[Hysteroscopic treatment of uterine fibromas]. / Le traitement hystéroscopique des fibromes utérins.

OBJECTIVES: To study retrospectively the long-term outcome after hysteroscopic treatment for intrauterine fibromas. METHODS: From October 1987 to January 1993, endouterine glycolol resection was performed in 239 patients with intrauterine fibromas. The operation had to be repeated in 39 patients due to incomplete resection or recurrent symptomatology. Patients presented with menometrorrhage, post-menopausal metrorrhage or infertility. RESULTS: Intra-operative complications were rare, mainly uterine perforations (7 cases) or metabolic syndromes due to reabsorption of glycine (5 cases). Mean follow-up was 2.5 years. The couple was sterile in 16 cases and 4 pregnancies were obtained (25%). Postmenopausal metrorrhage was present in 27 patients and the symptomatology disappeared in 24 (89%). In all, 196 women consulted for bleeding, good results were achieved in 81.1%. CONCLUSION: Endouterine resection is a sure, effective and long-lasting treatment for intrauterine fibromas.

[Extrauterine pregnancy]. / La grossesse extra-utérine.

The pattern of ectopic pregnancy, defined by an ectopic site of the fertilised ovum, has changed in recent years in developed countries. It is only rarely responsible for maternal death in industrialised countries though the possibility remains (1/4000). However, it plays an increasing role in the pathophysiology of female infertility. In terms of epidemiology, the increase in its rate is linked to that of salpingitis and sexually transmitted diseases, and the sequelae of tubal surgery. Regarding symptomatology and prognosis, dramatic, life-threatening forms are in clear decline, because of the possibility of the early detection of pregnancy by sensitive and rapid assay of beta sub-unit human chorionic gonadotrophin (beta-hCG) and transvaginal ultrasonography. This enables conservative management regarding the tube, but is associated with the risk of recurrence. In terms of treatment, laparoscopic surgery is gradually taking the place of laparotomy. Such laparoscopic surgery must now be considered "theoretically" to be the reference treatment. Medical treatment methods using methotrexate are currently being evaluated and it is even possible in certain cases to suggest that no treatment is required.

[Serious forms of arterial pregnancy-related hypertension]. / Formes graves de l'hypertension artérielle gravidique.

Pregnancy related hypertension is the primary cause of perinatal mortality and morbidity. Its incidence is of the order of 10%. Serious forms, which account for 10% of all cases of pre-eclamptic toxemia, remain a potential cause of maternal mortality and morbidity. Retroplacental hematoma, neurological problems dominated by eclampsia, coagulation disorders, Hellp syndrome, and hepatic, pulmonary, cardiac and renal problems are the essential complications of this pathology. They are described separately here, but are often associated. These potential complications require the careful evaluation of the severity of materno-fetal status. The management of these patients requires cooperation between the anesthetist/intensive care specialist, obstetrician and pediatrician. Such teamwork results in appropriate management for each individual patient. The various types of treatment are reviewed. Maternal and fetal mortality and morbidity could nevertheless be reduced by the early and careful management of high-risk patients, in particular by the prescription of low doses of aspirin and by careful clinical, ultrasound and velocimetric monitoring.

[Delivery after 2 previous cesarean sections. A series of 41 uterine trials]. / Accouchement des utérus bicicatriciels. Une série de 41 épreuves utérines.

It has been possible to consider how delivery should be carried out in view of the progress that has been made handling scarred uteruses. Over 21 months 41 tests of uterine function have been authorized in our department out of 67 cases where there were two scars in the uterus (67%). 26 patients delivered vaginally (63.4%) and 5 had Caesarean sections because of failure of the test of the scar. When the relationship between the fetus and the pelvis was satisfactory, the fact that the cervix was not ripe and the presenting part was not engaged, did not prevent carrying out a trial of scar in 78% of cases. It is important to assess conditions continuously during labour and this assessment should include fetal heart monitoring, internal tokometry, fetal pH assessment and ultrasound of the scar at the onset of labour. Oxytocics had to be used in 96.2% of cases because there was at the outset marked dynamic dystocia. Epidural anaesthesia was used in 90.2% of cases. A full obstetric team must be present throughout the whole labour so that the conduct of the labour can be observed, and if necessary corrected quickly if anything in its progress is becoming abnormal. It has become reasonable to carry out tests of uterine scars even after two scars have been made in the uterus because of the absence of any maternal or fetal complications in this series or in the literature.

[Triplet pregnancies in France. Results of a retrospective, multicenter study of two years (1987-1988). Proposals for optimal management]. / Les grossesses triples en France. Résultats d'une enquête rétrospective multicentrique sur deux ans (1987-1988). Propositions pour une prise en charge optimale.

The explosion of procedures for medically assisted parenthood (MAP) has resulted in a previously little known type of pregnancy: triple pregnancies. In order to assess the current obstetrical and pediatric situation, the authors have carried out a major retrospective, multicenter survey in France concerning the triple pregnancies from 1987 to 1988: 156 case histories have been collected. The finds are compared with those reported in the French and international literature, showing that in France, three-quarters of such pregnancies result from MAP, mainly due to ovulation-inducing agents. Hospitalization is prolonged (averaging 27 days), early (24 WA) and imposed by complications (in 8 out of 10 cases), prophylactic hospitalization being rarely prescribed. The main complications encountered are late miscarriages (1.9%), in-utero death (6.41%), dysgravidia (16.6%), hydramnios (5.12%) and serious cardio-pulmonary complications related to the use of beta-mimetics. A Cesarian is performed in only 87 percent of cases. The mean birth weight was 1,776 g. Neonatal mortality is on the decline, but still equivalent to 80.3 per thousand. Hypotrophy is common (27%). Birth is nearly always premature (99.3%), but very early prematurity (28-32 WA) was reduced. The approach suggested for optimum management is based on the personal experience of the authors, the findings of their survey and of the international literature. It is based on the prevention of prematurity and a fundamentally multidisciplinary approach.

[Meta-analysis on randomized trials comparing the results of low-molecular weight heparins to those of fractioned heparins in the prevention of deep venous thrombosis]. / Méta analyse sur les essais randomisés comparant les résultats des héparines de bas poids moléculaires à ceux des héparines fractionnées dans la prévention des thromboses veineuses profondes.

The main reason for using low molecular weight heparin (LMWH) is its capacity to keep the antithrombotic effect of standard non-fractioned heparin (NFH) while reducing its hemorrhagic power. Various studies comparing LMWH to NFH gave contradictory results, so we carried out a meta-analysis of randomized trials comparing these two treatments in prevention of deep-vein thrombosis (DVT) (and in prevention of deep-vein thrombosis or pulmonary embolism). From a selection of ten trials we could not show any significant difference in the DVT rates, as well as for the whole of surgical indications as for the subgroups of abdominal and orthopedic surgery. The weighted global difference between the DVT rates is so low that, in spite of the use of meta-analysis, the power is clearly insufficient. The hemorrhagic risk is not statistically reduced as well for the whole of surgical indications as for the subgroups.

[Intraperitoneal insemination]. / Inséminations intrapéritonéales.

Intra-perineal insemination is a technique used in assisted reproduction. The principle is to stimulate the ovaries, to obtain the partner's sperm and to prepare it by similar techniques to those used in in-vitro fertilization so that the sperm can be placed near the ovaries in the Pouch of Douglas by a direct puncture of the posterior vaginal fornix without using anaesthesia. The woman's pelvis has to be absolutely normal. This technique is useful in cases of unexplained sterility, cervical sterility and inadequate sperm function.