[Anal sphincter tears after vaginal delivery: risks factors and means of prevention]

To identify incidence and risks factors of obstetrical anal sphincter lacerations, we reviewed all cases of 3rd and 4th degree sphincter lacerations after vaginal deliveries (VD) occured in a tertiary maternity between 2005 and 2010. 78 anal sphincter lacerations were identified (3.8/1000 deliveries). 66 women (85%) were nulliparous. The mean age of women was of 29 +/- 5 years. The mean duration of the second stage of labour was of 3.4 +/- 1,7 hour. The birth weight of 12 newborns (15%) was greater than 4000 grams. Fourty-six women (2.5%) had sphincter lacerations after instrumental delivery and 32 after spontaneous vaginal delivery (0.2%). 51 patients out of 78 (65%) had a medio-lateral episiotomy, 82% occured after instrumental extraction and 43% after spontaneous delivery. A forceps of Tarnier was used in 18 cases, a Suzor forceps in 12 cases, spatula in 12 cases and vacuum in 4 cases. 76% of foetuses were in anterior presentation and 78% at the medium part of the pelvis. 2 patients experienced anal incontinence in early post-partum. Anal sphincter lacerations are relatively frequent after VD especially after instrumental delivery. Macrosomia, nulliparous women, prolonged second stage of labor were associated with anal sphincter tears. Medio-lateral episiotomy does not protect enough anal sphincters. Anal sphincter lacerations lead to anal incontinence in some cases.A long follow-up is useful for these patients.

Multiple square sutures for postpartum hemorrhage: results and hysteroscopic assessment

OBJECTIVE

The purpose of this study was to evaluate the efficiency and morbidity of multiple square sutures in severe postpartum hemorrhage.

STUDY DESIGN

A retrospective study encompassed 30 multiple square sutures that were performed for severe postpartum hemorrhage in 26,605 deliveries in a tertiary maternity center. The main outcome measures were the ability to stop hemorrhage and the assessment of the uterine cavity by hysteroscopy at 3 months.

RESULTS

Multiple square sutures stopped postpartum hemorrhage in 28 of 30 cases (93%). Twenty women underwent hysteroscopy after multiple square sutures. Eight women (40%) did not have intrauterine adhesions. Nine women (45%) had thin and localized intrauterine adhesions that were removed easily by the tip of the hysteroscope; 2 women had moderate intrauterine adhesions that were resected. One patient had endometritis followed by severe intrauterine adhesions.

CONCLUSION

Multiple square sutures are effective and safe for the control of severe postpartum hemorrhage and for uterine conservation in most cases. Although some patients had moderate or severe adhesions, a normal uterine cavity or minimal intrauterine adhesions that were removed easily were the most frequent findings at hysteroscopy. A prospective study may be helpful to compare the safety and efficiency of square and brace sutures.

Toxoplasmose congénitale : un nouveau cas d'infection pendant la grossesse chez une femme antérieurement immunisée et immunocompétente

Congenital toxoplasmosis is a potentially serious infection which usually affects infants born to non immune women.

CASE REPORT

Our case report focuses on a baby born to a normally immunocompetent woman previously immunized against toxoplasmosis. To our knowledge only three similar cases have been published until now.

CONCLUSION

We conclude that in front of a patient neonatal congenital infection picture, toxoplasmosis cannot be excluded on the ground of maternal immunity status and must be quickly investigated, given the emergency of appropriate treatment.

[Color and pulsed Doppler ultrasonography imaging of tubal ectopic pregnancy: study of 100 cases]

OBJECTIVE

To describe the color-Doppler findings and the spectral forms of pulsed Doppler in tubal ectopic pregnancies.

MATERIALS AND METHODS

A prospective study of one hundred patients with tubal ectopic pregnancies was carried out in the emergency ward by two operators from January 1993 to March 1999. Following transabdominal and/or endovaginal sonography of the pelvis, color Doppler of the adnexa and of any suspected latero-uterine abnormal vascularity were studied with pulsed Doppler. The diastolic index (D/S) was measured on 4 consecutive complexes.

RESULTS

Sixty-six peripheral hypervascularizations, 27 irregular hypervascularizations and 7 false negatives were found with color Doppler. The pulsed Doppler spectrum revealed a low-impedance flow in 47 cases (D/S index > or = 0.35) and a high-impedance flow in 46 cases (D/S index < 0.35). The latter spectrum was found in 7 cases of tubal rupture with massive hemorrhage and 39 cases of barely evolutive ectopic pregnancies.

CONCLUSION

Color Doppler facilitated the diagnosis of small ectopic pregnancies (gestational sac less than 1 cm and echogenic lesions less than 2 cm in maximum diameter). Our work with pulsed Doppler revealed the frequence of high-impedance flow which, in the absence of massive hemoperitoneum, strongly suggests a barely evolutive ectopic pregnancy.

[Ultrasonography of placenta previa at the third trimester of pregnancy: research for signs of placenta accreta/percreta and vasa previa. Prospective color and pulsed Doppler ultrasonography study of 45 cases]

OBJECTIVES

In a population of 45 placenta previa observed at third trimester of gestation we have tried to make the prenatal diagnosis of placenta percreta and vasa previa with color and pulsed Doppler ultrasonography.

MATERIALS AND METHODS

We used a transabdominal sonography with full bladder and a transvaginal sonography with empty bladder. The first images obtained showed 20 placenta previa over the internal cervical os, 3 marginal and 22 low-lying placenta previa. We tried to find evidence of placenta percreta with gray-scale ultrasonography (loss of normal hypoechoic retroplacental myometrial zone, focal disruption of the uterine serosa and surrounding tissues, presence of intra placental lacunae) and with color and pulsed Doppler (arterial vessels with a diastolic flow value less than the flow value of a spiral artery behind the placenta, arterial vessels crossing from the placenta to surrounding tissues, intraplacental lacunae with arterial flow). We tried to find evidence of vasa previa in color and pulsed Doppler (a fetal vessel in seen above the lower segment of the uterus and below the fetal head. There is no change in the location of the vessel despite positional changes in both mother and fetus). The positivity of one sign in gray-scale ultrasonography or in color and pulsed Doppler led us to believe that the patient was affected by the anomaly. The final diagnosis of abnormal adherence of the placenta and of vasa previa was made on histological examination.

RESULTS

Among the 20 placenta previa over the internal cervical os, we found 1 placenta percreta, 1 placenta accreta and 3 cases of vasa previa. In spite of our limited sample of cases of abnormal adherences, our results showed that gray-scale ultrasonography was sufficient to make a prenatal diagnosis of placenta accreta/percreta. Negative predictive value is 100% on a sample of 43 patients with no abnormal placental adherence. Color and pulsed Doppler brought no further evidence. In our population, color and pulsed Doppler had 100% positive predictive value for diagnosis of vasa previa.

CONCLUSION

We found the only 2 cases of abnormal adherent placental fragments and the 3 cases of vasa previa present in our population. The study of the lower segment of the uterus should be thorough as abnormal zones may be small-sized. Color Doppler is the reference technique for sighting vasa previa and gray-scale ultrasonography for abnormal adherences of the placenta.