[Giant retroperitoneal hematoma in the peripartum of a normal delivery, "expectative attitude"]

We describe a case involving spontaneous retroperitoneal hematoma complicating a normal delivery in a context of a Disseminated Intravascular Coagulation (DIVC) at the end of the pregnancy. Given the defaced symptomatology, an abdomino-pelvic scanner and an examination with a general anaesthesia made it possible to diagnose and to monitor the hematoma in intensive care. The correction of the hemostasis troubles and of the anemia, without another invasive intervention, allowed a return to home at the eighth day. The pathophysiological mechanisms underlying development and practicable treatments of this post-partum hematoma are discussed.

Use of ultrasound to distinguish between fetal hyperthyroidism and hypothyroidism on discovery of a goiter

OBJECTIVES

To determine whether sonography can be used to distinguish hyperthyroidism from hypothyroidism in pregnancies with fetal goiter.

METHODS

This was a retrospective study of 39 cases of fetal goiter. The majority of the mothers had Graves' disease. Fetuses were scanned for the existence of a hypertrophic thyroid gland (goiter) beginning at 22 gestational weeks. Once a goiter was diagnosed, different echographic features were analyzed and the effect of chosen treatment on fetal thyroid development was monitored.

RESULTS

On color Doppler, 68.8% of hypothyroid goiters had a peripheral vascular pattern vs. 20% in cases of fetal hyperthyroidism (P = 0.0574). No hypothyroid goiter presented central vascularization whereas half the hyperthyroid goiters did (P = 0.0013). Fetal tachycardia was a good indicator of hyperthyroidism (57.1% v.s 6.3%; P = 0.0055). Delayed bone maturation was seen in hypothyroid goiters (46.9% vs. 0%; P = 0.0307), while advanced bone maturity was specific to hyperthyroid goiters (85.7% vs. 0%; P < 0.0001). Lastly, an increase in fetal movement was observed in cases of fetal hypothyroidism (43.8% vs. 0%; P = 0.0364).

CONCLUSION

Based on the color Doppler pattern of goiter, fetal heart rate, bone maturation and fetal mobility, we established an ultrasound score to predict fetal thyroid function in cases of fetal goiter.

[Bladder endometriosis and barrenness: diagnostic and treatment strategy]

Deep infiltrating endometriosis is a well-known female disease responsible for chronic pelvic pain, urinary dysfunction, infertility, and altered quality of life. Endometriosis and infertility are complex entities and the optimal choice of management of both of them remains obscure. Mechanism of development of the disease has to be understood to optimize patients care. The link between barrenness and endometriosis is well known, but there is no direct link between bladder lesion and infertility. Bladder endometriosis is a deeply infiltrating endometriosis lesion. Its management is first diagnostic and then remedial. In case of ineffectiveness of medical strategy, surgical treatment is indicated. However, for patient suffering from symptomatic isolated bladder endometriosis, surgical management can be offered in first intention. Isolated bladder injuries due to endometriosis are mostly treated by conservative laparoscopic surgery, after a complete evaluation of endometriosis disease and barrenness by clinical exam and imaging techniques.

[Assessment of the urinary side effects after surgery for deep pelvic endometriosis]

OBJECTIVE

To evaluate the urinary side effects after laparoscopic surgery for deep endometriosis.

PATIENTS AND METHOD

Longitudinal study including 86 patients operated for deep pelvic endometriosis : 58 (68%) with colorectal endometriosis, 21 (24%) with utero-sacral ligament endometriosis and 7 (8%) with recto-vaginal septum endometriosis. Assessment of the urinary side effects was permormed using the Bristole Female Lower Urinary Tract Symptom questionnaire.

RESULTS

On postsurgical follow-up, almost all patients described: hesistancy (p = 0.02), strain to start (p = 0.04), stopping flow (p = 0.01), incomplete emptying (p = 0.008) and reduce stream (p=0.02). Only patients who had resection of both utero-sacral ligaments had significative postsurgical urinary dysfunction with stopping flow (p = 0.02) and incomplete emptying (p = 0.004). Patients with colorectal resection had also significative postsurgical urinary dysfunction with hesitancy (p = 0.02), strain to start (p = 0.03), stopping flow (p = 0.007) and incomplete emptying (p = 0.004). In patients with rectal resection, urinary dysfunctions are raised when rectal resection is associated to resection of both utero-sacral ligaments.

CONCLUSION

Postoperatively, urinary side effects occurred only in patients with segmental colorectal endometriosis resection associated with bilateral utero-sacral ligament resection. Sparing nerve surgery of the pelvic nerves, can reduce these urinary side effects.

Uterine compression sutures for postpartum bleeding with uterine atony

OBJECTIVE

To assess the efficacy of a new uterine compression suturing technique in reducing postpartum haemorrhage secondary to severe uterine atony.

DESIGN

Retrospective study.

SETTING

University hospital between December 2000 and March 2006.

POPULATION

Twenty women with uterine atony and postpartum bleeding that did not react to usual medical management.

METHODS

All these women underwent compression suturing of the uterus, in which the anterior and posterior walls of the uterus were attached so as to compress the uterus.

MAIN OUTCOME MEASURES

Arrest of the bleeding, complications and fertility.

RESULTS

Uterine compression suturing was sufficient to stop the bleeding immediately in 95% of the women. None of the women developed complications related to the procedure. All the women recovered normal menstrual cycles. Since uterine compression suturing, eight women have tried to conceive and six (75%) have had a term delivery.

CONCLUSION

Uterine compression suturing is a simple conservative procedure to stop postpartum haemorrhage in the case of failure of the usual management. This surgical technique can be performed quickly and does not seem to decrease fertility.