Cervical cancer screening in France.

In France, as in other European countries the incidence and mortality rates of carcinoma of the cervix uteri indicate a clear decrease in invasive cancers. Opportunistic screening has spread and, presently, approximately 60% of the female population undergo a regular cytological test. This rate increases up to 80% in the younger age groups and decreases to 20% after the age of 60 years. In 1990, intervention procedures were defined at a consensus conference; the major recommendations were to screen all women exclusively by cervical smears, for ages 25-65 years over a 3-year period. Guidelines on the quality control of cervical smear taking and reading were published by the national agency of evaluation of health intervention (ANAES). Since 1990, four population-based, organised pilot programmes, have been implemented in Isère. Doubs, Bas-Rhin and Martinique. These programmes evaluate the participation rate (from approximately 20-80% depending upon the age and the geographical area), the rate of abnormal tests (0.2-3%), according to the laboratories, the cancer detection rate (0.04%-0.15%) and some other quality indicators. Recently (November 1998) a law was passed stipulating that the screening test will be free of charge when performed in agreement with the national recommendations. A specific organisation for cytological quality control will be implemented. An effort to better identify and to include the screening process the women in the population who are not yet participating has to be made.

Acute versus chronic conditions for studies of fetal nutrient requirements: applicability to the human.

In order to validate results obtained in 'acute' versus 'chronic' experimental conditions, two fetal sheep nutrients, lactate and glucose, have been determined in 'acute' conditions and compared with the 'chronic' data in the literature. Maternal and fetal blood glucose in 'acute' conditions was in the range of published 'chronic' data. Fetal blood lactate was similar in 'acute' and during 'chronic' conditions. Maternal and fetal veno-arterial (VA) differences were in the same direction in 'acute' and in 'chronic' conditions for both lactate and glucose and of the same magnitude for lactate. For glucose, a good relationship was observed between umbilical VA differences and maternal arterial concentrations for all 'acute' and 'chronic' values. Thus no fundamental differences appear in the results obtained in 'acute' or during 'chronic' conditions. The applicability of such animal results to the human and the use of acute conditions to study fetal nutrition in the human are discussed.

Rapid bedside estimation of plasma and whole blood lactic acid.

A rapid method for the bedside measurement of plasma, intracellular and whole blood lactates is described. The paper described a new method of measuring the L-lactate content of blood using an apparatus ("Lactate Analyzer 640", manufactured by Roche Bio-electronics, Basel) previously designed for this purpose but using aqueous solutions. A novel feature of this new method is the facility to use small blood samples (100-150 mul). We therefore believe that it will become an invaluable tool in obstetrics and neonatology.

Does fetal acidosis develop with maternal glucose infusion during normal labor?

The actual effects of glucose infusion on fetal acid-base status were studied during 125 normal deliveries in which plasma glucose and acid-base parameters were determined after maternal infusion of either 10% glucose or Ringer's solution. After 80 minutes, mean (+/- SD) plasma glucose levels were significantly higher in the glucose group (N = 59) than in the Ringer's group (N = 66), both for the mother (183.6 +/- 46.8 versus 95.3 +/- 18.0 mg/dL) and the fetus (108.4 +/- 41.4 versus 64.8 +/- 16.2 mg/dL). Fetal plasma lactate concentrations did not differ between the glucose and the Ringer's groups, but were significantly lower in the fetuses delivered by elective cesarean section in both groups. With glucose administration, fetal pCO2 was higher and pH values were lower than in the Ringer's group. However, the magnitude of acid-base status changes, indicated by both pH and pCO2 shifts (ie, the difference between umbilical artery and scalp values), failed to differ between the two groups. In fetuses with progressing hypoxia, no differences in any of the acid-base parameters were observed between glucose and Ringer's administration. These data indicate that at a glucose infusion rate of 30 g/hour, fetal acidosis, when it occurs, results from hypoxia rather than from maternal glucose administration.

The validity of fetal heart rate monitoring during the second stage of labor.

Fetal blood pH, pCO2, and lactic acid were measured before and after the final period of the second stage of labor in an attempt to better understand th validity fetal heart rate (FHR) monitoring at this time. Following a classification derived from Melchior, six FHR patterns were recognized: 0, 1, 2a, 2b, 3, and 4. In the second stage of labor, until bearing-down efforts began, the fetal acid-base status did not change regardless of the type of tracing. At the time of delivery, as compared with values measured before the beginning of the final stage, the highest shift of lactic acid, coupled with the lowest pH shift, was associated with the type 3 pattern. The most rapid increases of lactic acid and pCO2 and decreases in pH were associated with type 2b patterns. Both type 3 and 2b patterns were ominous, but low Apgar scores were more frequent in type 3 because the duration of the final stage of labor was longer. Working from the mean slopes of the shifts of biologic parameters as a function of time, theoretical limits were derived and discussed for safe duration of the final stage of labor.

Transvaginal sonographically controlled follicle puncture for oocyte retrieval.

Transvaginal sonographically guided follicle aspiration under local anesthesia was performed on more than 100 patients and compared favorably with the other techniques that have been proposed to retrieve oocytes for in vitro fertilization. Sonography employs a sector scanner placed on the abdomen, and the needle is introduced through the posterior fornix of the vagina into the cul-de-sac and the ovary. In case of a high ovary, a transvaginal-transvesical variation may be used. The method is not painful and is easy to learn and perform. The sole adverse incidents have involved inadvertent venous puncture with no sequelae. The number and quality of recovered oocytes are good, and five normal children conceived after this method of retrieval were recently born. The technique permits substantial simplification of egg recovery for in vitro fertilization, which can now be performed in an outpatient setting without the risk and expense of laparoscopy and general anesthesia or the discomfort of transabdominal-transvesical ultrasound-guided aspiration.

[Fetal heart. Present investigative means]. / Fetal heart. Present investigative means.

Non invasive exploration of the fetal heart has been greatly facilitated by utilisation of high resolution echography using pulsed Doppler combined with B-scan. Investigation of the fetal heart in human medicine opens three important fields of interest. Better knowledge of fetal hemodynamics. Measurement of fetal heart function. Recognition of congenital heart disease. Acquisition of some fundamental knowledge is required for an ultrasonic approach to fetal echocardiography. Embryogenetic data lead to an understanding of the periods of vulnerability for each cardiac segment, whereas an understanding of physiology of the fetal circulation helps to explain the consequences of fetal congenital heart diseases and the methods used to evaluate fetal cardiac function. One section is devoted to the etiology of congenital heart disease. The most important cardiopathies encountered in cases of chromosomal anomalies and genetic disease as well as those due to environmental causes are presented so that the echographist may relate the examination to the clinical picture. In most instances the diagnosis of congenital heart disease is made by routine morphologic scanning of the fetal heart. Indications are given for the best orientation of the scans. All echographists should have precise knowledge of the echographic semeiology of the normal heart. When a cardiopathy or an anomaly of cardiac rhythm are recognized or suspected, the examination should be repeated with help of a cardiopediatrician so as to make an exact diagnosis and take the right decision. Study of fetal heart function is the most recent field for progress and covers in addition to the evaluation of congenital heart disease the development of new parameters allowing recognition of fetal jeopardy. Pulsed Doppler has already allowed the acquisition of interesting facts and certainly is one of the most exciting new inroads for progress in the field of fetal cardiology.

Topical treatment of vaginal candidosis with sertaconazole and econazole sustained-release suppositories.

OBJECTIVE: To compare the efficacy and safety of sertaconazole and econazole sustained-release suppositories in the treatment of vulvovaginal candidosis. STUDY DESIGN: 369 women with symptoms and signs of vulvovaginitis were enrolled in this multicenter, randomized, double-blind study. After clinical examination and vaginal sampling, 183 women were treated with a 300-mg sertaconazole suppository and the other 186 with a 150-mg econazole suppository. They were evaluated 1 week after treatment and those who were clinically uncured received a second suppository and were re-assessed 1 week later. All women were evaluated 1 month after the last administration. At each follow-up visit, clinical efficacy was assessed and a vaginal sampling was performed for microscopic examination and culture. RESULTS: Of the 369 women included, only the 310 who had a positive culture for a strain of Candida were taken into account for efficacy analysis: 150 in the sertaconazole group and 160 in the econazole group. One hundred and five women (49 in the sertaconazole group and 56 in the econazole group) were not clinically cured after 1 week and received a second suppository. There were no differences between the two groups for the rates of clinical recovery (disappearance of signs and symptoms) and mycological recovery (negative culture), 1 week after the first application (62.1 and 67.7%, respectively), 1 week after the second application for women treated twice (72.3 and 80.6%, respectively) and for all patients 1 month after the last application (65.3 and 62.0%, respectively). Among the patients cured 1 week after the last application, the mycological recurrence rate after 1 month was significantly higher in the econazole group (32.7 vs. 19.8%, P=0.035). There was a trend towards better efficacy of sertaconazole after the first application, whereas the two treatments had similar efficacy in women treated twice. There were no serious adverse events and only local irritation was reported, without any statistically significant difference between the two groups. CONCLUSION: Single topical administration of sertaconazole and econazole had similar efficacy and safety but the former is associated with a lower rate of mycological recurrence one month after achieving a negative culture.

[Results of cisplatin-based polychemotherapy and analysis of prognostic factors in ovarian cancer. Apropos of 106 cases]. / Résultats d'une polychimiothérapie à base de cisplatine et analyse des facteurs pronostiques dans les cancers de l'ovaire. A propos de 106 cas.

One hundred and six patients with stage Ic to IV ovarian carcinoma were treated by a protocol consisting of optimal debulking surgery followed by 9 cycles of CHAP chemotherapy. Clinical response was confirmed by a second-look procedure. Sixty-nine patients (65%) responded with 54 histological complete remissions (50.8%). Nineteen patients did not receive any complementary treatment due to a negative reaction, or prolonged neutropenia. Seven patients received maintenance chemotherapy, 10 an abdominal radiotherapy, 22 intraperitoneal chemotherapy and 11 autologous bone marrow transplantation. The 5-year survival rate was 32.5% and disease-free survival rate was 39.7%. Prognostic-factor analysis showed that age, initial staging, residual disease and cytological grading were significant. The authors propose a classification based on the risk of relapse, and different therapeutic indications for improving response rate and patient survival.

Intraperitoneal mitoxantrone as consolidation treatment for stage III ovarian carcinoma: a pilot study.

In June 1986 we initiated an intra-peritoneal (IP) mitoxantrone chemotherapy trial as consolidation treatment for ovarian carcinoma in CR or PR after induction therapy (surgery + CHAP combination chemotherapy). Thirty-two patients received 25 mg IP mitoxantrone every 3 wk for 6 months. The most frequent side-effects were abdominal pains; haematological toxicity was minimal. The response was assessed by third-look surgery. In group I patients (patients in histological complete remission at second-look surgery) 12 of 14 evaluable patients remained in CR at the time of third look. Ten of the 12 patients are still alive with no evidence of disease (NED) with a median follow-up of 9.7 months after completion of treatment. In group II patients (microscopic residual disease at second-look surgery), 7 of 9 evaluable patients entered in CR at the time of third look; 6 of the 7 are still alive with NED and with a median follow-up of 14.3 months. In 7 group III patients (macroscopic residual disease at the time of second look) no response to IP therapy was observed and all patients progressed. We conclude that IP mitoxantrone is a valuable consolidation treatment for patients in CR or with minimal residual disease; further follow-up is necessary to assess the impact on duration of remission and survival.

[Carboplatin and cyclophosphamide in stage Ic-IV ovarian carcinoma: retrospective study of 101 cases]. / Carboplatine et cyclophosphamide dans les cancers de l'ovaire de stade Ic à IV: une série de 101 patients.

We report our experience of CBDCA-CPM combination chemotherapy as first line therapy in 101 ovarian cancers. The therapeutic scheme was: initial cytoreductive surgery followed by six chemotherapy cycles (CBDCA 400 mg/m2/d IV dl, CPM 600 mg/m2/d IV dl, dl = d21) and second-look laparotomy. The initial stages were four Ic, three IIa, four IIb, four IIc, 15 IIIa, 28 IIIb, 23 IIIc and 20 IV. After initial surgery, there were 39 macroscopic residual diseases superior to 2 cm, 26 macroscopic residual diseases inferior or equal to 2 cm, four microscopic diseases and no residual disease in 30 cases (unknown in two cases). The overall response rate to chemotherapy was 83% with 56% histologic complete response rate. The main toxicity was haematological with 60% of leucopenia grade III-IV, 52% of thrombopenia grade III-IV. Age at diagnosis, residual disease after first look surgery and length of CA 125 normalization were significant prognostic factors for survival in this series.

[Chronic pelvic pain. Another diagnostic and therapeutic approach]. / Douleur pelvienne chronique. Une autre approche diagnostique et thérapeutique.

Chronic pelvic pain (CPP) is a frequent and difficult problem because despite the quality and diversity of diagnostic procedures no relevant etiology will be found in 30 to 40% of all cases. Psychologic and psychotherapeutic counselling is than usually proposed and usually not well accepted. A different approach can now be proposed according to a new semeiologic overall. In many cases the pain dominant is not visceral but parietal. The pelvic envelope is actually more painfull than the pelvic content. In these cases one can evoke the diagnosis of pelvic fibromyalgia and this is quite similar to classic fibromyalgia. This pelvifibromyalgia can be quantified with an algometric index. This form of pain actually is the somatisation of a past and difficult issue which will be very slowly and progressively revealed in the realm of a multidisciplinary and simultaneous physical and psychological approach. In the majority of cases these women have occurred physical, moral or sexual trauma inflicted by family members or a third party. Taking in account the physical dimension of body pain at the same time as psychotherapy will considerably enhance the efficiency of treatment. In our experience 70% of all women will be cured using this new approach.

[Hysteroscopic metroplasty for uterine enlargement: a treatment for diethylbestrol-exposed and hypoplastic uteri]. / Métroplastie hystéroscopique d'agrandissement: un traitement des utérus DES et des hypoplasies utérines?

OBJECTIVE: To determine the feasibility of correcting the uterine deformity in the diethylbestrol-exposed uterus and hypoplastic uterus. DESIGN: Hysteroscopic metroplasty. Patients served as their own controls. PATIENTS: Five patients referred for primary sterility (2 cases) or primo-secondary infertility with recurrent pregnancy loss or ectopic pregnancy (3 cases). Three of them had been exposed in utero to diethylbestrol. All of them have a hypoplastic uterus or uterine deformities as seen by hysterosalpingogram. OUTCOME MEASURES: Postoperative hysterosalpingogram aspect. Ability to conceive and carry pregnancy to livebirth. RESULTS: All the postoperative hysterosalpingograms appeared more normal than the preoperatively. Three patients have conceived since surgery. CONCLUSION: Hysteroscopic metroplasty is feasible. It gives good anatomic results. This technique could be used in the patients with diethylbestrol-exposed or hypoplastic uteri, with severe infertility, recurrent pregnancy loss or implantations failures in a IVF programm.

[Benckiser's hemorrhage. 2 case reports and a review of the literature]. / L'hémorragie de Benckiser. A propos de 2 cas et revue de la littérature.

Benckiser's haemorrhage is a pure foetal bleeding due to rupture of one or several umbilical vessels located within the presentation area and usually associated with velamentous insertion of the cord. The frequency of this accident has been estimated at 1:2000 to 1:5000 deliveries. The clinical picture consists of haemorrhage occurring during rupture of the membranes and rapid foetal suffering responsible for foetal death from acute exsanguination in 75 to 100% of the cases. The maternal prognosis is excellent. Since the first clinical description, in 1801, less than 200 cases have been published. Many atypical forms delaying the diagnosis have been noted. The authors report 2 lethal cases with misleading clinical presentations. With intact membranes, prevention rests on the diagnosis of vasa praevia made by vaginal palpation, amnioscopy or even ultrasonography combined with colour-coded doppler velocimetry. With ruptured membranes, the diagnosis is usually retrospective and bases on examination of the secundines. Testing foetal haemoglobin in the vaginal blood can be very useful in the absence of acute foetal suffering. The management of this haemorrhage is discussed.

[Resection under echographic control of septate uteri]. / Section sous contrôle échographique des cloisons utérines.

Septate uterus can be responsible for such infertility as requires surgical treatment. This series of this kind of uterine malformation in 37 cases makes it possible to evaluate the efficacy of a new technique for correction of the septum. It has the merit of not requiring laparotomy and above all it avoids carrying out hysterotomy which definitely weakens the uterus. The technique assists in correcting the defect through the cervix with scissors under ultrasound control. The morphological results on the uterine cavity are perfect in 19 patients. In 12 patients there was an arcuate fundus left and in 5 cases the section was insufficient and required a repeat procedure. This brings up to 20 the number of perfect corrections and 16 the number left with an arcuate fundus. The simplicity results were assessed in infertile patients and show that the number of abortions per patient dropped from 1.72 on average to 0.38 thanks to the ultrasound correction that was carried out. The simplicity of this method which can be carried out on an outpatient basis makes it possible to spread the indications to a situation where the Bret-Palmer technique could not be carried out and in particular in cases where IVF was being considered.

[Can we and must we organize cervical cancer screening in France? Results of the pilot project "EVE" in the department of Bas-Rhin]. / Peut-on et faut-il organiser le dépistage du cancer du col de l'utérus en France? A propos des résultats due project pilote "EVE" dans le département du Bas-Rhin.

EVE is a pilot project for cervical cancer screening whose aim is to test the feasibility of organized screening in the French liberal health system with a consensus of medical participants. After three and a half years, 74.8% of women aged 25 to 64 had had at least one smear. Coverage varies with age, from 89% between 25 and 29 to 56% between 55 and 60. Only 8% of smears are taken by General Practitioners. There is a tendency to space out smears because only 14% of women had had a second smear within one year and 41.1% within 2 years. On the other hand more then 20% percent of women do not return after 3 years. Pathological smears represent 1.94% of all smears. For these, a questionnaire is sent to the physician in order to get information on follow-up. This enables cytologic/histologic correlation. The histologic exam reveals a pathological lesion in 95% of cytologies consistent with invasive cancer, 91% of those consistent with high grade lesions and 70% of those consistent with low grade lesions.

[Ogilvie's syndrome after cesarean section. Apropos of 3 cases. Review of the literature]. / Syndrome d'Ogilvie après césarienne. A propos de trois cas. Revue de la littérature.

Ogilvie's syndrome or pseudo-obstruction of the colon shows up as a clinical picture of acute obstruction of the large bowel without an associated pathological lesion as usually occurs in older patients. Three cases of Ogilvie's syndrome following Caesarean section are reported in this work. Caesarean section seems to be the most common operative procedure associated with this syndrome. Up till now 41 cases have been described in the literature. This syndrome is serious because it is possible for the caecum to burst causing faecal peritonitis which carries a heavy mortality. Seventeen cases of perforation of the caecum have been reported in the literature. The diagnosis is made by x-raying the patient's abdomen without any pre-x-ray preparation; if an enema of gastroffin is given it can be shown that there is no organic cause for the obstruction. The pathological cause seems to be disturbance of the autonomic innervation of the colon. The colon should be decompressed rapidly; and the present technique is to do this using a colonoscope with or without epidural anaesthesia. Surgery should be reserved for cases that have complications or that have been refractory to conservative treatment. Of our three cases two were treated successfully by colonoscopic decompression and one with the use of drugs.

[Glucose tolerance on long-term treatment with a progestogen (etynodiol diacetate) (author's transl)]. / Glycorégulation et traitement progestatif au long cours (diacétate d'etynodiol).

Continuous long-term treatments with progestogens are able to bring about an hyperinsulinic reaction, which up till now has been considered to be due to a peripheral anti-insulin effect. Isolating the levels of immuno-reactive plasma insulin and of human C-peptide at the same time when loads of glucose and of tolbutamide are given after one another would seem to demonstrate that there is a primitive beta-islet of Langerhans origin for this hyperinsulinaemia. These results show that it is safe to prescribe etynodiol diacetate to "normal" patients as well as to "diabetic" patients.

[Pelvic actinomycosis: the value of preoperative diagnosis. Apropos of a case]. / Actinomycose pelvienne: intérêt du diagnostic préopératoire. A propos d'un cas.

Pelvic actinomycosis is a chronic suppurative granulomatous disease caused by an anaerobic Gram positive germ, Actinomyces. This rare disease can be severe and life-threatening. A intra pelvic bridge becomes chronic and produces a pseudo-tumoural syndrome of the pelvis with retroperitoneal infiltration or extension to neighbouring organs. Initially, neoplasia is usually diagnosed, leading to mutilating surgical exeresis before the pathology results reveal the presence of pelvic actinomycosis. The most difficult task is to entertain the diagnosis in a patient with an intrauterine device and poor general health, signs of infection and a pelvic syndrome. We observed such a case where the diagnosis was suspected before surgery. Adapted first intention antibiotic therapy led to spectacular recovery and allowed limited surgery without unnecessary ablation of neighbouring organs.

[Teratogenicity of retinoids. A case and review of the literature]. / Tératogénicité des rétinoïdes. Un cas et revue de la littérature.

Retinoids are vitamin A derivatives used in dermatology. One of them, isotretinoin, is frequently prescribed for refractory juvenile acne. The teratogenetic power of this drug is substantial, being estimated at 15 to 45% of exposures in utero. The risk is maximum in the first trimester of pregnancy and persists up to one month after treatment has been discontinued. The most frequently described multiple malformation syndrome involves the face, the central nervous system and the heart. There is also a 20 to 30% rate of spontaneous abortion. The authors report a case where exposure during the first trimester did not result in foetal malformation. From a full review of the literature the various malformations observed, the presumed mechanisms of teratogenesis and the strict rules of prescription and surveillance in women child-bearing age are presented. The problem of the measures to be taken in case of retinoid treatment during pregnancy is discussed. The teratogenic risk from other retinoids is dealt with.