infusion with LGA infants in T1DM. Further study is warranted to better guide targeted interventions to reduce high rates of LGA birthweight in T1DM/T2DM.

[Vaccination During Pregnancy]

Vaccination During Pregnancy Abstract. Vaccinations administered to women during pregnancy can provide protection against serious infectious diseases for the mother, for the newborn, or both. Two vaccines are routinely recommended during pregnancy: Influenza and Pertussis. While the influenza vaccine protects mainly the pregnant mother, who is at an increased risk for severe affection, the pertussis vaccine is an effective protection to infants who are at particularly high risk of pertussis complications and mortality in the first three months of life.

Long-acting reversible contraception: A route to reproductive justice or injustice

This article presents information on unintended pregnancies and the ongoing efforts of policy makers to promote long-acting reversible contraception (LARC) to reduce the numbers of such pregnancies. Also discussed is the tension between the encouragement of LARC to promote the public's interests in achieving that goal versus the need to assure that all women can decide about their bodies and reproductive needs. Our discussion includes information, primarily from the United States, on (a) risks associated with unintended pregnancies, (b) LARC devices approved in the United States (copper intrauterine devices (IUDs), hormone IUDs, and implants), (c) public and social benefits of increasing the use of LARC, (d) disadvantages and barriers to using LARC, (e) dangers of promoting LARC in unjust ways, and (f) the meaning of reproductive justice and its connection to social justice. By sharing the information with the audience of this journal, we hope that it will be integrated into clinical work and research on mental health and development. We also hope that experts in those fields will become discussants in the conversation regarding women's reproductive health and social justice that is taking place in the United States and elsewhere.

Safety and efficacy of Option B+ ART in Malawi: few severe maternal toxicity events or infant HIV infections among pregnant women initiating tenofovir/lamivudine/efavirenz

OBJECTIVES

Malawi's Option B+ universal antiretroviral therapy (ART) program for pregnant and breastfeeding women does not include routine laboratory monitoring. We report safety outcomes of pregnant women who initiated ART through Option B+.

METHODS

We analysed 12-month data from an observational cohort study on Option B+ among women newly initiating tenofovir/lamivudine/efavirenz (TDF/3TC/EFV) at a government antenatal clinic in Lilongwe, Malawi. Proportions of women engaged in care, incidence of DAIDS grade ≥ 2 laboratory toxicity, grade ≥ 3 adverse events (AEs), viral suppression (<1000 copies/mL), birth outcomes and infant HIV infections are reported.

RESULTS

At ART initiation, participants (n = 299) had a median age of 26 years (IQR 22-30), median CD4 count of 352 cells/μl (IQR 231-520) and 94% were in WHO Stage 1. We noted 76 incident DAIDS Grade ≥ 2 laboratory results among 58 women, most commonly elevated liver function tests (n = 30 events) and low haemoglobin (n = 27). No women had elevated creatinine. Clinical AEs (n = 45) were predominantly infectious diseases and Grade 3. Five participants (2%) discontinued TDF/3TC/EFV due to virologic failure (3) or toxicity (2). Twelve months after ART initiation, most women were engaged in care (89%) and had HIV RNA < 1000 copies/ml (90%). 8% of pregnancies resulted in preterm birth, 9% were low birthweight (<2500 g), and 2% resulted in infant HIV infection at 6 weeks post-delivery.

CONCLUSION

Most women remained on ART and were virally suppressed 12 months after starting Option B+. Few infants contracted HIV perinatally. While some women experienced adverse laboratory events, clinical symptom monitoring is likely reasonable.

Management and Outcomes of Maturity-Onset Diabetes of the Young in Pregnancy

Maturity-onset diabetes of the young (MODY) is a group of monogenic disorders that accounts for 1% to 5% of diabetes. The most common mutations are those in the hepatocyte nuclear factor-1-alpha (HNF-1-alpha) and in the glucokinase (GCK) genes. Although management of MODY is well established, no guidelines currently exist for management during pregnancy. Both maternal glycemic control and fetal mutation status are factors that may influence outcomes during pregnancy. The primary aim of this project was to describe cases of MODY during pregnancy to highlight the clinical implications of management of this disorder during pregnancy. The Ottawa Hospital is the primary referral centre for high-risk obstetrical patients, including those with diabetes in pregnancy, in Ottawa, Canada. Referrals between 2008 and 2018 were reviewed and a case series of three women and five pregnancies is described. Together with the illustrative cases, a literature review of MODY in pregnancy is used to highlight clinical considerations unique to MODY in pregnancy. We describe 5 pregnancies with MODY-2 (GCK mutation) and MODY 3 (HNF-1-alpha mutation). Important issues identified included monitoring of fetal growth and individualization of maternal glycemic control, particularly in cases where fetal mutation status is unknown. Management of MODY in pregnancy is challenging and there is little evidence to guide recommendations. Fetal growth can be used to guide management of maternal glycemic targets when fetal mutation status is unknown.

[Maternity professionals working with pregnant and homeless migrant women]

Maternity professionals are sometimes required to provide care to migrant women in precarious circumstances. Decisions regarding the future and the social and medical support provided to these mothers and their babies must be made quickly and be efficient and effective, despite having to contend with a lack of resources. A qualitative study focused on professionals' emotional reactions in these contexts combining pregnancy, vulnerability, migration and perinatal care. It enabled an original research protocol to be established favouring professionals' reflexivity.

Cyclooxygenase inhibitors for treating preterm labour: What is the molecular evidence? 1

Preterm birth (<37 weeks of gestation) significantly increases the risk of neonatal mortality and morbidity. As many as half of all preterm births occur following spontaneous preterm labour. Since in such cases there are no known reasons for the initiation of labour, treatment of preterm labour (tocolysis) has sought to stop labour contractions and delay delivery. Despite some success, the use of cyclooxygenase (COX) inhibitors is associated with maternal/fetal side effects, and possibly increased risk of preterm birth. Clinical use of these drugs predates the collection of molecular and biochemical evidence in vitro, examining the expression and activity of COX enzymes in pregnant uterine tissues with and without labour. Such evidence is important to the rationale that COX enzymes are, or are not, appropriate targets for the tocolysis. The current study systematically searched existing scientific evidence to address the hypothesis that COX expression/activity is increased with the onset of human labour, in an effort to determine whether there is a rationale for the use of COX inhibitors as tocolytics. Our review identified 44 studies, but determined that there is insufficient evidence to support or refute a role of COX-1/-2 in the onset of preterm labour that supports COX-targeted tocolysis.

Prenatal determinants of childhood obesity: a review of risk factors 1

Childhood obesity is a predictor of adult obesity and has its roots in the pre-pregnancy or pregnancy period. This review presents an overview of the prenatal risk factors for childhood obesity, which were categorized into 2 groups: biological risk factors (maternal pre-pregnancy body mass index, gestational weight gain, diabetes in pregnancy, and caesarean section), and environmental and behavioural risk factors (maternal smoking and exposure to obesogens, maternal dietary patterns, maternal intestinal microbiome and antibiotics exposure, and maternal psychosocial stress). Identifying modifiable predisposing prenatal factors for obesity will inform further development of inventions to prevent obesity over the life course, and future directions for research and intervention are discussed.

Malnutrition and depression in pregnancy and associations with child behaviour and cognitive function: a review of recent evidence on unique and joint effects 1

Accumulating studies suggest that prenatal experiences can shape a child's neurodevelopment. Malnutrition and depression occur in pregnancy relatively often and may affect child neurodevelopment independently as well as synergistically. We aimed to provide an overview of recent studies that have examined malnutrition and (or) depression in pregnancy and associations with child behavioural problems and cognitive function. We conducted a literature search in PubMed, using the following main search terms: "depression", "nutrition", "BMI", "pregnancy", "offspring", "cognition", and "behaviour". We included studies in human populations published from 2013 onwards. The literature search yielded 1531 articles, of which 55 were included in the current review. We presented the evidence on the associations between prenatal markers of nutritional status and (or) depression and child behaviour and (or) cognitive function. We additionally discussed interventions and mechanisms. Both malnutrition and depression in pregnancy are associated with increased externalizing behavioural problems and attentional deficits, and to some extent with poorer cognitive function in the child, but the evidence is not conclusive. Studies on synergistic effects of both factors on child behaviour and cognitive function are still scarce, and more research is needed. Potential shared mechanisms include the hypothalamic-pituitary-adrenal axis, the immune system, epigenetics, and oxidative stress.

[Blocked Nose, Nosebleeds, Ringing in the Ear: ENT Diseases During Pregnancy]

Blocked Nose, Nosebleeds, Ringing in the Ear: ENT Diseases During Pregnancy Abstract. In this overview the clinical pictures of ear, nose and throat diseases and their symptoms, which occur frequently but also particularly during pregnancy, are presented. In addition, the respective therapy options in this partially vulnerable phase of mother and child are discussed. The primary principle is 'as much as necessary, but as little as possible'. Even if the complaints often disappear with the birth of the child, there may be considerable suffering of the pregnant woman and therapy may be necessary. Moreover, an adequate therapy should be applied with all ENT diseases, even for those not specifically associated with pregnancy.

[A pregnancy after perinatal bereavement]

A pregnancy following a perinatal bereavement has a rather particular dimension to it. It requires attentive support and monitoring in order to enable the future baby to take its place within the family. An interview with Marie-José Soubieux, child psychiatrist and psychoanalyst.

[Anorexia and the desire to become pregnant]

The desire to have a baby for a woman suffering from anorexia requires the health professional to address the issues of restrictive behaviour, weight gain and body image. The players concerned must be able to recognise these patients and their frailty. They need to be aware of and trained in eating disorders. Multi-disciplinary monitoring is essential in order to provide care adapted to the mother and the infant.

[First Diagnosis of a Squamos Cell Carcinoma of the Cervix Uteri FIGO 1B1 in Pregnancy]

First Diagnosis of a Squamos Cell Carcinoma of the Cervix Uteri FIGO 1B1 in Pregnancy Abstract. The squamous cell cancer of the cervix uteri is one of the most frequent detected cancers in pregnancy. As the tumor is in direct contact to the pregnancy, the treatment is challenging and has to be tackled individually. So far, standard concepts or studies are missing. Treatment should be focused on the oncological security of the mother like in non-pregnant women and should be according to current guidelines. Thanks to the existing therapy options during pregnancy, it is a reasonable option to maintain the pregnancy in compliance with oncological standards. An interdisciplinary approach is therefore necessary.

[Pregnancy and delivery for women aged 40 years and over at the reference health center of commune II of Bamako district, Mali]

GOAL

The aim of this study was to compare the maternal-fetal prognosis of pregnancies at 40 years of age and above with that of pregnancies obtained before 40 years of age in the obstetric gynecology department of the reference health center of commune II of Bamako district.

MATERIALS AND METHODS

This was a prospective cohort study that was conducted at the maternity ward of Reference Health Center of Commune II of Bamako district from 1st January to 31 December 2012. Were included in our study as patients exposed, all the pregnant women of 40 years and over and as unexposed patients, pregnant women aged 20-39 who gave birth in our service. Teenage pregnancies were not included in this study. The statistical tests used were Pearson's Khi2 and Fisher's test with a significance level of 5%.

RESULTS

The frequency of pregnancy among women aged 40 and over was 1.68%. These were large multiparas unschooled patients in 60% of cases, with hypertension in 6.7% of cases. Pregnancy in her patients was associated with a high rate of caesarean section in 16.7% of cases, term overrun in 6.7% of cases, seat presentation in 6.7% of cases, macrosomia in 6.7% of cases and fetal malformation in 1.7% of cases.

CONCLUSION

Slight account of its many maternal-fetal complications, pregnancies in women 40 years and older deserve special attention.

The role of aspirin and inflammation on reproduction: the EAGeR trial 1

Inflammation has been linked to several complications in pregnancy, including pregnancy loss. Due to its anti-inflammatory properties, aspirin, a widely available and inexpensive therapy, has potential to help mitigate the negative effects of inflammation along the reproductive pathway. Therefore, the Effects of Aspirin in Gestation and Reproduction (EAGeR) trial was designed to elucidate whether preconception-initiated daily low-dose aspirin would increase the live birth rate in women with 1-2 prior pregnancy losses and no infertility diagnosis and attempting unassisted conception. Here, we present an overview of the collected findings. Low-dose aspirin was associated with an increased live birth rate among women with a single loss at <20 weeks gestation within the past year. When stratified by tertile of C-reactive protein (CRP), a biomarker of inflammation, treatment with aspirin restored a decrement in the live birth rate in women in the highest CRP tertile (relative risk 1.35, 95% confidence interval 1.08-1.67), increasing to similar rates as women of the lower and mid-CRP tertiles. The same effect modification by inflammation status was observed when examining the effect of low-dose aspirin on offspring sex ratio. These results suggest that inflammation plays an important role in reproduction, and that chronic, low-grade inflammation may be amenable to aspirin treatment.

[Caregivers' feelings and practices faced with teenage pregnancies]

Teenage pregnancy does not comply with social norms; perceived as a failure, it poses a challenge. How do caregivers support these young girls? Confronted with a variety of situations, they are particularly vigilant with regard to their representations and to literature data. At the same time, practices are based on a transferential relationship similar to a parent-child relationship. The care of a pregnant teenager requires specific adjustments.