[Diagnostic echography of extrauterine pregnancy (EUP). Apropos of 228 EUP confirmed by laparotomy]. / Diagnostic échographique des grossesses extra-utérines (GEU). A propos de 228 GEU confirmées par la laparotomie.

The department of gynaecology and obstetrics of the University Hospital in Libreville carried out in the five years between 1984 and 1988 8,688 ultrasound examinations of which 1,234 (14.2%) were performed because an ectopic pregnancy was considered possible. 213 correct diagnoses (32.8%) were confirmed by laparotomy. 649 surgical procedures for ectopic pregnancy were carried out of which 228 (35%) were helped by the ultrasound examination. The diagnosis was made 138 times (60.5%) accurately and suspected 75 times (32.9%). On the other hand, diagnosis was wrong 15 times (6.6%). These false negatives are worrying: in 4 cases there was an intra-uterine pregnancy as well and in these cases the intra-uterine zygote gave a false sense of security for the diagnosis. The 11 other cases were false diagnoses of adnexal infections which were diagnosed correctly by laparoscopy or culdocentesis. There were also 27 false positive diagnoses mainly in tubo-ovarian infectious and rarely where an ovarian cyst or pedunculated fibroid had twisted or the pregnancy was developing in a blind hemi-uterus. The assessment of the results makes its possible to show that in 88.75% the procedure was valuable in making the diagnosis and in 98.5% was valuable for excluding the diagnosis. Since the sensitivity of the test is 93.4% and its specificity is 97.3% it follows that ultrasound examination should have a very important place in the diagnosis of ectopic pregnancy particularly because in our unit we cannot at present carry out biological tests (beta HCG estimations). The test is rapid, cheap and easy to perform (as long as one avoids the traps).(ABSTRACT TRUNCATED AT 250 WORDS)

[Unusual causes of hemoperitoneum of genital origin]. / Causes inhabituelles des hémopéritoines d'origine génitale.

Extra-uterine pregnancy is the most common emergency in gynaecology and obstetrics in the Hospital Centre of Libreville, and the diagnosis of blood in the peritoneal cavity is synonymous with extra-uterine pregnancy. All the same, when the authors reviewed 429 cases of haemoperitoneum 17 were shown not to be due to ectopic pregnancy. Ruptures of ovarian cysts and uterine perforation from illegal abortions are often found but more rarely, have been rupture in the blind horn of a bicornuate uterus, choriocarcinoma in the tube, tubal bilharzia and thrombopenia due to AIDS. It is essential to carry out histological examination for the differential diagnosis between an ovarian pregnancy and a ruptured cyst as well as choriocarcinoma or bilharzia. If it is not possible to find the site of the bleeding even after looking underneath the mesocolon, a search must be made for coagulation disorders due to a virus such as HIV.

[Extra-uterine pregnancy. Study of 509 cases surgically treated at the University Hospital Center of Libreville]. / La grossesse extra-utérine. Etude de 509 cas traités chirurgicalement au CHU de Libreville.

Extra-uterine pregnancy is the principal emergency procedure undertaken in the University Department of Libreville. We study 509 cases treated surgically between 1984 and 1987, which is a level of 16/1,000 deliveries. The incidence of rupture of the tube has driven us to search for the best possible means to diagnose the condition earlier. Ultrasound gives the best results, dropping the level of ruptured tubes from 83% in 1984 to 50% in 1987. Extra-uterine pregnancy in nulliparous patients (25% of the group) presented a third of recurrent ectopics. The anatomopathological examination of the tissues emphasizes how common acute or chronic infections of the tubes are (25%) and salpingitis isthmica nodosa (31% of cases). If sexually transmitted diseases can be prevented the incidence of ectopic pregnancies will drop. We have tried since 1986 to be conservative in our surgery hoping that a secondary plastic operation will improve the fertility of these young patients. Mortality was high (13.75/1,000 ectopics). The principal factor responsible for this high figure is the absence of blood transfusion banks which delayed resuscitation and exposed the patients to the risk of coagulation defects when surgery is practised on these patients who are still shocked.

[Serology of Chlamydia and ectopic pregnancies. Incidence of Fitz-Hugh-Curtis syndrome]. / Sérologie des Chlamydiae et grossesse extra-utérine. Fréquence du syndrome de Fitz-Hugh-Curtis.

The authors report a prospective study of anti-chlamydia trachomatis serology in extra-uterine pregnancies, which happened to coincide with an increase in the ectopic rate during the year 1989 (p less than 1.10(-6]. The subjects of the study were those patients operated on for ectopic pregnancy between the 1st January and the 31st May 1989. There were two control groups: the first were those that were delivered and the second were those pregnant women who were at risk of ectopic pregnancy because of their age, or the number of pregnancies they had had and their parity, without taking any account of the duration of the pregnancy. The level for sero-positive reading was 1 in 64 using an indirect immunofluorescent method (Spot IF, Bio Merieux). The results showed 81% sero-positive in those who had had ectopic pregnancies as against 63% in the control groups. The two control groups had identical readings. There was a significant difference statistically (p less than 0.01). There was no statistical difference in the incidence of HIV (human immunodeficiency virus) in the two groups (3% and 1%). The clinical study of the other tube showed no particular lesions. On the other hand, adhesions between the liver and the diaphragm (Fitz-Hugh-Curtis Syndrome) were demonstrated in 34% of those with ectopic pregnancy with a statistical significant level of igG above or equal to 1:128 (p 0.02). Perisplenitis was rare (3 cases). Histological finding of salpingitis isthmica nodosa in 49% of cases raises the problem of the pathology of chlamydial lesions being due to a host invader reaction. The increase in the incidence of ectopic pregnancy (1 in 44 deliveries) was accompanied by an increase in the prevalence of chlamydia trachomatis in the group with ectopics and the control groups. If the frequency of ectopics creates a major problem of public hygiene, the prevalence of chlamydia in the female population, apart from its effect on fertility, explains the action of sexually transmitted diseases as a factor in the heterosexual transmission of HIV in Africa.

PIP: A prospective study of antichlamydia trachomatis serology in extrauterine pregnancies which coincided with an increase in the rate of ectopic pregnancy during the year 1989 (p1.10-6) is reported. The subjects were patients operated on for ectopic pregnancy between January 1-May 31, 1989. There were 2 control groups, those who were delivered and those who were at risk for ectopic pregnancy because of their age or their parity. The level for seropositive reading was 1 in 64 using a direct immunofluorescent method (Spot IF, Bio Merieux). Results showed 81% seropositive in those who had ectopic pregnancies as compared with 63% in the control groups. The 2 control groups had identical readings. There was a significant difference statistically (p.01) but there was no statistical difference in the incidence of HIV among the 2 groups (3% and 1%). The clinical study of the other tube showed no specific lesions. However, adhesions between the liver and diaphragm (Fitz-Hugh-Curtis syndrome) were demonstrated in 34% of those with ectopic pregnancy with a statistically significant level of IgG or= 1:128 (p.02). Perisplenitis was rare (3 cases). Histological findings of salpingitis isthmica nodosa in 49% of the cases raises the problem of pathology of chlamydial lesions due to a host invader reaction. The increase in incidence of ectopic pregnancy (1 in 44 deliveries) was accompanied by an increase in prevalence of chlamydia trachomatis among the group of ectopics and the controls. If the frequency of ectopics creates a major problem with public hygiene, the prevalence of chlamydia among the female population, apart from its effect on fertility, explains the action of sexually transmitted diseases as a factor in the heterosexual transmission of HIV in Africa. (author's modified)

[Maternal mortality at the Hospital Center of Libreville (1984-1987)]. / La mortalité maternelle au Centre Hospitalier de Libreville (1984-1987).

Maternal mortality at the University Hospital of Libreville was 152.5 for every 100,000 live births. There were 48 maternal deaths out of 31,799 deliveries carried out between 1984 and 1987. The principal causes were: haemorrhage in 45.8%, infections in 20.8%, intercurrent diseases in 20.8%, vasculo-renal syndromes in 10.4% and thromboses in 2%. The main differences between this country and developed countries were the large number of haemorrhages and the rarity of thrombosis. Poor prognostic factors were SS sickle-cell disease in 10.4% of the cases who died and in deaths due to anaemias, of which 25% were due to haemorrhage connected with the afterbirth. Complications occurring in the 1st trimester of pregnancy caused nearly a third of all maternal deaths. Complications of abortion occurred in 16.6% and of extra-uterine pregnancies in 14.6%. If the maternal mortality rate is to be reduced it is important to have a proper blood bank. The risks of caesarean section are ten times greater than of vaginal delivery, although it is a good way out for difficult situations. The indications for the operation have to be carefully considered. Comparing the statistics reported from Cotonou, the University Hospital in Libreville has a lower incidence of maternal mortality but it is too high and requires real progress to be made.

[ Ambulatory laparoscopic gynecological surgery in Africa: feasibility]. / Coeliochirurgie gynécologique ambulatoire en Afrique: faisabilité

We report a prospective survey conduced between March 1998 and February 1999 among 100 women classes ASA I and II who underwent laparoscopic surgery for gynecological disorders under general anesthesia. Among these laparoscopies 85 (85%) were performed for operative purposes and 12 (10.7%) for diagnostic purposes. Minimal monitoring was used (no capnography) so prophylacti fluid loading with 0.9% saline was used before insufflation to reduce hemodynamic changes induced by abdominal overpressure and to avoid potential massive air embolism. Insufflation pressure was limited to 14 mmHg. The main agent used for all procedures was propofol. Mean duration of the procedures was 55 minutes. There were no cases of complications or delayed recovery. Complete exsufflation by abdominal compression at the end of the procedures induced minimal abdominal pain and scapulalgia. Ketoprofen as effective postoperatively. Twenty-five patients (25%) complained of nausea and vomiting in the recovery room and were treated effectively with metoclopramide. All patients were discharged and accompanied to their home six hours later after a well-tolerated light meal. The postoperative course was uneventful.

[Büschke-Loewenstein tumor during pregnancy. Apropos of 2 cases]. / Tumeur de Büschke-Loewenstein au cours de la grossesse. A propos de deux observations.

The authors report two cases of Büschke-Loewenstein tumors during pregnancy. The considerable development of this giant condyloma requires a caesarean section, to prevent a possible neonatal contamination of the newborn. The course is complicated with recurrences and the treatments are disappointing during the pregnancy. After birth, regression may be spontaneous (case no. 2). Most of the time, after a surgical biopsy is performed, for an accurate pathological examination, electrocoagulation, cryotherapy or CO2 laser result in the cure of the patient. Monitoring must be long-lasting because of the risk of spinocellular degeneration and node metastases. The papillomavirus in cause is the type HPV 6 or 16 and a few cases are described with types 16, 18, 32. The high frequency of accumulated condylomas and the possibility of rapid spread make this disease very current: the human immunodeficiency virus is one of the cofactors of transformations into verrucous carcinoma.

[Early prenatal diagnosis of diprosopic syncephalic joined twins]. / Diagnostic anténatal précoce de jumeaux conjoints syncéphaliques diprosopes.

The authors summarize the case of diprosopic syncephalic joined twins diagnosed at 22 weeks of pregnancy by ultrasonography performed because of hydramnios. The rate of separation anomalies of monozygotic twins is assessed by a review of the literature: from 1 to twenty to fifty thousands for joined twins to 1 per cent fifty thousand to fifteen millions for diprosopus. The etiology is the result of a late division of the egg between D12 and D16. Often an encephalic diprosopic joined twins cause elevated levels of maternal serum alpha protein. Early ultrasonography permits to consider a vaginal therapeutic abortion.

[Perinatal and maternal risks in multiple pregnancies]. / Risques périnatal et maternel des grossesses multiples.

The perinatal risk in multiple pregnancies is part of the traditional gabonese culture. The authors study the perinatal mortality of twins which is four times higher than in single pregnancies. Prematurity represents the main etiology: 30 p. cent of twin deliveries occur before 32 weeks. The fetal prognosis improves from 2,000 g but deteriorates beyond 2,500 g, emphasizing the role of intra-uterine hypoxia aggravated by the obstetrical trauma. The increased mortality of the second twin, which was demonstrated by all, and the birth delay, become harmful beyond 30 minutes. The maternal pathology consists in frequent hypertensive complications and severe gravidic anemias. The maternal mortality is three times higher than in single deliveries and is related to delivery haemorrhages. The authors propose to improve the prognosis with early ultrasonographic diagnosis and pregnancy monitoring, along with social measures covering a number of prenatal tests, with hospital delivery supervised by obstetrical and neonatal teams. On the contrary, they do not believe that caesarean section is a determining factor in the improvement of fetal prognosis.

[Eclampsia at the Hospital Center of Libreville. 53 cases among 41,285 deliveries from 1985 to 1989]. / L'éclampsie au Centre Hospitalier de Libreville. 53 cas pour 41,285 accouchements de 1985 à 1989.

Eclampsia is a serious complication at the end of pregnancy. This retrospective study over a 5-year period at the Libreville CHU hospital shows that the incidence of 0.12 p. cent is comparable to the incidence fond in other countries at a similar level of development. Promoting causes include youth of the patients, twin births, the "cold" season, the lack of follow-up after prenatal consultations. The consequences are increased maternal and perinatal death. Cesarean section remains the best way of dealing with an attack of eclampsia and improves both maternal and fetal prognosis. It is possible to eliminate, or at least reduce, the number of cases by developing conscientious and regular prenatal consultations.

[Recurrent extra-uterine pregnancies. 63 cases treated at the Hospital Center of Libreville from 1985 to 1989]. / Les grossesses extra-utérines récidivantes. A propos de 63 cas survenus au Centre Hospitalier de Libreville de 1985 à 1989.

Ectopic implantation of the fertilised ovum, whether for the first time or as a recurrence, is not uncommon in this department. In a study in the Libreville Hospital group from 1985 to 1989, the authors found 828 cases of ectopic pregnancy (EP) including 63 recurrences, i.e. 7.61 per cent. These recurrences most often involved young women (26 per cent of cases) and nullipara (30%). The chief common etiology for the first occurrence remained tubal infection (57.28 per cent of cases). Treatment consisted most often of radical macrosurgery because of the advanced state of tubal disease, thus leading to the permanent sterilisation of 48 patients, i.e. 71.2 per cent of recurrences. Nineteen patients had a history of previous conservative surgery, including 8 homolateral recurrences (43 per cent). Reducing the incidence of such pathology essentially involves the prevention of gynecological infections, and in particular sexually transmitted diseases, as well as the possibility of early diagnosis of EP. Despite the fact that it seriously compromises the subsequent fertility of these young patients, total salpingectomy remains the treatment of choice for avoiding recurrences.

[The sequela of peri-hepatitis due to Chlamydia trachomatis (Fitz-Hugh-Curtis syndrome) seen during an ectopic pregnancy]. / Séquelles de péri-hépatites à Chlamydia trachomatis (syndrome de Fitz-Hugh-Curtis) observées lors d'une grossesse extra-utérine.

Between January 1st and May 31 1989, there were 31 cases of perihepatic adhesions (Fitz-Hugh-Curtis syndrome) about 90 ectopic pregnancies (rate: 34 p. cent). The Chlamydia's serology is positive at 1/64 level in 97 p. cent of cases and at 1/256 level in 72 p. cent. Only three cases are not allied with pelvic disease. Peri-splenitis accompanies severe hepatitis (3 cases) and no perinephritis was observed in this study. The authors emphasize the wish to explore perihepatic space in all pelvic surgery. In the department of Gynecology and Obstetrics at the University Hospital of Libreville, increased the rate of ectopic pregnancy (1 for 44 deliveries), this coincides with the increased prevalence to Chlamydia trachomatis infection (81 p. cent ectopic pregnancies and 63 p. cent deliveries). This situation creates a new and greater problem of health in sub-Saharan Africa.