Déséquilibre des cavités cardiaques et des vaisseaux avec petit coeur gauche en échographie anténatale

Un cœur fœtal normal est équilibré. Le risque d'obstacle sur la voie cardiaque gauche est significativement plus élevé à la naissance chez les fœtus qui ont un petit cœur gauche anténatal. Objectif : L'objectif de ce travail est de trouver des éléments du pronostic post natal devant un déséquilibre dans la taille des cavités cardiaques et des gros vaisseaux observé à l'échographie anténatale. Matériel et méthodes : Il s'agit d'une étude prospective sur 5,5 ans de 72 fœtus adressés au cardio pédiatre pour déséquilibre dans la taille des cavités cardiaques et des vaisseaux. Ont été inclus les fœtus présentant soit un rapport ventricule droit/ventricule gauche (VD/VG) > 1,25, soit artère pulmonaire sur anneau aortique (AP/Ao) >1,5, soit valve tricuspide sur valve pulmonaire (T/M) > 1,3. Pour chaque fœtus étaient notés : le terme de l'échographie, l'aspect du foramen ovale, l'aspect du retour veineux pulmonaire, le diamètre de la valve mitrale, le rapport T/M, la mesure du VG, le rapport VD/VG, la mesure de l'anneau aortique, le rapport AP/Ao, la mesure de l'isthme aortique. La mesure de l'anneau aortique et de l'anneau mitral a été comparée à celle des enfants né pendant la même période avec une coarctation de l'aorte non diagnostiquée avant la naissance. Résultats : 54,2% des nouveaux nés avaient un cœur normal, 15,3% avaient un obstacle gauche et 30,5% avaient une autre anomalie cardiaque (veine cave supérieure gauche, communication inter-ventriculaire, communication inter-auriculaire, anévrisme du septum inter-auriculaire, anomalie du retour veineux pulmonaire partielle...) Le rapport VD/VG et le rapport T/M n'étaient significativement pas différents dans le groupe obstacle gauche par rapport au groupe sans. Par contre, le rapport AP/Ao était significativement plus élevé dans le groupe avec obstacle et les mesures du VG de l'anneau aortique et de la valve mitrale étaient significativement plus basses dans le groupe avec obstacle. La mesure de l'isthme aortique était significativement inférieure dans le groupe avec coarctation de l'aorte. Le terme d'apparition était significativement plus précoce dans le groupe obstacle gauche. Les enfants nés avec un diagnostic prénatal semblent aller moins en réanimation néonatale. L'analyse des valves, le doppler du foramen ovale et le doppler de l'isthme aortique permettent d'orienter le diagnostic. Conclusion : Le diagnostic d'obstacle gauche en période prénatale est possible, il se fait sur un faisceau d'argument. Les obstacles gauches sont les anomalies les plus graves recherchées en cas de déséquilibre dans la taille des cavités cardiaques et des gros vaisseaux. D'autres anomalies cardiaques sont fréquemment retrouvées, elles sont généralement mineures.ROUEN-BU Médecine-Pharmacie (765402102) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Screening for small for gestational age infants in early vs late third-trimester ultrasonography: a randomized trial

International audienceBACKGROUND: Recent studies have demonstrated that a routine third-trimester ultrasound scan may improve the detection of small for gestational age infants when compared with clinically indicated ultrasound scans but with no reported reduction in severe perinatal morbidity. Establishing the optimal gestational age for the third-trimester examination necessitates evaluation of the ability to detect small for gestational age infants and to predict maternal and perinatal outcomes. Intrauterine growth restriction most often corresponds with small for gestational age infants associated with pathologic growth patterns. OBJECTIVE: This study aimed to assess the performance of routine early ultrasound scans vs late ultrasound scans during the third trimester of pregnancy to identify small for gestational age infants and fetuses with intrauterine growth restriction. STUDY DESIGN: This was an open-label, randomized, parallel trial conducted in Upper Normandy, France, from 2012 to 2015. The study eligibility criteria were heathy, nulliparous women older than 18 years with gestational age determined using the crown-rump length at the first trimester routine scan and with no fetal malformation or suspected small for gestational age fetus at the routine second trimester scan. Pregnant women were randomly assigned to a third-trimester scan group at 31 weeks gestational age ±6 days (early ultrasound scan) or at 35 weeks gestational age ±6 days (late ultrasound scan). The primary outcome of this trial was the ability of a third trimester scan to predict small for gestational age infants (customized birth weight <10th percentile) and intrauterine growth restriction (customized birth weight <third percentile) using birth weight as the gold standard. The purpose of these adjustments was to optimize the detection of fetal weight associated with pathologic growth patterns. It was calculated that a sample size of 3720 women would be required to obtain 80% power at a 2-sided level of 0.05 with a 15% difference in sensitivity between the 2 intervention group to detect small for gestational age fetuses in favor of the late ultrasound scan group and considering that small for gestational age infants would represent 10% of all live births. Secondary outcomes were maternal and perinatal morbidities with interventions reported. The analysis was based on the intention-to-treat principle. RESULTS: Results from 1853 women assigned to the early ultrasound scan group and 1848 women assigned to the late ultrasound scan group were analyzed. The sensitivity was found to be higher in the late ultrasound scan group than in the early ultrasound scan group, both for identifying small for gestational age infants (27%; 22%–32% vs 17%; 13%–22%; P=.004) and intrauterine growth restriction (44%; 35%–54% vs 18%; 11%–27%; P<.001). There was little difference in the specificity between the late ultrasound scan and early ultrasound scan groups in identifying cases of small for gestational age (97%; 96%–98% and 98%; 97%–99%, respectively; P=.04) and intrauterine growth restriction (96%; 95%–97% and 97%; 96%;–97%, respectively; P=.24). Overall, the maternal and neonatal outcomes were comparable between the early ultrasound scan and late ultrasound scan groups with the exception of additional (at least 1) ultrasound scans performed (25% in the early ultrasound scan group vs 19% in the late ultrasound scan group; P<.001). Rates of perinatal death (0.4% vs 0.8%; P=.12) and adverse perinatal outcomes (1.8% vs 2.7%; P=.08) were comparable between the early ultrasound scan and late ultrasound scan assigned groups, and the overall sensitivity to detect small for gestational age infants and intrauterine growth restriction, including in the last ultrasound scan performed before delivery, were also similar (30%; 25%–36% vs 26%; 21%–31%; P=.23; and 50%; 40%–60% vs 38%; 28%–48%; P=.07). CONCLUSION: A late ultrasound scan performed in the third trimester increases the probability of detecting small for gestational age infants and intrauterine growth restriction with fewer additional scans reported than for the early ultrasound scan group. The overall perinatal outcome risk was comparable between the 2 groups. However, the overall sensitivity for detecting small for gestational age fetuses and intrauterine growth restriction, including in the last ultrasound scan performed before delivery, remains comparable between the late ultrasound scan and early ultrasound scan groups

Expression of LHCGR in Pheochromocytomas Unveils an Endocrine Mechanism Connecting Pregnancy and Epinephrine Overproduction

International audienceBackground: The mechanisms by which pregnancy may unmask pheochromocytomas and paragangliomas are not totally understood. We hypothesized that gestational hormones may participate in the pathophysiology of catecholamine excess during pregnancy. We report a case of silent pheochromocytoma revealed in a pregnant woman by life-threatening adrenergic myocarditis. Methods: In vitro studies were conducted to investigate the effect of estradiol and the pregnancy hormone hCG (human chorionic gonadotropin) on epinephrine secretion by cultured cells derived from the patient’s tumor. Expression of LHCG (luteinizing hormone/chorionic gonadotropin) receptor was searched for in the patient’s tumor, and a series of 12 additional pheochromocytomas by real-time reverse transcription polymerase chain reaction and immunohistochemistry. LHCGR expression was also analyzed in silico in the pheochromocytomas and paragangliomas cohorts of the Cortico et Médullosurrénale: les Tumeurs Endocrines and The Cancer Genome Atlas databases. Results: hCG stimulated epinephrine secretion by cultured cells derived from the patient’s pheochromocytoma. The patient’s tumor expressed the LHCG receptor, which was colocalized with catecholamine-producing enzymes. A similar expression pattern of the LHCG receptor was also observed in 5 out of our series of pheochromocytomas. Moreover, in silico studies revealed that pheochromocytomas and paragangliomas display the highest expression levels of LHCG receptor mRNA among the 32 solid tumor types of The Cancer Genome Atlas cohort. Conclusions: Pregnancy may thus favor surges in plasma catecholamine and hypertensive crises through hCG-induced stimulation of epinephrine production by pheochromocytomas