Cytomegalovirus (CMV) is the leading cause of viral congenital infections. In children, the consequences may be severe, especially in case of maternal primary infection during pregnancy. A prospective study was carried out in the department of Isère, in 1,018 pregnant women, in order to establish the seroprevalence of CMV, the frequency of primary infections during pregnancy and the associated risk factors. The overall seroprevalence was 51.5%; it increased significantly with age, parity, and low socioeconomic status. It was higher in women born in the South of France (51.6%) than in those born in the North (37.4%). Among a total of 878 women with serological follow-up, 7 primary infection cases (0.8%) were observed. Seventeen women (1.9%) presented border IgM values in the first serum, and these values were not related to recent infection. Extrapolation of the results to the whole department of Isère, suggests that each year about 100 pregnant women would be concerned by CMV primary infection, with 2 or 3 cases of death or severe sequelae in children. In light of these results, the interest of serological screening is discussed.
We have examined 1,200 placentas in a fresh state and have compared the results of these examinations with maternal pathology on the one hand and the neo-natal pathology on the other hand. It turns out that most abnormalities of pregnancy are associated in a significant way with the pathological findings in the placenta, and that the good or pathological health of the newborn is significantly associated with the normal of pathological character of the placenta. The principal weakness in this method of examination is the absence of information about infection. This is why it seems important to us to carry out smears from the placenta before examining it macroscopically.
In a study carried on 25 years and about 50 000 births, the authors analyse 1 238 malformed children, with two purposes: 1. to determine a maternal population with high risk of malformations, in order to have a better survey and to look for many anomalies before the birth: 2. to make a "portrait" of the malformed child in order to suspect the existence of congenital anomalies during the obligatory examination in neo-natal time.
Hospital or nosocomial infection, or infection acquired in hospitals, is a health problem in all hospital departments and particularly in the maternity department. We report on a prospective survey of surveillance of hospital-acquired infections both from the mother and the baby's point of view after delivery vaginally or with caesarean carried out at the obstetrical clinic of the Edouard Herriot Hospital in Lyon (France) over three successive years with a series of 9,204 deliveries. The incidence of infection in women who were delivered without caesarean section was 1.37% when urinary tract infections had been excluded but 13% in women who had caesarean sections. Endometritis, skin infections and urinary tract infections were the leading causes. As far as the newborn were concerned, hospital infection ran at about 2.60% and this in the main was due to staphylococcal pustules in the skin. These figures are still too high and prevention should be based on more information given and more care taken by the whole staff of such a hospital.
The authors present a study of 1,383 cases of invasive carcinoma of the cervix treated exclusively by radiotherapy between 1970 and 1981. Combination external radiotherapy followed by intra-cavitary applications was carried out. The study was carried out in 9 different radiotherapy centres in France using the same protocol and the same recording systems. The therapeutic results which have been recorded at every stage are among the best obtained until now, with 90% success for stage I after 5 years, 80% success for stage II, 52% for stage III growths. Only 2.1% failures occurred in the cervico-vaginal region. Pelvic recurrences were 7% in stage I and IIA, 14% in stage IIB and 24% in stage III. These recurrence rates are lower than have generally been recorded. Complication rates are also low and became less as the study continued, thanks to better use of dose distribution in individual cases which took note of doses received by neighbouring organs. The prognostic value of lymphography was analysed.
Samples of sperm have been obtained from 95 who consulted us for infertility. In each case seminal plasma was examined for levels of alpha-1,4-glucosidase and L-carnitine. Our results have led us to fix the threshold value of 42.6 mlU per ejaculate for alpha-1,4-glucosidase and 960 nanomoles of L-carnitine below those levels that we thought occur where the origin of the oligospermia is obstructive (series 1 patients). In series 2 patients the cause of the oligospermia purely being secretory, there is normal epididymal function and therefore the excretory doubts are proven. It is not impossible to have both pathologies because we have found this in men of the intermediate groups C and D. We have found that there is a correlation between the presence of epididymal pathology and a drop in epididymal markers which can be found in severe oligospermia (which can be epididymal in origin and not testicular). Also when there is non abnormalities in the spermogram. This last situation can occur in "invisible" abnormalities of spermaturation in the epidymus.
Twelve years experience with 6,000 incisions carried out in the Tertre Rouge clinic in Le Mans and 1,545 cases published by other authors demonstrate that the suprapubic transverse incision with section of the recti abdominis muscle is becoming more popular for pelvic surgery. The technique of the operation and its variations according to different authorities in different countries are fully described. There is also a review of the indications for the procedure, to show how it can be used for caesarean section especially when carried out under epidural anaesthesia. Finally, the incision is compared with those more usually used.
To evaluate our clinical practice for Group B streptococcus (GBS) screening during pregnancy and antibiotic therapy during delivery.
We performed a retrospective evaluation of our SBS screening protocol, by vaginal swab, for a period of two years, including 1,674 asymptotic patients. Intra partum antibiotic prophylaxis was administrated for GBS-positive women.
The rate of GBS carriage was 6.9%. Antibiotics were administrated for 79.3% patients with GBS-positive culture. Of these women only 39% had an interval greater than four hours between antibiotic injection and delivery. In the group of patients with positive GBS culture, no newborn was infected and only 5% were colonised. In the GBS-negative group with 1.3% of the newborns were GBS positive.
We were surprised by our low rate of GBS carriage and the non optimal application of antibiotics during labor. We reviewed our results with all our team and a prospective evaluation has been initiated.
3,300 women were delivered between January 1986 and July 1990 inclusive. 1,267 of them had no pathology and 341 were induced for a pathological reason. Our attitude is to suggest systematically to every pregnant woman that her labour can be programmed to the time that she reaches the middle of the 39th week of amenorrhea providing she is sure of her dates and that the cervix is favourable. Labour is induced by using the electric pump to administer Syntocinon and by rupturing the membranes early. If an epidural anaesthetic is anticipated this is carried out during the first hour after induction. This policy does not bring about premature labours (the mean duration of amenorrhoea was 39.73 weeks) and it does not involve long labours (the mean total duration of labour was 5.68 hours and 7 hours for primipara) 1 UI Oxytocin was delivered per hour. In the group where labours were induced the Caesarean section rate at 6.35% was lower than those who went into labour spontaneously. There were fewer Cesareans for acute fetal distress. Five children had to be transferred to the Paediatric unit and one died after major fetal distress at 9 cms, 48 hours after delivery. The series shows that it is possible to have a policy for programming labour and increasing the comfort of the parturient and controlling her labour. Furthermore, the work of the staff in the labour ward and its staff are helped.
In order to avoid the misuse of laparoscopy by an unnecessary increase in the indications for the procedure the authors have reviewed the evolution of these indications in the five years between 1973 and 1977. Certain indications have stayed stable, such as chronic pain in the pelvis, masses found in the pelvis, symptoms suggestive of upper genital tract infection or of ectopic pregnancy and tubal or unexplained sterility. Stability in these indications is correct because laparoscopy and laparoscopy alone can give a precise diagnosis of the lesion and complete the clinical findings and the other methods of investigation. There are two indications which have become less frequent and these are: ovarian sterility and amenorrhoea. This is logical since more reliance has come to be placed on biological methods. Laparoscopy should be reserved in these conditions for cases where are contradictions between biological findings or where there are therapeutic failures. An increase in the indications which is very justified is in those laparoscopies which are carried out as a control of the results of tubal surgery, because there a prognosis can be given and therapy can be carried out (such as division of adhesions) and in cases of malignant tumours of the ovary which, although the procedure will give less precise information than laparotomy, has the advantage that it can be repeated from time to time.
We carried out the Oxytocin Challenge Test (or OCT as American authors call it) by injecting 5 m.U. per minute into pregnant women who are suspect of having high fetal risk from the 34th week of pregnancy onwards. The material that we have examined is from 1,366 cases with 1,827 tests. The perinatal mortality over all was 13.17 per thousand of the cases. We have described three types of response: normal (87.44%), pre-pathological (7.77%) and pathological (6.78%). We have concluded that the test has a good prognostic value and point out the significance of the pre-pathological results, which we think have up till now not been accorded sufficient attention.
The aim was to compare acceptability of a percutaneous 0. 1% estradiol gel (Gel A, Estreva(R) Gel, Laboratoire Théramex, Monaco) to that of an 0.06% estradiol gel (Gel B, Oestrodose(R), Laboratoires Besins-Iscovesco) in its new formulation and packaging.
This randomized, crossed, simple-blind study was carried out in 48 volunteer healthy postmenopausal women. The volunteers applied on one forearm 1.5 mg/day of cutaneous estradiol in the form of either gel, according to randomized allocation, for four days without free period between the two therapeutic periods. The application and drying times of the two gels were measured during the first application; gel subjective women assessment was collected at the beginning and at the end of the study.
Mean application and drying times with Gel A are significantly reduced, compared to Gel B (p=0.0259 and p=0.0001, respectively) with drying time 61% shorter; these data are confirmed by subjective women evaluation. The two gels are not significantly different regarding several criteria as consistency, ease of application and sensation of lasting stickiness. However, a significant difference is found in favour of Gel A on the following items: practicality of application (p=0.007), ease of penetration (p<0.001), quantity of gel to apply (p<0.001) after the first application. After four days of administration, a same significant difference is observed concerning practicality of the gel (p=0.0078), duration of use (p<0. 001), packaging, women opinion on the gel (p=0.022) and the product, gel and packaging (p<0.001). At the end of the study, gel A utilization is considered by women more practical (p=0.001) with an easier application (p<0.001) and less restricting while applying (p=0.001), compared to Gel B; 72.9% of women prefer the Gel A and 12. 5% of women prefer the Gel B.
A better acceptability of the 0.1% estradiol gel and of its packaging compared to that of the 0.06% estradiol gel in this new formulation and packaging is observed in this study.
Serum levels of 25-hydroxyvitamin D [25-(OH)D], calcium, phosphate and alkaline phosphatase activity were measured between December and July in 110 pregnant women during the last trimester of pregnancy, and in their infants on the fifth day of life. This study showed a fall, during spring, below 6 ng/ml, of the maternal 25-(OH)D concentration at the time of delivery, and a fall of the 25-(OH)D and calcium concentrations in newborns. The existence of a positive correlation between calcium and 25-(OH)D levels in the newborns suggests that the low calcium concentrations found in the infants born in spring is related to a vitamin D deficiency of the infant and therefore of the mother. The administration of a single low dose of vitamin D3 (100,000 I.U.) on the sixth or seventh month of pregnancy allowed to prevent the seasonal fall in serum calcium and 25-(OH)D concentrations. This dosage appears therefore to be sufficient to reduce the risk of vitamin D deficiency of the newborn and the occurrence of neonatal hypocalcemia.
The author having learned the true character and the value for teaching of his own complications set out a questionnaire which would draw a line distinguishing between complications that seemed in retrospect to have been inevitable and those that could be attributed to the inexperience or lack of care of the operator. The analysis of 194 severe complications occurring in 100,000 laparoscopies performed over 20 years includes 53 cardio-respiratory complications, of which 15 were fatal, 122 injuries or burns due to the instrument, of which 4 were fatal and 18 different complications. No statistical conclusions can be drawn because the figures are approximate and probably below the true levels. But a calculated comparison of the risks can be significant, so long as one avoids mixing up the operators who are well trained, careful and personnally responsible for their actions with those who work hurriedly without proper estimation of the difficulties and dangers. Most opinions agree that apart from the risk of embolus and of general anaesthesia there is no risk of a fatal complication due to laparoscopy. This is particularly true of cardio-respiratory complications, which can be avoided if empirically proven prophylactic measures are taken which take into account the various theories of the aetiology and pathology, which are still being studies. From the results of this enquiry it emerges that certain criteria of care have to be followed which are too often neglected, but they should be applied systematically even when they appear to be unnecessary.
The authors analysed 1061 early amniocentesis carried out during 1000 pregnancies. The indications were as follows: chromosomal abnormalities (79,6 p. 100), fetal karyotypes for X-linked diseases (4,7 p. 100), metabolic disorders (5,9 p. 100), amniotic fluid alpha-foetoprotein (9,8 p. 100) in neural tube defect or congenital nephrosis. Amniotic fluid was obtained on the first attempt in 98.2 p. 100 and on the second attempt in 100 p. 100. The fluid was heavily blood-stained in 1,7 p. 100, sanguinolent in 3,8 p. 100 and brownish in 2,40 p. 100. Cells were grown on the first attempt in 98 p. 100 and on the second attempt in 100 p. 100. The outcome of pregnancies was correlated with the indications of amniocentesis. The rate of spontaneous abortion is 1,7 p. 100, but only 6 of them can be due to amniocentesis (0,6 p. 100). Perinatal mortality was 1,8 p. 100: mortinatality (1,2 p. 100) and neonatal mortality (0.6 p. 100). All this fetal deaths have other causes. The fetal loss was 3,9 p. 100. Fetal morbidity was low: none fetal injuries, none cutaneous scar, few premature deliveries (1,6 p. 100), some malformations more or less serious (2,6 p. 100) with 4 congenital luxations of the hips (0,45 p 100). Maternal morbidity was limited at a greater cesarean section rate: 21 p. 100 (30 p. 100 in women 40 years old and more), none feto-maternal rhesus immunization was observed because immunoprophylaxis was strictly performed. The rate of therapeutic abortion was 4,6 p. 100 without any diagnostic error. Diagnostic accuracy was 100 p. 100. Several conditions are necessary to be the procedure safe accurate and reliable: appropriate genetic counseling, exact determination of gestational age (17 international weeks), sufficient volume of amniotic fluid counseling, exact determination of gestational age (17 international weeks), sufficient volume of amniotic fluid (uterus size: 12 cm), gynecologic examination by operator himself, perfect echography to localize the placenta and detect multiple gestations, adequately trained obstetrician, use of 20 gauge spinal needle, stric asepsis, experimented laboratory and experienced staff.
To assess the clinical efficacy of mifepristone 100 mg followed two days later by misoprostol 400 microg orally in women undergoing medical termination of pregnancy up to 56 days gestational age.
Retrospective study over 8.5 months of 762 cases early medical abortion. 100 mg mifepristone was used on day 1 after clinic visit and vaginal ultrasonography. Misoprostol 400 microg was administered orally on day 3. Following administration of prostaglandin, women were observed in the ward for 4 hours. A control visit on day 15 was systematic. Success was defined as a complete uterine evacuation without the need for surgical intervention.
Medical terminations accounted for 42% of all abortions. 16% of women were pregnant for < 42 days, 76% for 43 to 49 days and 8% for 50 to 56 days. Termination occurred within 4 hours after administration of misoprostol in 80.2% of the women. Only one woman aborted within 48 hours of mifepristone administration only. The success rate in this study was 94.4% and the failure rate increased with the gestational age. Pain was the predominant side effect. Six cases of bleeding required a surgical intervention. No patient required transfusion. 96% of patients attended a control visit on day 15. The acceptability rate of the method has been 94%.
Mifepristone 100 mg followed two days later by misoprostol 400 microg orally is safe and effective for early termination of pregnancy.
To analyze the spectrum of congenital malformations among fetuses with Down's syndrome sent for necropsy. Materials and methods. Necropsies following medical termination of pregnancy during the second and third trimester were performed during a 4 year period.
The incidence of each malformation was determined. Talipes equinovarus and aberrant lobation of the lung were present in 6% of cases. We are able to state precisely the incidence of 11 pairs of ribs: 11%.
A precise knowledge about Down's syndrome associated malformations is essential for genetic counselling. The exact incidence of each sign is important to lead ultrasound examination when this syndrome is revealed.
The treatment of locally advanced cervical carcinoma of uterine cervix is based on concurrent chemoradiotherapy (CCR). The role of laparoscopic lymphadenectomy before CCR and hysterectomy after CCR is not consensual.
Retrospective multicentric study on 102 patients treated for locally advanced carcinoma of uterine cervix between 1999 and 2008. Disease-free survival and overall survival (OS) were studied.
Stages were: stage IB 42%, II 47% and stage III and IVA 11%. All patients received CCR. Eighty-one patients had associated brachytherapy. Sixty-two patients underwent laparoscopic lymphadenectomy before CCR and 31 patients had also para-aortic lymphadenectomy. Eighty-two patients had hysterectomy after CCR. Forty-seven percent (29/62) of patients had a histologically proven pelvic lymph node involvement and 58% (18/31) had a histologically proven para-aortic lymph node involvement. There is no predictor of the presence of residual tumor on hysterectomy. The lymph node involvement before treatment and the presence of residual tumor on hysterectomy were poor prognostic factors on relapse-free survival (SSR) and OS. It has not been shown to benefit from surgery pre- or post-CCR on survival.
Surgery can provide major prognosis factor and especially lymphadenectomy before CCR can improve the therapeutic strategy but does not demonstrate significant survival benefit.
This retrospective study of 102 patients with uterine synechias treated exclusively hysteroscopically included 52 (51%) low fertility patients, 44 (43%) with menstrual disorders and 6 (6%) with no other symptoms. More than three-fourth of the patients (76.5%) had a past history of trauma on a gravid uterus. Operative hysteroscopy was performed 148 times, including sections with scissors in 63 cases (42.4%), section with laser in 4 (3%), uterine collapse in 19 (13%) and electrosection in 62 (41.6%). A single endoscopic procedure was sufficient in 70 patients (68.6%) and 2, 3, 4 procedures were required in 22.6%, 3.9% and 4.9% of the patients respectively. No complications due to infection, bleeding or metabolic disorders occurred, but perforations were seen in 6 patients (5.8%) including 4 cases with complexe synechias. Mean follow-up was 24.4 months (range: 6-49 months); 10 patients were lost to follow-up. Good anatomic results were achieved in 88 patients after 1 or 2 hysteroscopic procedures (86.2%). Clinical results were less satisfactory, particularly in cases with low fertility in which another pathology was often associated (59%). We obtained good results in 75% of the patients with dysmenorrhoea. However, one or more pregnancies was achieved in 28 of the 50 patients contacted later (a total of 34 pregnancies including 10 abortions and 24 normal deliveries). A hysteroscopic procedure should be proposed as first intention treatment in all cases with synechia. In addition to diagnosis, hysteroscopy allows selective, reproducible treatment with little morbidity and conservation of the surrounding endometrium. After several unsuccessful procedures, surgery using Musset's technique can be proposed.
Prenatal diagnosis of a limb reduction defect poses difficult medical and ethical problems. Prenatal diagnosis can be at the origin of two opposing medical attitudes, either a medical termination of pregnancy, or the specific management of the child at birth. The objective is to carry out an enquiry of practices and to determine whether there is a threshold in the gravity of the malformation from which the medical termination of pregnancy is accepted.
The study was carried out by a questionnaire addressed to the members of the French-speaking Club of Fetal Medicine.
Outcome of 103 fetuses with limb reduction defect was described. Prenatal diagnosis and management of observed malformations were explained.
Decisions concerning the outcome of the pregnancy are very variable from one couple to another and from one medical team to another. Parents making a request must be given complete information and accompanying psychological support. Collegial with a multidisciplinary team is necessary. For the parents, it is the physician's duty to avoid judgement errors related to anxiety and ignorance of the medical consequences. The physician should guide the parents towards the continuation of the pregnancy or its interruption. The proper decision proceeds from the reunion of the confidence of the couple and the conscience of the physician.
Subcutaneous ultrasound guided puncture of the umbilical cord was carried out in order to obtain samples of blood in 103 fetuses. This was done to get the result of the karyotype quickly, i.e. in 72 hours. The indications were for diagnosis, particularly of malformations (63 cases) or intra-uterine growth retardation (24 cases). A small proportion of the indications were those for failures to carry out amniocentesis early or for checking on mosaics that were obtained after the culture of amniotic fluid cells. In 88% of the cases it was possible to obtain a karyotype and the results were checked with the sex of the fetus and the karyotype that had been obtained from amniocentesis. There were 11 abnormalities diagnosed. The chief indication of chromosome abnormality is fetal malformation. Because the result are obtained so quickly cordocentesis should replace late amniocentesis, at present when looking for fetal abnormalities.
The Mauriceau manoeuvre has a poor reputation in France where some obstetricians believe it leads to an increase in the number of neonatal traumal injuries. To evaluate this hypothesis we examined the results of a personal series of 103 cases of breech extraction where foetal head extraction was performed using the Mauriceau manoeuvre. Our study showed that the level of traumal complications was not worse than that of the general neonatal population. We therefore conclude that this active and organized method of breech delivery is safe and provides a young obstetrician with valuable experience of practical obstetrical manipulation.
To evaluate the predictive value of postoperative urodynamic assessment on the apparition or the resurgence of genuine stress incontinence after a surgical procedure for genitourinary prolapse.
103 patients operated on for prolapse, with or without an associated surgical procedure for genuine stress incontinence. A review of the results of the urodynamic assessment carried out during the early post operative period was effected.
77.7% of the patients had an associated procedure for stress incontinence during surgery for prolapse. An urodynamic abnormality such as intrinsic sphincter deficiency and/or transmission ratio default was noted in 83.3% of the women who demonstrated incontinency during postoperative assessment, and in 76.7% of the patients without any problem of continence. During long term follow up, only 41.7% of the women who were incontinent shared intrinsic sphincter deficiency, and an abnormal cytometric parameter was noted in 74.4% of continent patients. 86% of the patients who were incontinent in the early postoperative period will remain so, whatever the result of the cystometric evaluation.
Our results show that there is no correlation between the various cystometric parameters evaluated during the postoperative period, and the symptoms described by the patients. The absence of abnormal urodynamic assessment cannot consistently predict normal bladder function. Only postoperative symptoms can be considered to be predictive of a satisfactory surgical cure.
The authors have reviewed the notes of 103 pregnant women who contracted hepatitis during pregnancy and compared it with a controlled series of hepatitis occurring in 100 women who were not pregnant but were of reproductive age. The mortality rate in the pregnant group was considerably higher than in those who were not pregnant--27 deaths out of 103 cases as against 4 deaths in the control series of 100 cases. The fetal prognosis was very bad in the group of women who died. 3 out of 4 pregnancies resulted in loss of the fetus. It was less bad in those who had mild hepatitis--39.3% lost the fetus and one out of two pregnancies had a premature labour. Loss of consciousness was a very bad prognostic sign. The prognostic value of marked drop in prothrombin and raised white blood counts is emphasized in the cases who died. When the series of women who were pregnant and who survived is compared with those who survived in the control group, the authors found that judgment had to be used carefully in evaluating the prodromal signs in the pregnant women. They found in the two groups that the haemoglobin level and the serial levels of protein and albumen are comparable to those found in developed countries. They conclude that their maternal mortality due to hepatitis was comparable to that reported in underprivileged countries but that "malnutrition" in the broader sense of the term does not explain the serious state of affairs.
To evaluate the importance of thrombocytopenia in the management of HELLP syndrome (hemolysis, elevated liver enzymes, low platelet count).
This retrospective study included all patients with HELLP syndrome treated in the three departments of the Pellegrin Maternity Hospital in Bordeaux, between January 1993 and December 2001. One hundred and four patients were included and were divided into two groups according to the severity of thrombopenia: group 1 (platelet count<50000/mm(3)) and group 2 (50000<platelet count/mm(3)<100000).
In group 1 complications occurred in 79% of cases and thrombocytopenia put patients at-risk for serious or life-threatening bleeding complications mainly in this group.
It is crucial to class patients according to severity of thrombocytopenia, on admission. Termination of pregnancy should be considered for patients included in group 1. The other patients are best managed conservatively (depending on gestational age).
To study the ferritin level in women using an intrauterine device.
104 women were enrolled before and during use of the intrauterine device. The subjects were divided into four groups according to whether or not they had used oral contraception previously.
There was a significant decrease in ferritin level, particularly in women who had not used contraception previously (Student's test).
Ferritin assay is a better test for measuring the effect of an intrauterine device on iron depletion than blood cell count or haemoglobin level.
Clinical signs and symptoms of the pudendal neuralgia are very rich, with a great individual variability. The clinical diagnosis is difficult. It is confirmed or invalidated by the electrophysiologicals tests. Since October 1998 patient selection has been possible using a diagnosis score. Over a four-year period, the diagnosis of pudendal neuralgia was confirmed by electrophysiological investigations in 212 subjects. We rejected 12 patients because of a radiculo-medullary organic etiology. We only describe here cases of women with a peripheral pudendal nerve injury (200 patients). Thirty-eight neuropathies free of canal symptoms (obstetrical, post-traumatic...) were treated by infiltration therapy. The study of a total of 162 canal syndromes showed prevalent injury at the sacro-spino-tuberal ligamental grip which was observed in 68% of the cases, compared to the Alcock canal which was present in only 20% of the cases. One hundred four of these patients underwent surgical decompression via a trans-ischio-rectal approach after negative results of the infiltration therapy. We report here the surgical methodology, the post-op follow-up and the results, which appear quite successful: after one year 86% of the subjects are symptom-free or with a significant reduction of pain.
Between January 1988 and June 1993, laparoscopic distal tuboplasty was carried out on 104 patients. The mean age of the patients was 32 years: the duration of infertility was 3.2 years; infertility was primary for 44 patients (42.3%) and secondary for 60 patients (57.7%). The patients were classified according to the French cooperative tubal scoring system: stage 1: 21 patients, stage II: 49 patients, stage III: 22 patients, stage IV: 12 patients; 37 patients underwent a fimbrioplasty (35%) whereas 67 patients underwent a neosalpingostomy (65%). No complications were observed either during or after the operation. All patients were discharged two or three days after the operative procedure. Antibiotic and antiinflammatory treatments were systematically administered post-operatively.
Thirty-four patients obtained intrauterine pregnancies (32.5%) and 5 patients obtained ectopic pregnancies (4.8%); 76% of the intrauterine pregnancies were obtained within the 1st postoperative year. The pregnancy outcome was directly correlated to the tubal scoring system. Intrauterine pregnancy rate decreased with the severity of the tubal damage: stage 1: 12/21 (57%), stage II: 19/49 (38.7%), stage III: 3/22 (13.6%), stage IV: 0/12.
Laparoscopic surgery represents the first-choice treatment of distal tubal occlusion in stage I and II. In stage IV, IVF should be suggested immediately. In stage III, the choice of treatment is more difficult: the main prognostic factor might be the tubal mucosal appearance.
To demonstrate the effectiveness and safety of mifepristone 600mg with misoprostol 800 mg, for termination of pregnancy at 9-14 weeks gestation.
This prospective study included 105 women at 9 to 14 weeks gestation given 800 mg of vaginal misoprostol, 2 or 3 days after a single dose of 600 mg of mifepristone for pregnancy termination. Outcomes measures included mean expulsion time, the interval between fotal and placental expulsion, adverse effects, vaginal bleeding, requirement for analgesia, and hospital stay, analyzed by parity and gestational age.
Pregnancy termination was successful in 92.4% of the patients without requirement for surgery. The mean time to expulsion was 6 hours. The fetus and placenta were expelled together in 79% of the cases. In 15% the conception products were retained in the cervical canal, and removed with a ring forceps. Additional misoprostol doses were necessary in 33% and analgesia (nalbuphine sublingually, mean dose was 10mg) in 56%. Significant bleeding was observed in 7.5%, leading to curettage in 2 patients. No statistically significant differences were found between the rate of success and term (9-12 versus 12-14) or parity.
Combining oral mifepristone and vaginal misoprostol is a successful alternative to surgical termination of pregnancy, even after 9 weeks' gestation. The use of nalbuphine for analgesia improves acceptability; sublingual administration helps avoid invasive procedures. Before 14 weeks gestation, the legal limit for termination of pregnancy in France, the choice between the surgical and medical alternatives should be left to the patient.
Study of hemostatic disorders during eclampsia, their risk factors, maternal complications and associated mortality.
Retrospective study concerning 106 cases of severe eclampsia treated in intensive care between September 1992 and December 96. Patients with or without hemostatic disorders were compared for laboratory findings, maternal complications and mortality.
Forty patients had hemostasis disorders as follows: isolated thrombopenia in 19 cases, disseminated intravascular coagulation (DIC) in 5 cases, Hellp syndrome associated to DIC in 7 cases and Hellp syndrome in 9 cases. Hemostasis disorders were associated to maternal advanced age, but not with gestational age or blood pressure in admission or time of convulsions. Complications and mortality associated with hemostasis disorders were more frequent compared to patients without hemostasis disorders. Among the 17 deaths of our series, 10 had hemostasis disorders.
Hemostasis disorders were prognosis factors in eclampsia requiring systematic laboratory tests at admission and immediate delivery.
Describe management of severe postpartum haemorrhages (PPH) and its compliance with national guidelines and identify determinants of non-optimal care.
Population-based cohort study of 1379 women with severe PPH due to uterine atony after vaginal delivery, conducted in 106 French maternity units between December 2004 and November 2006. Severe PPH was defined by a peripartum haemoglobin drop of 4g/dL or more, blood loss of 1000 mL or more, hysterectomy, or transfer to intensive care for PPH. The frequency of each recommended procedure for the management of PPH was described. Associations between quality of care and both individual and institutional characteristics were assessed by univariate analysis and multivariate logistic regression.
Management of severe PPH was not optimal in 65.9% of cases. The recommended components that were applied least often were administration of second line uterotonics, and transfusion of patients with a low haemoglobin. After adjustment for individual characteristics, the risk of either non- or suboptimal care was significantly higher in non-university public maternity units (aOR 2.62 [95% CI: 1.49-4.54]) compared with university hospital units, in units with fewer than 2000 annual deliveries (aOR 2.32 [95% CI: 1.49-3.57]), and in units without an obstetrician always present (aOR 1.96 [95% CI: 1.26-3.03]).
Management practices for severe PPH can be improved, to an extent that varies by component of care and type of hospital. A qualitative approach should help to identify the individual and organizational factors explaining why guidelines are not fully applied.
To estimate the incidence, to describe the aetiology and to identify the risk factors of postpartum haemorrhage (PPH).
Prospective study conducted in 106 French maternity units of six perinatal networks between December 2004 and November 2006. PPH was defined by a blood loss superior to 500mL or necessitating an examination of the uterus, or a peripartum haemoglobin drop superior to 2g/dL. Severe PPH was defined by at least one of these criteria : peripartum haemoglobin drop superior or equal to 4g/dL, embolization, conservative surgical procedure, hysterectomy, transfusion, transfer to intensive care or death.
The incidence of PPH was 6.4% [CI 95% 6.3-6.5] with variations between maternity units from 1.5% to 22.0%; incidence of severe PPH was 1.7% [CI 95% 1.6-1.8] with variations between units from 0% to 4%. Atony was the main aetiology of PPH, whatever the mode of delivery and severity. The risk factors identified were those classically described in the literature.
In these six French perinatal networks, in 2005-2006, the PPH profile was characterized by an incidence of severe forms higher than previous population-based estimates from other countries. This suggests a more frequent aggravation of PPH and the implication of inadequate PPH management.
The authors give biological reference figures obtained from 106 fetuses that were sampled in utero between the 20th and 34th week of amenorrhoea. These fetuses were considered to be normal because there was no clinical or ultrasound evidence of an abnormality. Furthermore the biological values sought in antenatal testing and the absence of all pathology in the first year of life, confirmed that these were normal fetuses. The result has been expressed as a global figure for all 106 fetuses; then they have been divided up according to the gestational age groups (20-23, 24-27, and 28-34 weeks of amenorrhoea). These biological reference values and their changes as the age of the fetuses advanced are discussed and compared with the figures reported in the literature.
The authors undertake to show that the obstetric future of women who have been operated on for uterine synechiae is not as poor as would appear from previous publications. 59 p. 100 of 75 women who wanted to become pregnant did so and 46 p. 100 went on to have at least one living child. If one only takes into account those women who were able to be followed up, 71 p. 100 became pregnant and 55 p. 100 had pregnancies with a viable child. When women with only uterine synechiae and without an associated lesion were considered, 81 p. 100 of them became pregnant and 67 p. 100 had a viable child. From this it is important to screen for an associated lesion by laparoscopy. The authors also write about the value of hysteroscopy carried out to find synechiae more easily and to control the treatment.
We report our experience concerning the laparoscopic treatment of ectopic pregnancy (EP). One-hundred and nine women with EP were treated in our department over a 4 year period, between February 1988 (date of our first laparoscopic surgery for EP) and December 1991. Twenty-two of these women underwent laparotomy and the remaining 87 laparoscopic surgery alone. Four therapeutic failures were noted in women treated by laparoscopy. Our results are compared with those of other series and the indications, as well as the modalities of laparoscopic treatment are detailed. It is concluded that laparoscopic surgery of EP is a reliable method which must always be considered, except for a few rare indications.
Exclusive hepatocele is defined as a hernia containing in majority the liver with possibly some intestinal loops. This study was undertaken to evaluate neonatal morbidity and mortality in this series of exclusive hepatoceles.
We reviewed 11 cases of exclusive hepatoceles with delivery at the hospital Jeanne-de-Flandre in the CHRU of Lille, in France.
The mean gestational age of diagnosis was 14.5+/-3.4 weeks of gestation. Karyotype determination was performed in 100% of cases: it was abnormal in one case of 11. One termination of pregnancy was performed because of trisomy 13. The mean gestational age at delivery was 38+/-1.8 weeks of gestation. Cesarean deliveries were performed in nine cases. Morbidity was important with: one case of fetal growth retardation on total hepatocele, three cases of severe respiratory distress, two cases of severe digestive complications. The mean length of stay was 42.8 days. The mean length of parenteral feeding was 14.4 days. Postnatal mortality concerned one child, which died because of a severe respiratory distress due to pulmonary hypoplasia.
In this series, morbidity is thus important, making of exclusive hepatoceles a full entity among the omphaloceles. The multidisciplinary take care is more complex but conceivable.
To construct French reference charts and equations for nuchal translucency thickness (NT) using a large sample of fetuses. To compare this new reference with previous ones.
The study data were obtained from a single large screening center over seven years. Only measurements taken by trained and certified (Fetal Medicine Foundation) operators, with crown rump length (CRL) between of 45 to 84 mm were used. Multiple pregnancies, abnormal karyotype, cystic hygroma or measurements performed by operators performing less than 500 examinations over the study period were excluded. Raw centiles were computed for each CRL. They were then fitted using a least square regression model with high order polynomials. Predicted median values for NT were compared to previously published references and the impact of deviation in median NT was evaluated.
There were 19,198 measurements included for NT modelling. New charts and equations for NT centiles calculations are reported. Median values were comparable to those reported in other populations. The small discrepancy in median NT did not impact on screening efficiency.
We present new French reference charts and equations for NT at first trimester. These may serve as a basis for ongoing audit and quality control. Although they were derived from a very and unselected sample, they do not show clinically relevant difference as compared to existing references. Our results do no support the use or development of customized French reference charts and algorithm for first trimester screening.
The gynaecologist-obstetrician may be the medical witness who has to give evidence about the extent of the initial trauma after the presumption of a sexual assault on a victim who comes to consult him, or as an expert witness. The certificate that he gives at the time of the first consultation is an essential document for the examining magistrates who have to decide whether there has been an offence. It is also a very great help to support the brief for the lawyers in a civil action taken by the victim, who is claiming damages as compensation for physical or psychological damage resulting from the sexual abuse. The authors reported it useful to look through 64 case documents that were considered in 11 years. They studied the differences in the penalties that were awarded for criminal offences and the sums of money for indemnity that were awarded in civil cases. These were before the new law concerning rape was passed on the 23rd December 1980, and after this law had been applied. It tends to improve the position for the victim in civil cases and increases the sentences that can be passed for aggravated rape (as on a minor by an adult, or in particular somebody who has a position of responsibility to the child). The authors point out especially how important it is to take note of sexual precocity and to have a detailed account of the first investigations carried out after the sexual assault. These can be used to make the sentences differ and to make it possible to increase and widen the awards given to compensate the victims. As far as civil action is concerned, as there is usually a fixed scale for every regional Court of Assizes according to a definite formula, it is advisable according to the authors that the initial expert assessment presented by the magistrates should establish in its conclusions the details of the indemnity to be considered by professional judges of the Assize juries. They should take particular notice of added injuries that are not physical and are often not considered, such as pain and suffering, loss of pleasure and the aesthetic, the sexual, the obstetrical and the moral as well as the juvenile points of view. In certain cases ad full medical assessment presented before the end of the case will help the professional judges of the jury of Assizes who have to give judgment in a civil action by giving them information that will support the true interests of the victim.
To clarify and classify the still debated diagnostic and prognostic elements of borderline tumours of the ovary and analyze the data obtained in our series.
Develop an adapted management scheme, integrating relatively good prognosis and known or suspected factors of poor prognosis. SIEGE: Department of Gynaecology-Obstetrics, Hôtel-Dieu (CHU) Rennes, France.
Eleven patients with borderline tumour of the ovary diagnosed and managed over the last 5 years.
Current morphology and macroscopy examinations of the tumour do not provide data capable of predicting malignancy. The borderline nature of the tumour is not a histological diagnosis. The problems encountered lead to a search for new techniques such as digitalized nuclear morphology. Some progress has been made in classifying prognosis factors. Other than stage, important factors appear to be age, histological type, mitotic index, atypical cells and invasive peritoneal implants. Management decisions depend on prognosis factors but should especially take into account parity. Methods include cystectomy and total hysterectomy with annexectomy. Evaluation of chemotherapy and radiotherapy is still to preliminary.
The slow clinical course, allowing good mid-term prognosis, is still the best reason for a moderated therapeutic approach relying on conservative or more aggressive surgery alone.
To describe medical responsibilities of midwives in maternity units and to compare these responsibilities between categories of maternity units.
A mail survey was carried out in 1996 on a random sample of midwives. The analysis was based on 884 midwives providing antepartum, perpartum or postpartum care in public or private maternity units.
For many procedures and decisions, medical responsibilities of midwives were more important in the public sector than in the private sector. Responsibilities were more extended in university hospitals than in other public hospitals. These differences were observed in the postnatal ward, in the antenatal ward, and for some specific tasks in the labor ward. In the private sector, responsibilities varied according to the status of the maternity unit: midwives performed fewer procedures in profit-based maternity units than in non-profit ones.
The roles of midwives vary from one type of maternity unit to another, but differences are also observed within the same categories of units. Consensus on what are the medical responsibilities of midwives does not exist in a variety of situations, even with regard to the management of normal pregnancies and deliveries.
The authors describe a population-based birth defects registry, started in 1976. The system surveys about 85,000 births per year, occurring in 140 maternity units and representing more than ten per cent of all the births in France. Monitoring first covered the Rhône-Alpes region, then was extended to the Auvergne region in 1983 and to the Jura district in 1985. The method of investigation was "multi-source", because any doctor in the zone covered was in a position to notify a malformation to the registry. (497 obstetricians, pediatricians, pediatric surgeons, fetopathologists, geneticists and cytogeneticists). Malformations were coded with a specific terminal elaborated in the registry (1,600 items). The mothers' exposures to drugs during the first trimester of pregnancy were coded by trade names. The registry is a full member of the International Clearinghouse for Birth Defects Monitoring Systems, an international organisation now including in this group 25 regional or national birth defects registries and covering more than 3 million births per year. The 1986 results of monitoring birth defects in the described registry are given as examples. Within the eleven years (1976-86), 15,000 cases of malformations were registered, and two clusters have been detected and followed-up: femoral aplasia/hypoplasia in 1980-81 and oesophageal atresia in 1984. No cause was found for these "epidemics". The strong association between in utero exposure to valproic acid with spina bifida is the main result of the activities of the registry since its creation.
The authors present 11 cases of Krukenberg tumour and have reviewed the literature concerning this condition. They conclude that the expectation of cure is increased if the primary tumour is removed early and if chemotherapy, hormono-therapy when indicated and immunotherapy are carried out, preferably together. No treatment at present seems to be specific for this condition.
The aberrant right subclavian artery is a malformation of the aortic arch present at less than 2 % of the individuals in the general population. This incidence is higher in trisomy 21, making it possible use the aberrant right subclavian artery as a prenatal marker of trisomy 21.
This work, which relates to a series of 11,479 consecutive fetal autopsies aims to measure the force of association between the aberrant right subclavian artery and trisomy 21, to confront our results with the sonographic series previously published and to contribute to assess the place that can have this sign in the echographic screening and the fetopathologic diagnosis of trisomy 21.
The isolated presence of an aberrant right subclavian artery does not represent an argument sufficient for the indication of a karyotype. But the detection of this anomaly must make pay a special attention in search of other associated signs.
On the results of this study, the aberrant right subclavian artery has to be considered as a part of the spectrum not only of trisomy 21, but also of many other congenital syndromes.
The authors report their experience concerning 110 cases of acute salpingitis that were diagnosed and controlled laparoscopically one month after antibiotic treatment had been achieved. During the second look laparoscopy three parameters were appreciated: pelvic adhesions, tubal patency, and residual inflammation. Laparoscopic findings at the time of early second look have shown relationship between the occurrence of tubal sequelae and the seriousness of initial PID: the relation was statistically significant regarding pelvic adhesions and tubal patency. Chlamydia trachomatis infections were associated with a poorer reproductive potential outcome. Second look laparoscopy seems particularly indicated after severe form of PID (pyosalpinx, tubo-ovarian abscess), in the presence of Chlamydia trachomatis, among young nulliparous woman wishing to conceive.