[Management of side effects under hormonal replacement therapy in menopausal women: Abnormal uterine bleeding. Postmenopausal women management: CNGOF and GEMVi clinical practice guidelines]

OBJECTIVES

To publish, under the aegis of the French National College of Gynecologists and Obstetricians (CNGOF) and the Study Group on Menopause and Hormonal Aging (GEMVi), recommendations based on the evidence available in the literature for the management of abnormal uterine bleeding (AUB) in women taking hormonal replacement therapy (HRT). A review of the literature was performed by consulting Medline, Cochrane Library data as well as international recommendations in French and English up to September 1, 2020.

RESULTS

AUB occurring in a woman taking HRT (FIGO 2011) is one of the main factors of poor adherence to the HRT. AUB must seek an organic cause including endometrial cancer. The main functional causes of AUB in a woman taking HRT are resumption of ovarian activity, poor compliance, and trophic disorders of the endometrium. AUB are dependent on the type of HRT. In the event of AUB under HRT, it is suggested to perform a pelvic ultrasound at the end of the progestational sequence in the event of sequential HRT. In a single episode of AUB and when the ultrasound estimates the endometrial thickness less than or equal to 4mm, it is possible to postpone further uterine exploration. In case of recurrent AUB or when the endometrium thickness is greater than 4mm in a postmenopausal woman, additional uterine investigations (hysteroscopy and histology) are recommended.

CONCLUSION

AUB under HRT must seek an organic cause. The measurement of endometrial thickness by pelvic ultrasound is relevant for screening for endometrial cancer.

Two miscarriages, consecutive or non-consecutive, does it change something?

OBJECTIVES

To assess the rate of anomalies in the etiological evaluation of patients presenting recurrent early miscarriages (RM) according to miscarriage chronology (number of miscarriages, history of live birth and succession of RM).

METHODS

Retrospective single centre study including RM, defined as at least 2 miscarriages at less than 14 weeks of gestation (WG) between the 1st January 2012 and the 31st December 2015. Clinical data and etiological evaluation include blood glucose levels, screening for antiphospholipid syndrome (APS), endocrine assessment, vitamin levels, pelvic imaging, karyotyping of both partners, chronic endometritis and thrombophilia screening.

RESULTS

Two hundred and eighty-eight patients were included over this period, 118 (41%) patients had no history of live birth. Two hundred and twenty-three (77%) patients had consecutive RM and 65 (22%) patients had non-consecutive RM. For consecutive RM, 62,8% had thrombophilic disorders versus 69,8% for non-consecutive RM (P>0,05); 44,7% had endocrine disorders or vitamin deficiencies versus 39,7%; 34,6% of patients with consecutive RM had uterine anomalies versus 45,5% respectively. No difference was found depending on the recurrence of RM or the history of live birth (P>0.05) apart from the age of the patient. Fifty-nine (17.4%) patients had uterine anomalies. There are 24 chronic endometritis on 31 biospsies performed. Seventy-eight (27%) patients were offered treatment. Ninety-four (90%) patients showed good therapy compliance. Eighty-one (78%) patients became pregnant.

CONCLUSION

An etiological evaluation provides, for over half of the cases, an etiology or the identification of risk factors responsible for RM, as well as in some cases offering an adapted, efficient, therapeutic approach. This evaluation should be offered regardless of the obstetric history of the patient.

[Parental project of general medicine residents from Aix-Marseille university: Theoretical knowledge in reproduction and behavior towards parenting]

OBJECTIVES

Analyze residents' intentions about parenting and knowledge about fertility, as well as their alleged behavior towards a diagnosis of diminished ovarian reserve.

MATERIALS AND METHODS

Prospective study with distribution of self-administered questionnaire to residents of Aix-Marseille university from June to September 2015. The questionnaire was composed of a first descriptive part including generic and personal informations about the residents and their intentions towards parenting. The second part was a 9 questions survey aimed at testing their knowledge about fertility and ovarian reserve and a final question placing them in a situation of a diminished ovarian reserve diagnosis in order to analyze their reactions.

RESULTS

The overall participation rate was 53.2%, including 220 women with an average age of 27 years (SD: 1.8 years) and 116 men with an average age of 27.3 years (SD: 2.2 years). The 11.8% of female residents (n=26) already had one or more children vs.6.9% of male residents (n=8). Among the residents without children, 99% of females (n=192) and 91.7% of males (n=99) said they wanted to have children in the future, planning an average age to have their first child of 29.6 years (SD: 1.9 years) for females and 30.4 years (SD: 2.2 years) for men. Moreover, 58.3% of female residents (n=112) and 53.5% of male residents (n=53) reported that they were postponing their plan to have children after the completion of their medical studies. In a simulation of couples facing a diagnosis of diminished ovarian reserve, 73.6% of females and 61.2% of males would be ready to change their life choices and conceive a baby sooner than originally planned.

CONCLUSION

Almost all the general medicine residents have plannedto have children in the future and more than half of them postpone their parental plan after the end of their residency, although the decline of female fertility in relation to aging is widely known among them.

[Methods of induction of labor in termination of pregnancy after 22weeks: About 3procedures]

OBJECTIVES

To propose a protocol for induction of labor to terminate pregnancy after 22weeks of amenorrhea allowing to decrease the duration of labor and of hospitalization but also, allowing to reduce the number of emergency pretreatment-induced fetal death, to improve the experience of the patients and to limit the cost.

METHODS

We realized a retrospective single-center study including 269patients and comparing three protocols, with and without laminaria and with various intervals mifepristone-misoprostol (14 and 38hours). The outcome measures were the misoprostol-delivery interval, the delivery time and the number of emergency pretreatment-induced fetal death.

RESULTS

We showed that the misoprostol-delivery interval and the delivery time were comparable for the three periods of our study, even after decrease of 24hours of the mifepristone-misoprostol interval and in the absence of laminaria. The misoprostol-delivery interval was between 7h30 and 8h35 between protocols (P=0.055). The delivery time was between 5:18pm and 6:48pm between protocols (P=0.252). The early administration of misoprostol allowed the patients to give birth earlier (P=0.001). Finally, we showed that the increase of the size and the number of laminarias were risk factors of emergency pretreatment-induced fetal death (respectively P=0.013 and P=0.002).

CONCLUSION

The absence of laminaria and the reduction of the interval mifepristone-misoprostol of 24hours do not change the time to delivery and allow to reduce the duration of hospitalization, the number of emergency pretreatment-induced fetal death and the cost of the TOP.

[Impact of the loop electrosurgical excision procedure for cervical dysplasia on sexual function]

OBJECTIVE

To assess the consequences of loop electrosurgical excision procedure (LEEP) on the quality of sexual life.

MATERIAL AND METHODS

A prospective observational study in two university hospital departments in Marseille, France, including women requiring a LEEP. Sexual quality of life was assessed before LEEP and three months after the procedure with a self-administered validated questionnaire: the Brief Index of Sexual Functioning for Women (BISF-W).

RESULTS

Among the 100 women included, 69 filled both questionnaires. Among the 69 women whose outcomes were available, composite BISF-W score was significantly lower before LEEP than three months after LEEP (28.3±13 vs 30.1±13.2; P=0.01). The items scores concerning desire (D1) and orgasm (D5) were significantly improved after LEEP (4.3±2.3 vs 5±2.2 [P<0.001] and 4.3±2.5 vs 4.7±2.6 [P<0.001]).

CONCLUSIONS

This study found an improved quality of sexual life after LEEP. These findings suggest that the psychological impact of HPV infection on sexual function is greater than the anatomical and functional impact of LEEP.

[Assessment of shoulder dystocia related knowledge among French obstetrics and gynecology residents]

OBJECTIVE

To study the related knowledge of French residents in obstetrics concerning maneuvers for shoulder dystocia (SD).

MATERIALS AND METHODS

Multicenter descriptive transversal study conducted from June to September 2014. Data collection was performed through questionnaires sent by email to French resident in obstetrics.

RESULTS

Among the 1080 questionnaires sent, 366 responses were obtained with a response rate of 33.9%. One hundred and forty-three residents (39.1%) were in the first part of their training (≤5th semester) and 60.9% (n=223) were in the second part of their training. Theoretical training on the SD was provided to 88.2% of resident (n=323). In total, 38.8% (n=142) obtained their French degree in mechanical and technical obstetric and among them 77.5% (n=110) had the opportunity to train on simulators and dummies. Concerning their practical experiences, 31.5% (n=45) residents ≤5th semester reported having experienced SD during their residency vs 58.3% (n=130) amongst oldest residents (P<0.001). In the second part of residency, 40% of residents (n=89) expressed to feel able to manage shoulder dystocia. Only 19.1% (n=70) were satisfied with their residency training program vs 39.1% (n=143) who were unsatisfied.

CONCLUSION

Our study showed that less than one resident out of two (40%) felt able to perform maneuvers for SD in the second part of residency. We think that simulation activities should be mandatory for residency training programs in Obstetrics and Gynecology, which have to develop dependable measures to assess resident competencies to execute practical maneuvers for clinical emergencies in obstetrics.

[Comparative study of patients with placenta accreta with or without a history of cesarean section]

OBJECTIVE

To evaluate characteristics of placenta accreta (PA) in patients without previous cesarean section.

MATERIAL AND METHODS

Retrospective cohort study from December 1993 to April 2010 in two departments of obstetrics in university hospitals, Marseille, France. Comparison of clinical characteristics, circumstances of diagnosis, maternal morbidity and treatment was performed between PA diagnosed in patients with (n=63) and without prior cesarean section (n=35).

RESULTS

In group of patients without previous caesarean section, rate of placenta praevia, and antenatal diagnosis were lower (16/35 [46 %] vs. 44/63 [70 %], [P: 0.02]) and (4/35 [11 %] vs. 28/63 [44 %], [P<0.001]) and rate of pregnancies obtained by IVF was higher (5/35 [15 %] vs. 2/63 [3 %], [P=0.05]). In this group, no hysterectomy was performed but risk of uterus necrosis following embolization was increased (3/35 [8.6 %] patients vs. 0/63 patients [P: 0.02]).

CONCLUSIONS

Patients without previous caesarean section have specific characteristics in terms of risk factor and of management.

Fetal heart disease and interruption of pregnancy: factors influencing the parental decision-making process

OBJECTIVE

To identify factors influencing parental decision when a fetal cardiac disease is diagnosed.

METHOD

All pregnancies with fetal cardiac abnormalities diagnosed at three academic hospitals of Marseille, France, between 2004 and 2008, were retrospectively studied. The association between maternal and fetal variables (maternal age, parity, ethnicity, gestational age at diagnosis, nuchal translucency, fetal gender, chromosomal and extra cardiac abnormalities, and severity of the cardiopathy) and parental decision was tested using univariate and multivariate statistical methods

RESULTS

One hundred eighty-eight cases of fetal cardiac disease were analysed, of which 63 were interrupted pregnancies (IP) and 125 continued pregnancies (CP). Four factors were important in the parental decision-making process: the severity of cardiac malformation, the ethnic origin of the parents, the gestational age at diagnosis and the chromosomal abnormalities.

CONCLUSION

Counselling of parents following the diagnosis of a congenital heart disease should take into account that, in addition of the severity of the congenital heart disease (CHD), ethnicity, gestational age at diagnosis and chromosomal abnormalities influence parental decision regarding pregnancy continuation or interruption.

[HPV prophylactic vaccine coverage in France: Results of a survey among high school and university students in Marseilles' area]

OBJECTIVE

To assess HPV prophylactic vaccine coverage among French high school and university students as well as their level of education about this vaccine.

PATIENTS AND METHODS

An anonymous survey was conducted among 2500 high school and university students from the area of Marseilles, France, from December 2009 to April 2010.

RESULTS

A total of 2018 questionnaires were collected (80.7% participation rate). Mean age of participants was 20 years (range, 15-45 years). Only 671 (35.4%) participants reported having been vaccinated against HPV, of whom 510 (73.4%) had completed the three injections scheme. Practice of cytological cervical cancer screening was not significantly influenced by vaccination status. Thus, 578 (45.2%) participants who had not been vaccinated already had had a cervical cytology performed, versus 295 (43.3%) vaccinated ones (P=0.445). Among those not being vaccinated, 671 (49.8%) fulfilled criteria for a catch-up vaccination, of whom only 325 (48.4%) agreed for such a catch-up. Main reasons given for refusal for a catch-up vaccination were the lack of information about HPV vaccine and fear of side effects. In total, 1722 (90%) considered themselves as educated about the HPV vaccine. Source of education was attributed to doctors and media by 54.4% and 53.7% of participants, respectively. Educational role attributed to school and university was poor (3.4%).

CONCLUSION

Despite apparent satisfactory level of education, HPV prophylactic vaccine coverage among high school and university students appears to be insufficient.

[A look into the past: improves in obstetrical and neonatal outcome in maternity since the 19th century]

OBJECTIVE

Evaluate changes in obstetrical and neonatal outcome of women who delivered in maternity hospital since the 19(th) century.

MATERIALS AND METHODS

Data from a historic cohort of 1022 women who delivered between 1871 and 1874 in the hôtel Dieu hospital of Marseille were compared to those from 1159 women who delivered from 2005 to 2006 in the level 3 maternity of Nord hospital of Marseille (contemporary cohort). Deliveries that had occured before 22 weeks and/or with a foetal birth weight of less than 500 g were excluded.

RESULTS

A total of 2131 pregnancies were included: 1011 and 1120 in historic and contemporary cohort, respectively. Despite comparable mean term of delivery, mean birth weight of neonates from historic cohort were significantly lower: 2971 g (550-4900 g) vs 3250 g (500-5375 g), respectively (p<0.001). Stillbirths were reported in 72 (7.1%) cases in historic cohort compared to nine (0.8%) in contemporary cohort (p<0.001). Neonatal mortality was 3.7% in historic cohort and 1.9% in contemporary cohort (p=0.012). A total of 99 (9.8%) maternal deaths were reported in historic cohort, while none in contemporary cohort (p<0.001). A wide majority of maternal deaths were caused by maternal infection (72.9%); 5.2% were caused by postpartum haemorrhage.

CONCLUSION

Our results illustrate the tremendous impact on maternal and neonatal outcome of advances in obstetrical management. The significant increase in the median foetal birth weight is likely to be related to wide changes in environmental conditions and behaviour.

[Institutional review board of the French college of obstetricians and gynecologists (CEROG).]

OBJECTIVE

To report the rules and the activity of the institutional review board of the French college of obstetricians and gynecologists (Comité d'éthique de la recherche en obstétrique et gynécologie [CEROG]) created in 2008. The submission requirements are also described.

METHODS

Retrospective study.

RESULTS

The Ethical Review Committee [institutional review board of the French college of obstetricians and gynecologists (CNGOF)] CEROG have examined 65 project studies in 2008. The median number of submitted studies was 5.5 per month (IQR: 3.75-6.25). The origins of the submission were as follows: tertiary care university hospitals (n=63, 97 %), Inserm (n=1), INRA (n=1). Researches were found to be in conformity with the French laws and regulations, to conform to generally accepted scientific principles and medical research ethical standards in 44 cases (68 %). In 13 cases (20 %), the study has been forwarded to the Persons Protection Committee (PPC) since it concerned biomedical research or "usual care research" (soin courant). In six cases (9 %), the investigators have not responded to IRB suggestions. In two cases (3 %), the information form has been judged unsatisfactory.

CONCLUSION

The CEROG is the first national IRB in obstetrics and gynecology. This new committee clarifies IRB submission procedure in France concerning non-interventional studies in the field of obstetrics and gynecology.

Bleeding pattern and safety of consecutive use of the levonorgestrel-releasing intrauterine system (LNG-IUS)--a multicentre prospective study

BACKGROUND

The LNG-IUS has increasingly been used for contraception, treatment of menorrhagia and endometrial protection during hormone replacement therapy since mid-1990s. Thus, many women use the LNG-IUS consecutively. However, published data on the bleeding pattern regarding consecutive use of the LNG-IUS is scarce.

METHODS

We performed a prospective 15-month multicentre study on the bleeding profile, removal and insertion procedures and safety of the second LNG-IUS in fertile-aged women who had used their first LNG-IUS between 4 years 3 months and 4 years 9 months and who opted for the insertion of a second IUS immediately after removal of the first IUS. Bleeding data were reported descriptively starting from the last 90 days of the first IUS use and continuing for up to 1 year.

RESULTS

Of the 234 subjects screened, 204 (87%) entered the trial. The median number of bleeding/spotting days during the last 90 days of the first LNG-IUS was 7 (25 and 75% percentiles 0 and 15). Due to bleeding associated with the insertion procedure, this increased to 8 days (4 and 18) during the first 90-day reference period, thereafter decreasing to 4 (0 and 10) days during the second to fourth reference periods. Only one expulsion and no pregnancies, pelvic inflammatory diseases or perforations occurred. A total of 12 subjects (5.9%) prematurely discontinued the study: five due to an adverse event and seven due to other reasons (inclusive of loss to follow-up).

CONCLUSIONS

This study confirms the favourable bleeding profile and safety of consecutive use of the LNG-IUS.

[Primary actinomycosis of the breast due to Actinomyces neuii]

Primary actinomycosis of the breast is a rare disease, with only 32 cases reported in the literature since 1893. The diagnosis is done in front of a recurrent abscess with fistulas and purulent discharge. Bacteriologic analysis only can confirm the diagnosis. We report the first case of primary actinomycosis of the breast caused by Actinomyces neuii, in a 46-year-old premenopausal woman. No cause of this condition was reported. Targeted antibiotic therapy did not improve the condition. A tumorectomy of the breast was decided. Six months after surgery, no recurrence has been observed.

Total and fetal cell-free DNA analysis in maternal blood as markers of placental insufficiency in intrauterine growth restriction

OBJECTIVE

To compare total and fetal DNA levels in the maternal plasma in three groups: pregnancies with intrauterine growth restriction (IUGR) due to placental insufficiency (PI) and other causes, and in control pregnancies.

METHODS

Total as well as fetal DNA was quantified in 78 maternal plasma samples. In 19 pregnancies, the fetus presented IUGR due to PI (group A), and in 31 pregnancies due to other causes (group B). The control group comprised 28 patients (group C). DNA quantification was done using real-time quantitative PCR with a standardized pool of plasmid calibrators. DNA concentrations of the three groups were compared using non-parametric tests (Kruskal-Wallis or Mann-Whitney tests).

RESULTS

The three groups did not statistically differ regarding maternal age (mean +/- SD: 30.5 +/- 5.4 years), gestational age (30 +/- 5.3 weeks) or the proportion of male fetuses (48.2%). Plasma total DNA was significantly higher in group A compared to groups B and C (p = 0.001 for both). An increase in fetal DNA was only observed in group A for patients beyond 28 weeks of gestation.

CONCLUSIONS

The plasma total DNA level is higher in patients with IUGR due to PI. These results suggest the presence of maternal endothelial damage independently of preeclampsia.

Advanced Combined Abdominal and Intrauterine Pregnancy: A Case Report

We present a case of simultaneous abdominal and intrauterine pregnancy following in vitro fertilization and embryo transfer diagnosed during the second trimester. The patient had a recent history of hysteroscopic metroplasty due to in utero exposition to diethylstilboestrol. The pregnancy was managed conservatively with a favorable outcome for the mother and both fetuses.

Determination of HPV type 16 and 18 viral load in cervical smears of women referred to colposcopy

It has been recognized that human papillomavirus infection is the major causal factor for high-grade cervical lesions. The aim of the study was to evaluate the relationship between HPV 16 and 18 viral loads and cervical status in different age strata. A duplex real time PCR method was devised to determine HPV 16 and 18 viral load per million of human cells using an in house plasmidic construct as a standard of quantification. The 151 cervical scrapes were collected before colposcopic examination from either abnormal cervico-vaginal smear (group 1, 97 patients) or from post treatment clinical follow-up (group 2, 54 patients). In women aged 30-40, the HPV16 viral loads were significantly higher in high-grade squamous intraepithelial lesion than in low-grade squamous intraepithelial lesion in both groups and HPV18 in group 1. In women aged 20-30 of group 1, high HPV viral load was associated in few cases with high-grade squamous intraepithelial lesion or low-grade squamous intraepithelial lesion, and surprisingly in some patients with normal cervix. HPV 16 and 18 viral loads are related to the severity of cervical lesion, and may be useful in the clinical management of cervical lesions. A specific follow-up may be useful for those with high viral load despite normal cervix.

[A tumor-like lymphocytis mastitis]

A 44-year-old woman presenting with an inflammatory and palpable firm breast lump underwent surgical excision. Intraoperative frozen section analysis showed an extensive lesion consisting of ducts with intraluminal "necrosis". In addition, a very dense stromal inflammation was observed around these ducts, suggesting an invasive ductal carcinoma with predominant intraductal proliferation. However, on paraffin sections, epithelial cells close to the lymphocytic infiltrate were rare, subatrophic, without any neoplastic feature. The density and architecture of the lymphocytic infiltrate mimicked a breast lymphoma. However, immunochemistry and molecular biology investigation favored the diagnosis of a tumor-like lymphocytic mastitis. Although extremely rare, this particular form of lymphocytic mastitis, a diagnostic pitfall particularly during peroperative examination, should be recognized by pathologists.

Extraction instrumentale par spatules de Thierry

OBJECTIVES

To describe the frequency of maternal and neonatal complications resulting from the use of Thierry's spatulas.

MATERIALS AND METHODS

This retrospective study included 166 patients treated during a 17-month period.

RESULTS

For 100% of the patients, the use of the spatulas allowed the extraction of the new born, in 68 cases (41%) the new born was engaged between one and two centimeters below the spines. A medio-lateral episiotomy was performed in 159 patients (96%). A serious perineal tear (Type 3) occurred for 6 of these patients (3.6%). A simple perineal tear (Type 1) or vaginal tear occurred in 24 (18%). Episiotomy was performed in 18 patients and was significantly protective. No case of serious neonatal complication were related to the use of the spatulas.

CONCLUSION

We found that perineal tear rate is similar to that observed with other instruments used for fetal extraction. No case of fetal trauma could be related to the use of the spatulas; this was the goal of Thierry who creation the instrument. The use of Thierry's spatulas as a reference instrument is warranted, particularly for cases of prematurity, as these spatulas fulfil the modern obstetrics requirements of fetal protection, without maternal risk.

Les fondements du pronostic en médecine prénatale : exemple de la trisomie 21

Establishing a prognosis in prenatal medicine is often a complex and uncertain task. Predictive tools such as imagery techniques and biological markers may lack accuracy since they are used while the fetus is still pursuing its development. In France, antenatal euthanasia and fetal abandon are legal issues and socially accepted. Several non-medical factors may interfere with the final outcome such as the manner a condition is announced by the staff, the way it is experienced by the parents and the acceptance of the handicap within the society. We analysed the different medical and non medical factors intervening in the prognosis work up for Down's syndrome. Currently, the outcome of fetus with Down's syndrome is influenced by the orientation of our society that promotes screening tests and pregnancy interruptions instead of emphasizing on therapeutic research and improving their social integration.

Value of endorectal ultrasonography for diagnosing rectovaginal septal endometriosis infiltrating the rectum

BACKGROUND AND STUDY AIMS

Rectovaginal septal endometriosis (RVSE) can pose serious therapeutic problems when there is infiltration of the rectal septum (which occurs in approximately half of the cases). The aim of this study was to assess the value of endoscopic ultrasonography in diagnosing rectal wall involvement by pelvic endometriosis.

PATIENTS AND METHODS

A prospective study was carried out from May 1998 to March 2003 at a single hospital center. The 30 patients included in the study presented with suspected RVSE and underwent systematic anorectal endoscopic ultrasonographic exploration prior to the surgical intervention. The endoscopic ultrasonography was carried out under general anesthesia with a 7.5-MHz miniprobe equipped with a distal balloon.

RESULTS

The anorectal endoscopic ultrasonographic examination (EUS) showed the presence of endometriosis in the rectovaginal septum in 26 patients (88 %), in the uterosacral ligaments in 10 patients (33 %), and in the ovaries in two patients (6 %). At EUS, the nodules were infiltrating the rectal wall in 17 patients (56 %). The surgical exploration demonstrated endometriosis in the rectovaginal septum in 26 cases, the uterosacral ligaments in 22 cases, and the ovaries in 16 cases. The rectal wall was completely infiltrated in 12 cases and only partly in four cases, and intestinal tract resection was required in 10 cases. The sensitivity, specificity, and positive and negative predictive value of anorectal endoscopic ultrasonography as a means of diagnosing endometriosis of the rectovaginal septum and infiltration of the rectal wall were found to be 96 %, 100 %, 100 % and 83 %, and 92 %, 66 %, 64 % and 92 %, respectively; and the diagnostic accuracy was at 96 % and 80 %, respectively. The sensitivity for detecting nodules in the uterosacral ligaments or in the ovaries was 42 % and 14 %, respectively, leading to diagnostic accuracy rates of 56 % and 53 %.

CONCLUSIONS

In terms of its sensitivity and its negative predictive value, anorectal endoscopic ultrasonography is a very effective means of detecting endometriosis of the rectovaginal septum and assessing possible infiltration of the rectal wall. However, this method is not as accurate for nodules located far from the EUS probe, as is the case with the uterosacral ligaments and ovaries.

[Do we have to monitor foetal heart rate during general anesthesia?]

We present a case of an emergency Caesarean section due to misinterpretation of the cardiotocography (CTG) trace during general anaesthesia for treatment of dental abscess. Following failure of the dental abscess treatment under local anaesthesia, a 29-year-old female in the 36th week of a twin pregnancy was to undergo general anaesthesia. Foetal well-being was monitored with ultrasonographic evaluations of foetal heart rate. During surgery, senior obstetrician recorded a lack of beat-to-beat variability of the cardiotocography trace. The CTG pattern was interpreted as foetal distress and an emergency Caesarean section was performed under general anaesthesia. That was probably due to general anaesthesia. Then, two infants were extracted without neonatal distress necessitating intubation. This case report underlines the risk to misread an intraoperative CTG monitoring and if the CTG monitoring is normal before anaesthesia, reduced foetal beat-to-beat variability with a normal baseline heart rate during general anaesthesia is probably normal.

[Surgical management of primary postpartum hemorrhage]

Despite the development of medical, obstetrical and arterial embolization techniques to control acute postpartum hemorrhage, familiarity with surgical procedures is essential. They may be the ultimate available option in order to obtain hemostasis. Conservative techniques consist of arterial ligations and uterine compression sutures that preserve the reproductive future and may be combined together. Radical options include hysterectomy which may be total or sub-total. To date, there are no comparative trials assessing the superiority of a given surgical option. In this review, the main surgical interventions are described and a practical stepwise approach is discussed according to the etiology, based on a professional consensus work-shop. Surgical management must be timely triggered after failure of first line treatments and integrated in a global strategy aimed to cease hemorrhage. It should be adapted to the available local health resources and in compliance with the various members of the medical staff.

[Female genital mutilation: generalities, complications and management during obstetrical period]

OBJECTIVES

Evaluation of female genital mutilation complications and their clinical management.

MATERIAL AND METHODS

Review of the literature.

RESULTS

Female genital mutilation is still performed in some regions of Africa. Although female genital mutilation are often considered as a religious act, tradition and social habits seems to be the best explanation. Infibulation is the most severe form, in which the clitoris, the labia minora and part of labia majora are removed. Stitching of the raw surfaces created covers the urethra and the vaginal entrance. There only remains a small opening at the base of the vulva. Health consequences directly depend on the severity of the initial mutilation. They are more severe in infibulated women. Pregnancy, childbirth and the obstetrical period are particuliary dangerous for the mother and the child. Female genital mutilation contributes to childhood and maternal mortality and morbidity. Decreasing the impact depends on the obstetrical team's competence. Defibulation is absolutely necessary for the delivery of infibulated women. This simple surgical act can be performed under local anesthesia.

CONCLUSION

With increasing immigration, obstetrical teams in developed countries can be confronted with such situations. They should be aware of proper clinical management practices for these women.

[Postpartum ovarian vein thrombophlebitis: report of 5 cases and review of the literature]

OBJECTIVE

Postpartum ovarian vein thrombophlebitis (POVT) is an uncommon life-threatening situation. It should be systematically evoked in case of persistent fever during the postpartum. We describe here the imaging techniques to assert the diagnosis and the different therapeutic options.

METHODS AND MATERIAL

We report five cases from 1997 to 2002. Only one patient was surgically treated.

RESULTS

No death was observed. In all cases, fever and pain rapidly disappeared.

CONCLUSION

Search for postpartum ovarian vein thrombophlebitis should be undertaken in patients with persistent fever. Treatment is more often medical.

Le misoprostol par voie rectale dans l'hémorragie de la délivrance

OBJECTIVE

To evaluate a post-partum hemorrhage treatment guideline, using rectally administered misoprostol.

PATIENTS AND METHODS

A descriptive study was carried out in a tertiary referral center from January 2002 to March 2003. During this period, 2670 patients delivered and 41 (1.5%) with severe post-partum hemorrhage unresponsive to oxytocin received 1000 microg of misoprostol (five tablets) rectally while awaiting sulprostone. Twenty-eight had delivered by the vaginal route and 13 by cesarean section.

RESULTS

Hemorrhage was controlled among 63% (26/41) of the patients within 10 min of the administration of rectal misoprostol. Fifteen (37%) patients received both misoprostol and sulprostone and no major adverse effects were noted when combining these two prostaglandins. Overall, hemorrhage was controlled among 87% (36/41) of the patients when oxytocics were combined with misoprostol and sulprostone. Five patients (12%) did not respond to the combination of uterotonics and required a conservative surgical treatment.

DISCUSSION AND CONCLUSION

Rectal misoprostol may be an effective second line treatment for the management of post-partum hemorrhage unresponsive to oxytocin. We did not observe major side effects when combining misoprostol with sulprostone. Our findings encourage further research on rectal misoprostol in the treatment of postpartum hemorrhage.

[Necrotizing enterocolitis during pregnancy in a woman operated on at six months of Hirschsprung's disease]

Necrotizing enterocolitis is a rare and severe complication of Hischsprung's disease. Aggravation of unknown or undertreated Hischsprung's disease may be seen during pregnancy. To our knowledge, the following case is the first combining those two elements: necrotizing enterocolitis in a 20 years old women operated on of Hischsprung's disease when she was six months. The final diagnosis was made 24 hours later. Definitive treatment was a three-stage ileal pouch-anal anastomosis.