[Instrumental extractions using Thierry's spatulas: evaluation of the risk of perineal laceration according to occiput position in operative deliveries]. / Extraction instrumentale par spatules de Thierry: évaluation du risque périnéal en fonction du dégagement.

OBJECTIVE: Risk factors for severe perineal lacerations are nowadays well-known and they include operative vaginal deliveries and extractions in occiput posterior (OP) positions. The aim of this study was to assess whether OP position increases the risk for anal sphincter injury when compared with occiput anterior (OA) positions in operative deliveries using Thierry's spatulas. METHODS: Retrospective study of 163 extractions with Thierry's spatulas over a five-year period (January 2000 to December 2005) performed in a general hospital. Singleton cephalic pregnancies at term were studied and the incidence of severe perineal lacerations was noted in deliveries in OP and OA positions. RESULTS: In these 163 cases, the varieties of presentation obtained by vaginal examination were 129 in anterior and 34 in posterior positions. Eleven posterior positions rotated anteriorly on delivery and 23 remained in a posterior position. The OA group (n=140) and the OP group (n=23) were constituted. Anal sphincter injury occurred significantly more often in the OP group compared with the OA group (17.4% versus 2.9%, p=0.014) with an odds ratio of 7.1 (95% CI 1.6-31). Only one fourth-degree laceration was noted. Within the OP group, the incidence of vaginal lacerations was increased compared to the OA group, but without any significant difference (43.5% versus 27.9%, p=0.20). In a logistic regression model, the OP position was 6.4 times (95% CI 1.3-31.5) more likely to be associated with anal sphincter injury than OA position. The incidence of OP position was 14.1% within the whole population studied and Thierry's spatulas permit anterior rotations of occipito posterior presentation in only 32.4% of cases. CONCLUSION: The efficiency of Thierry's spatulas is proven. As with forceps and vacuum extractors, extraction with Thierry's spatulas is a risk factor for perineal laceration compared to a spontaneous delivery. In deliveries with spatulas, OP head positions further increase this perineal risk against OA positions. OP positions before fetal extractions do not seem to be an ideal situation for using spatulas, even if an anterior rotation is achieved in one-third of cases.

[Thierry's spatula instrumental extraction: a study of foetal-maternal morbidity]. / L'extraction instrumentale par spatules de Thierry: étude de la morbidité maternofoetale.

OBJECTIVE: Assisted delivery is necessary in many obstetrical conditions but is involved in maternal and foetal complications. The legal pressure and the commendable aim consisting in less neonatal morbidity and mortality have called forth a reflection about the type and the way of instrumental foetal extraction. In 1950, Thierry had already felt this problem and he invented spatula to replace obstetrical forceps. Although this instrument appears empirically little deleterious, literature about its evaluation is very poor. We studied this instrument in a retrospective 190 cases series. PATIENTS AND METHOD: Retrospective study of 190 Thierry's spatula extractions, over a seven-year period (January 1996 to December 2002), at the Centre Hospitalier General of Montbeliard. RESULTS: Out of a total of 8126 deliveries for the study period, the instrumental extraction rate was 5.3%, with 40.6% spatula extractions (190 cases). No failure of Thierry's spatula extraction was noted. DISCUSSION ET CONCLUSION: Our study concludes that spatula is efficient but does not usually permit anterior rotation of occipito-posterior presentation. Maternal and foetal morbidity is not frequent.

[Deferred deliveries in multiple pregnancies. Discussion on a new case report]. / Accouchements différés de grossesses multiples. Discussion à propos d'un nouveau cas.

The authors report a new case of a triplet pregnancy in which an abortion occurred in the second trimester and twins were delivered at the 33rd week of gestation. The authors point out that it is possible to carry out a cerclage when a fetus and placenta are retained without necessarily causing an infection with clinical symptoms; but the authors do point out that there is always the possibility of infecting the mother and the fetus. As to the prognosis for the fetus, it is better it is given an opportunity to grow further in spite of the risk of infection.

[Antenatal diagnosis of achondrogenesis. Two successive cases in the same family]. / Diagnostic anténatal de l'achondrogenèse. A propos de deux cas successifs dans une même fratrie.

Achondrogenesis is a rare case of fetal skeletal dysplasia. Achondrogenesis in lethal. That is a autosomal recessive fetal skeletal dysplasia. There is a very important dwarfism with extreme micromely, macrocephalia and brevity of chest. The authors enumerate the echographics, radiologics and histologics symptoms of this chondro-dysplasia. The authors comment rapidly the others diagnosis of lethal fetal skeletal dysplasia. Genetic consul is a necessity.

[Neonatal alloimmune thrombocytopenia following immunization against the platelet antigen ZWA (PLA/1). 3 case reports in the same family and analysis of the literature]. / Les thrombopénies néonatales allo-immunes par immunisation contre l'antigène plaquettaire ZWA (PLA/1). A propos de trois cas d'une même famille et analyse de la littérature.

Allo-immune neonatal thrombopenia is to platelets what rhesus hemolytic disease is to red blood cells. There is a risk of haemorrhage when fetal platelets decreases below 50,000 per mm3. Such haemorrhage may occur at any time during the thrombopenia period. However they are mostly due to obstetrical traumatisms during delivery. Lethal complications and severe neurologic sequellae is estimated to affect about 30% of newborns: 1/3 these complications occur in utero and 2/3 during delivery. The authors have studied 3 familial cases of foeto-maternal allo-immunisation occurring with the PLA 1 system. They have made a briefing of the physiological, the pathological and the epidemiological aspects of such immunisation before insisting upon case findings of such affected fetus. A capillary blood sample taken from the scalp of the fetus at the beginning of labour allows a safe natural delivery if fetal blood count shows more than 50,000 platelets per mm3. A fetal blood sampling under ultrasonographic guidance will bring about to an early diagnosis and prognosis, this allowing an adequate treatment for fetus with a high risk of thrombopenia.

[The procedure to be adopted in cases of breech presentation: use of the vacuum extractor]. / Conduite a tenir devant une présentation du siège: utilisation du vacuum extractor.

The authors review the advantages of a non-standard method of extraction in cases of breech presentation, the vacuum extractor. This method should not only replace total extraction in cases of frank breech, but should also find much wider applications. In fact the technique, which is easily applied and always effective, permits extraction in cases of frank breech by the vaccum cup at the stage of complete dilatation, preferably when the breech is well engaged, without serious complications. The authors then explain how they have used the vacuum extractor in their general practice in cases of breech presentation: in 100 cases, the extractor was used 41 times, total extraction was used 19 times, caesarian section, 18 times, partial extraction 9 times, and there was no intervention in 9 cases some of which were terminated by the Mauriceau method. The corrected mortality was 1% and the corrected morbidity with an Apgar score of less than or equal to 6 et 1 minute, was 16.3 percent (excluding premature infants of less than 1,500 g and malformed infants). The use of the total extraction principle and particularly of the vacuum extractor avoids the occurrence of the unexpected and the necessity for the obstetrician to improvize a more difficult and perilous method of rescue.

[A sensory screening test in neonatal pathology]. / Test de dépistage sensoriel en pathologie néonatale.

Systematic investigation of auditory reactions in newborn babies has been started three years ago at the Centre Hospitalier Regional of Besançon. However, deafness screening at the Maternity has been used for a wider purpose by the authors, who investigated more especially the correlations between the response to auditory stimulus and antenatal and perinatal pathology. Their preliminary study was conducted on 340 newborn infants. A pathological component could nearly always be traced in children showing abnormal response to the sensory stimulus. In view of these positive preliminary results, the authors have undertaken a still more extensive study, in order to determine whether some etiological factors would not come to the foreground.

[Non-Hodgkin's malignant lymphoma with primary localization in the breast. Apropos of 2 cases: review of the literature]. / Lymphomes malins non hodgkiniens à localisation mammaire initiale. A propos de deux cas: revue de la littérature.

The malignant non-hodgkinian lymphoma (M.N.H.L.) with pripary mammary localization is relatively rare, but deserves to be accounted for in the evaluation of breast cancers. The diagnosis of the primary localization in the breast responds to definite criteria, well established by Wiseman and Liao. On the other hand, the initial mammary localization is more frequent, revealing a hemato-sarcoma clinically silent until then, but with nodal spread (most of the time lumbo-aortic). The problem is to know whether it is possible, in front of a breast nodule, to evoke lymphoma in view of some clinical and paraclinical characteristics. An accurate pathological diagnosis (International Formula for clinical use of the National Cancer Institute-1982) and a minutious work-up for spread determination (AnnArbor Classification) represent the two essential aspects of the prognosis. It is advised to resort to surgical excision-biopsy in order to obtain an exact histology with analysis of immunological markers, rather than an extemporaneous examination which often leads to the wrong diagnosis of cancer and a mutilating and unnecessary surgery. Progresses in chemotherapy have greatly contributed to improve survival of these hematosarcomas with extranodal localization, which remain however a neoplastic disease with a disseminating tendency.

[Update on delayed births]. / Mise au point sur la naissance différée.

Sixteen (16) cases of delayed births have been reported in the literature. All of these patients obtained at least one live child. This method can, therefore, be suggested in cases of premature birth after less than 28 weeks of amenorrhea for patients who present with a multiple, pluriamniotic pregnancy.