[Spontaneous rupture of the unscarred uterus during labor. Case report]. / Rupture spontanée de l'utérus non cicatriciel pendant le travail. A propos d'un cas et revue de la littérature.

We report a case of spontaneous uterine rupture in a 19 year-old patient Gravida 1 para 2 with no past history of uterine surgery. The diagnosis of uterine rupture, evoked in the early post-partum in the presence of acute abdominal pain, collapsus and haemoperitoneum on ultrasonography, was confirmed by laparotomy. Treatment consisted in hysterorrhaphy. The etiopathogenesis, clinical and therapeutical aspects of spontaneous unscarred uterine ruptures are discussed throughout a literature review.

[Hysterectomies performed for presumed leiomyomas: should the fear of leiomyosarcoma make us apprehend non laparotomic surgical routes?]. / Hystérectomies pour léiomyomes présumés : la crainte du léiomyosarcome doit-elle faire appréhender la voie d'abord chirurgicale autre que laparotomique ?

OBJECTIVES: The presenting symptoms of leiomyosarcoma (LMS) are the same as those of leiomyoma. The diagnosis of LMS is usually achieved retrospectively after pathological analysis of hysterectomy specimens. The aim of surgery in uterine sarcomas being resection without tumor morcellation, LMS poses the problem of the choice of surgical route because it is more likely to occur in relatively young women. This study was undertaken to determine, firstly, the frequency of LMS in a series of hysterectomies performed for presumed leiomyomas, secondly, if there exist any particular context in which LMS should be considered and how this may modify the choice of surgical route, thirdly, to discuss about the therapeutical aspects of those cases of LMS diagnosed incidentally after uterine morcellation. PATIENTS AND METHODS: A retrospective review, from 1996 to 2005, of cases of LMS diagnosed retrospectively in patients having benefited from hysterectomy for presumed leiomyomas, at the department of Obstetrics-Gynaecology, Belfort Hospital. RESULTS: From 1996 to 2005, 1297 hysterectomies have been performed for presumed leiomyomas in our department. Patients' mean age was 48 years (34 to 77 years). Menometrorraghia was the most common symptom having motivated surgery (57%), followed by pelvic pain (31%) and the notion of a rapidly growing uterine mass (12%). The distribution of surgical route was as follows: laparotomic route, n=393 (30%); vaginal route, n=855 (66%) and laparoscopic assisted vaginal route, n=49 (4%). Pathological analysis had revealed LMS in three patients (0.23%). DISCUSSION AND CONCLUSION: LMS is usually diagnosed incidentally on hysterectomy specimen analysis. Indeed, the surgeon may find himself in a therapeutic dilemma in cases where vaginal extraction has required tumour morcellation with an increased risk of peritoneal and/or vaginal dissemination. However, given the extremely low incidence of LMS in series of hysterectomies performed for presumed leiomyomas and the lack of specific preoperative context to clearly evoke this diagnosis, the fear of leiomyosarcoma should not make us apprehend nonlaparotomic surgical routes.

[Uterine carcinosarcomas associated with tamoxifen therapy. Report of two cases and review of the literature]. / Carcinosarcomes utérins associés au traitement par le tamoxifène. A propos de deux cas et revue de la littérature.

Carcinosarcomas are rare uterine cancers and carry poor prognosis. Although these tumours usually arise de novo, some cases developed under tamoxifen therapy have been reported. We report two more cases of uterine carcinosarcoma occurring in two postmenopausal patients benefiting from tamoxifen therapy as adjuvant treatment of breast cancer. A review of the literature is undertaken.

[Pure rhabdomyosarcoma of the uterine corpus: an exceptional tumor in postmenopausal women. Report on two cases]. / Rhabdomyosarcome pur du corps utérin: une tumeur exceptionnelle chez la femme ménopausée. A propos de deux cas.

Rhabdomyosarcoma (RMS) of the uterine corpus is rare in adult females. This tumor can be encountered in two distinct histopathological contexts: usually as a component of a malignant mixed mullerian tumor and exceptionally as a pure heterologous sarcoma. We report two cases of pure RMS of the uterine corpus occurring in postmenopausal women. The two patients suffered from vaginal bleeding and preoperative diagnosis was achieved in both cases. Both patients benefited from exploratory laparotomy, total hysterectomy and bilateral salpingo-oophorectomy. Both of them were free from the disease 15 months and 1 year respectively, after initial surgery. These two observations are worthy of publication because pure RMS of the uterine corpus is exceptional in postmenopausal women.

[Uterine sarcomas: clinical and histopathological aspects. Report on 15 cases]. / Sarcomes utérins: aspects cliniques et histopathologiques. A propos de 15 cas.

OBJECTIVE: Sarcoma of the uterus are rare uterine cancers with poor prognosis. They are characterised by pathological diversity and their symptomatology is not specific. The aim of this study was to review our experience with uterine sarcomas, to analyze their clinical and histopathological features, to discuss about diagnostic and therapeutic difficulties associated with these tumours and to compare our findings with previously published data. PATIENTS AND METHODS: A retrospective review, from 1996 to 2005, of cases of uterine sarcomas diagnosed and treated at the department of obstetrics-gynaecology, Belfort Hospital. Clinical and pathological features, types of treatment, tumoral stage according to the FIGO histological classification and patients' outcome were recorded. RESULTS: From 1996 to 2005, 15 cases of uterine sarcomas have been diagnosed in our department. Our study included six histological types: carcinosarcoma (n=5), leiomyosarcoma (n=3), rhabdomyosarcoma (n=2), adenosarcoma (n=2), stromal sarcoma (n=2), and undifferentiated sarcoma (n=1). Patients' mean age at the time of diagnosis was 67.6 years (range: 48-91 years). Vaginal bleeding was the most common presenting symptom, being present in 10 patients (67%). The mean time from onset of symptomatology and pathological diagnosis of sarcoma was 17.1 weeks (range: one to 60 weeks). In 10 patients (67%), definitive diagnosis of sarcoma was achieved only after surgical specimen analysis and in only three of them (30%), physical examination combined with pelvic ultrasonography had suspected malignancy. Dilation and curettage was performed in nine patients and failed to rule out neoplasia in three cases (33.5%). Fourteen patients (93%) underwent surgery: total hysterectomy with bilateral salpingo-oophorectomy in all of them and pelvic lymphadenectomy in four of them. Eight patients were in FIGO stage I, one patient in stage II, three patients in stage III and two patients in stage IV. Six patients benefited from adjuvant treatment: external beam radiotherapy and brachytherapy in three cases, brachytherapy in one case and chemotherapy in two cases. At the time of analysis, four patients were lost to follow-up, four patients were dead and with an average follow-up of 25 months, seven patients had a favourable outcome. DISCUSSION AND CONCLUSION: Uterine sarcomas are rare cancers with poor prognosis. Their symptomatology is non-specific and they are characterized by histopathological diversity. Early diagnosis is essential because patients' survival is correlated to tumour stage. However, preoperative diagnosis is often difficult and definitive diagnosis is frequently achieved after pathological analysis of hysterectomies specimens.

[The diagnostic problem of uterine sarcomas: report on a case of carcinosarcoma mimicking a gastro-intestinal disease]. / Difficultés diagnostiques des sarcomes utérins: à propos d'un cas de carcinosarcome simulant une pathologie digestive.

Uterine sarcomas are rare tumours with poor prognosis. The most common presenting symptoms are vaginal bleeding or pelvic pain. We present a case of uterine carcinosarcoma diagnosed retrospectively after surgical specimen analysis in a 69-year-old patient presenting gastro-intestinal complaints. At the time of diagnosis, the patient was in FIGO, stage IV.

Clinical outcome of patients with advanced coronary artery disease after viability studies with positron emission tomography.

OBJECTIVE: The aim of this study was to determine the prognostic significance of perfusion-metabolism imaging in patients undergoing positron emission tomography for myocardial viability assessment. BACKGROUND: Positron emission tomography using nitrogen-13 ammonia and 18fluorodeoxyglucose to assess myocardial blood flow and metabolism has been shown to predict improvement in wall motion after coronary artery revascularization. The prognostic implications of metabolic imaging in patients with advanced coronary artery disease have not been investigated. METHODS: Eighty-two patients with advanced coronary artery disease and impaired left ventricular function underwent positron emission tomographic imaging between August 1988 and March 1990 to assess myocardial viability before coronary artery revascularization. RESULTS: Forty patients underwent successful revascularization. Patients who exhibited evidence of metabolically compromised myocardium by positron emission tomography (decreased blood flow with preserved metabolism) who did not undergo subsequent revascularization were more likely to experience a myocardial infarction, death, cardiac arrest or late revascularization due to development of new symptoms than were the other patient groups (p less than 0.01). Concordantly decreased flow and metabolism in segments of previous infarction did not affect outcome in patients with or without subsequent revascularization. Those with a compromised myocardium who did undergo revascularization were more likely to experience an improvement in functional class than were patients with preoperative positron emission tomographic findings of concordant decrease in flow and metabolism. CONCLUSIONS: Positron emission tomographic myocardial viability imaging appears to identify patients at increased risk of having an adverse cardiac event or death. Patients with impaired left ventricular function and positron emission tomographic evidence for jeopardized myocardium appear to have the most benefit from a revascularization procedure.

Comparison of rubidium-82 positron emission tomography and thallium-201 SPECT imaging for detection of coronary artery disease.

The diagnostic performance of rubidium-82 (Rb-82) positron emission tomography (PET) and thallium-201 (Tl-201) single-photon emission-computed tomography (SPECT) for detecting coronary artery disease was investigated in 81 patients (52 men, 29 women). PET studies using 60 mCi of Rb-82 were performed at baseline and after intravenous infusion of 0.56 mg/kg dipyridamole in conjunction with handgrip stress. Tl-201 SPECT was performed after dipyridamole-handgrip stress and, in a subset of patients, after treadmill exercise. Sensitivity, specificity and overall diagnostic accuracy were assessed using both visually and quantitatively interpreted coronary angiograms. The overall sensitivity, specificity and accuracy of PET for detection of coronary artery disease (greater than 50% diameter stenosis) were 84, 88 and 85%, respectively. In comparison, the performance of SPECT revealed a sensitivity of 84%, specificity of 53% (p less than 0.05 vs PET) and accuracy of 79%. Similar results were obtained using either visual or quantitative angiographic criteria for severity of coronary artery disease. In 43 patients without prior myocardial infarction, the sensitivity for detection of disease was 71 and 73%, respectively, similar for both PET and SPECT. There was no significant difference in diagnostic performance between imaging modalities when 2 different modes of stress (exercise treadmill vs intravenous dipyridamole plus handgrip) were used with SPECT imaging. Thus, Rb-82 PET provides improved specificity compared with Tl-201 SPECT for identifying coronary artery disease, most likely due to the higher photon energy of Rb-82 and attenuation correction provided by PET. However, post-test referral cannot be entirely excluded as a potential explanation for the lower specificity of Tl-201 SPECT.

[Preliminary study of fetal head engagement diagnosis by transperineal ultrasound before operative vaginal delivery]. / Étude préliminaire du diagnostic d'engagement par une échographie transpérinéale avant une extraction instrumentale.

OBJECTIVES: Estimate the predictive value of perineum-fetal head distance obtained by transperineal ultrasound on results of an operative vaginal delivery. PATIENTS AND METHOD: A prospective preliminary monocentric study has been conducted on 28 patients between the 18th of April and the 31st of July 2011. Three successive perineum-fetal head distance have been measured before realization of an operative vaginal delivery. RESULTS: With caesarian section deliveries, average distances were higher than with successful operative vaginal deliveries but this result was not significant (49.3mm vs 39.7 mm; P=NS). Ultrasound measured distance was significantly correlated to the time of application of the instrument (r=0.45, P=0.0165). Beyond 50mm, the relative risk of caesarian was 10.5 (IC [0.76-145.36]). The measures were corresponding, with an average time of realization of 29.9 seconds. The transvaginal examination compared to ultrasound showed a discordance of 3.6% for the diagnosis of engagement and of 25% for the descent of fetal head. CONCLUSION: A larger study is necessary to confirm this result and to recommend the realization of a transperineal ultrasound before an operative vaginal delivery in cases of doubt about engagement after the transvaginal examination.

[Operative delivery data in France for 2007: results of a national survey within teaching hospitals]. / Données 2007 de l'extraction instrumentale en France: résultats d'une enquête nationale auprès de l'ensemble des centres hospitalo-universitaires.

AIM: Clinical Practice Guidelines of the French College of Gynecologists and Obstetricians concerning operative deliveries were published in December 2008. That is why a national survey was performed for the year 2007 so as to obtain an inventory of obstetrical practices regarding the geographical distribution of the type of instrument used for operative deliveries following the level of each teaching hospital concerned. MATERIAL AND METHODS: We included in our study 49 teaching hospitals from metropolitan France and the overseas departments and territories. For the year 2007, we noted the number of operative deliveries, the type of instrument used, as well as the level of the maternity concerned with its total number of patients, births, cesarean sections, vaginal deliveries, and episiotomies. RESULTS: We obtained data from all 49 centres. The mean number of deliveries per year was 2203 for level I teaching hospitals, 2060 for level II and 2720 for level III, respectively. The rate of operative delivery was quite different from one centre to the other, ranging from 5.3 to 34.1% of all births. Similarly, for the type of instrument used, there existed clear geographical disparities although the notion of "School's instrument" was not as preeminent as before since most centres used at least two instruments. Moreover, the rate of cesarean varied from 9 to 29.5% (all levels concerned) with a national mean rate of 20.7% for teaching hospitals. Finally, mean rate of episiotomies ranged from 3.6 to 60%. DISCUSSION: This study showed that important differences existed between teaching hospitals in the use of instruments and that obstetrical practices are far from being uniform. However, in 2007, the routine use of more than one instrument in each centre was most usual, as opposed to the situation some decades ago. The use of obstetrical vacuum extractors has been largely disseminated. Each of the three types of instruments has specific indications and mastering at least two instruments seems more secure in the management of the numerous obstetrical situations. It is up to teaching hospitals to make sure that the use of at least two instruments is taught for operative deliveries. The recent publication of Clinical Practice Guidelines would probably help in standardizing operative deliveries in years to come.

[Comparing fetal and maternal morbidities between operative deliveries by Teissier's spatulas and Minicup vacuum extractor]. / Morbidité materno-foetale liée à l'extraction instrumentale par spatules de Teissier. Etude comparative à la ventouse obstétricale de type Minicup.

OBJECTIVE: To compare fetal and maternal morbidities between operative deliveries by long Teissier's spatulas and Minicup vacuum extractor. MATERIAL AND METHODS: A retrospective study was conducted from January 2003 to July 2008 at the maternity ward, Besançon teaching hospital. Operative deliveries in term cephalic singleton pregnancies performed by Teissier's spatulas (case group) were compared to previous deliveries by vacuum extractor Minicup (control group). RESULTS: During the study period, 69 operative deliveries by Teissier's spatulas have been performed. No significant difference was found between the two groups in terms of maternal characteristics. Two third-degree perineal tears occurred following delivery by Teissier's spatulas with no third-degree tear in the vacuum extractor group (p = ns). The episiotomy rate in the Teissier's spatulas group was 15,9% compared to 11.6% in the vacuum extractor group (p = ns). Duration of operative delivery was significantly shorter in the Teissier's spatulas group (3.4 min vs 4.95 min; p = 0.007). Fetal morbidity was identical in the two groups. CONCLUSION: This study found no significant difference in terms of fetal and maternal morbidities between operative deliveries by Teissier's spatulas and vacuum extractor. Moreover, as opposed to Thierry's spatulas, the long Tessier spatulas can be adequately used in accordance with patient's wish and practice guidelines recommending a policy of restrictive episiotomy. However, a larger study is needed to confirm these preliminary results.

Comparison of thallium-201 SPECT redistribution patterns and rubidium-82 PET rest-stress myocardial blood flow imaging.

To compare regional thallium-201 SPECT redistribution patterns with rubidium-82 PET, we studied 81 patients with both imaging modalities. Sixty patients had significant coronary artery disease. All patients underwent PET imaging after dipyridamole infusion, while SPECT imaging was performed after exercise stress (38 patients) and dipyridamole (43 patients). Sixty-eight percent of patients with prior infarct had fixed defects on SPECT, compared to 39% with PET. Sixty-one percent of patients with prior infarct had PET perfusion defects which exhibited 'reflow' or normal rubidium-82 tracer uptake (p < 0.05 vs. SPECT). Similar results were seen in patients without prior infarct (26% fixed defects on SPECT vs. 12% for PET, p < 0.05). Regional analysis showed that 57% of fixed SPECT defects corresponded to PET defects with reflow or normal rubidium-82 uptake, while 78% of 'fixed' PET defects corresponded to fixed SPECT defects. PET reflow and normal rubidium-82 uptake in sites of fixed thallium-201 SPECT perfusion defects suggest that imaging modalities employing separate tracer injections at rest and after stress, such as rubidium-82 PET, may be more specific in the assessment of myocardial viability, especially in patients with prior myocardial infarction.

Relation of regional function, perfusion, and metabolism in patients with advanced coronary artery disease undergoing surgical revascularization.

BACKGROUND: Imaging of myocardial glucose metabolism using [18F]fluorodeoxyglucose (FDG) with positron emission tomography (PET) has been proposed for identification of tissue viability in patients with advanced coronary artery disease. This study was designed to evaluate the predictive value of flow and metabolic imaging for functional recovery after revascularization in myocardial segments of varying degrees of dysfunction. METHODS AND RESULTS: Thirty-seven patients (mean age, 59 +/- 11 years) with coronary artery disease and impaired left ventricular function (ejection fraction, 34 +/- 10%) were studied with PET using FDG and [13N]ammonia before surgical coronary revascularization (3 +/- 1 grafts per patient). Tissue was scintigraphically characterized as normal, nonviable (concordant reduction of perfusion and FDG uptake), viable without discordance of perfusion and metabolism (mildly reduced perfusion and metabolism), or ischemically compromised (mismatch of reduced perfusion and maintained FDG uptake). Functional outcome was assessed by serial radionuclide ventriculography before and at 13 +/- 13 weeks (median interval of 8 weeks) after coronary revascularization. Preoperatively impaired regional wall motion improved significantly in ischemically compromised (mismatch) revascularized segments but not in nonviable myocardium or in viable myocardium without discordance of perfusion and metabolism. The negative predictive value of PET for functional recovery was 86%, whereas the positive predictive value in revascularized regions ranged from 48% to 86% depending on severity of baseline wall motion abnormalities. CONCLUSIONS: PET identifies metabolically active tissue, which benefits from revascularization. Although the negative predictive value of PET for recovery was high, functional improvement of viable but ischemically compromised tissue was less frequent than previously reported. The predictive value of PET was highest in left ventricular segments with severe dysfunction and a mismatch or reduced perfusion but preserved metabolism. Integration of PET, angiographic, and functional data is necessary for the optimal selection of patients with advanced coronary artery disease and impaired left ventricular function for revascularization.