[Uterine and ovarian necrosis following embolisation of the uterine arteries for postpartum haemorrhagia]. / Nécrose utérine et ovarienne après embolisation des artères utérines pour hémorragie de la délivrance.

We report here the case of a young woman who presented with pain, fever and apparent cutaneous sub ischaemia following embolisation of the uterine arteries for postpartum haemorrhagia. This embolisation was carried out by bilateral selective catheterism of the uterine arteries using 45 to 150 micron polyvinyl alcohol particles. Investigative laparotomy was decided in view of the persistence of the symptoms, and the patient underwent hysterectomy with ablation of the right adnexa to treat uterine necrosis and adnexal atrophy. Because of the information that we have actually, we can explain that this complication is linked with the use of polyvinyl alcohol small size particles. The migration of those embolisation agents might be responsible for obliteration of a large number of distal vessels. Those embolisation agents must, because of recommendation for good practice published in 2004, be reserved to exceptional cases to minimize the complication of embolisation.

[Pregnancies occurring during oral contraception: lessons from the GRECO study]. / Grossesses survenant sous contraception orale: les leçons de l'étude GRECO.

OBJECTIVES: The GRECO study has collected data on pregnancies, regardless of their outcome, that occurred in women taking an oral contraceptive. PATIENTS AND METHODS: The analysis concerned 551 women prospectively recruited in services of gynaecology or obstetrics, termination of pregnancy centres, family planning centres or consultations of gynaecology in France throughout 2002 and who were 12 weeks pregnant or less. RESULTS: Contraception used during the cycle of conception was an estroprogestative combination in 88% of cases, a microprogestative in 8.7%, a macroprogestative in 0.9% or another type of pill in 2.4%. Progestatives were levonorgestrel 59.0%, gestoden 17.2%, desogestrel 4.7%, norethisterone acetate 2.9%, norgestimate 1.8%, cyproterone acetate 2.0%, norgestrel 1.6%. When asked about the potential cause of the oral contraceptive failure, 76.9% of women reported events such as missed pills which were the most frequent cause of failure (60.8% of failures and 80.1% of events, 2.7+/-2.7 missed pills), followed by vomiting and diarrhoea. 81.5% of women chose to terminate their pregnancy. DISCUSSION AND CONCLUSION: The GRECO study, despite its limitations (retrospective collection of missed pills data, declaratory data) showed that missed pills, even once, were the most common reason for oral contraceptive failure. The most frequent decision was the termination of pregnancy.

[Preliminary results from the OPNI observatory: long-term follow-up of a cohort of women using the progestagen contraceptive implant Implanon]. / Le suivi à long terme d'une cohorte de femmes porteuses d'un implant contraceptif (Implanon): analyse intermédiaire des données de l'observatoire OPNI.

OBJECTIVE: Describe the initiation and follow-up of Implanon insertion in current office-based practice in France and estimate the rate and causes of early removals. PATIENTS AND METHODS: A prospective cohort study of 1000 women having been inserted with Implanon by a representative national sample of prescribers (gynaecologists and general practitioners) was designed. The follow-up period was 3 years and the enrolment was planned for 2 years starting July 2002 according to a naturalistic design. RESULTS: The results are related to an intermediate analysis describing the situation of the cohort at the date 31 December 2003. 872 women were enrolled, of whom 784 (89.9%) by gynaecologists and 88 (10.1%) by GPs. Implanon was inserted in 691 (79.2%) and 360 (52.1%) had at least one follow-up visit at this date. The mean follow-up period after insertion was 10.5 months. 38 early removals were recorded (actuarial rate at 16 months of 8.8% [CI 95% 5.0-12.7]), integrating the distribution of follow-up duration and the assumption that women with no follow-up visit the still had device. DISCUSSION AND CONCLUSION: The estimated early removal rate was lower than the result of the meta-analysis of international clinical trials but this figure should be confirmed in the final analysis of the study.

[Fetal supraventricular tachycardia with anasarca complicating benign extrasystole: treatment with flecainide. Apropos of a case]. / Tachycardie supraventriculaire foetale avec anasarque compliquant une extrasystole bénigne: traitement par Flécaïne. A propos d'un cas.

We report a case of fetal supraventricular tachycardia with intra-uterine cardiac failure, who complicate benign premature beats. It was treated with oral administration of flecainide acetate (Flecaine) to the mother. This treatment was rapidly effective. The fetus converted to sinus rhythm in 5 days and the ascites had completely resolved in 10 days. We conclude, that fetus with premature beats must be observed every 15 days, and we believe that flecainide acetate can be used as the "first line agent" to the fetal supraventricular tachycardias with cardiac failure.

[Placental chorioangioma, value of ultrasonography: report of two cases]. / Choriangiome placentaire, apport de l'échographie: à propos de 2 cas.

Placental chorioangioma is the most frequent benign vascular placental tumor, and the prenatal diagnosis can be made by ultrasound. With color flow and pulsed doppler, ultrasound is helpful for the follow-up and the prognosis of this tumour associated with severe maternal and fetal consequences.

[Premature labor: tocolysis with non-steroidal anti-inflammatory agents]. / Menace d'accouchement prématuré: la tocolyse par anti-inflammatoires non stéroïdiens.

Utilization for premature labor of non-steroidal anti-inflammatory agent is well known for thirty years now. Since then, these molecules are regularly tested against others and proposed as efficacious tools. However their prescriptions are not so usual and easy as expected. Very often fetal risks are underlined and exacerbated. For this review of the literature we tried to present on an extensive analysis of complications encountered in clinical practice and ways of avoiding them, following the mechanism of actions of these anti prostaglandins. Perhaps in the near future use of cyclo-oxygenase-type-2-selective non-steroidal anti-inflammatory agent will resolve our dilemma. We present here possible developments.

[Laparoscopic hemi-hysterectomy for pseudo unicornuate uterus: apropos of 3 cases]. / Hémi-hystérectomie coelioscopique pour utérus pseudo unicorne: à propos de 3 cas.

Surgical management of unicornuate uterus with rudimentary horn is justified because of disabling dysmenorrhea but also because of associated morbidity and mortality complications. We describe here three new cases of laparoscopic removal of the horn following a new improved surgical technique.

[Ureteral suture by laparoscopy: a new case. Review of the literature]. / Suture urétérale par voie coelioscopique: à propos d'un nouveau cas. Revue de la littérature.

A wound to the ureter is a possible complication of laparoscopy and is usually repaired by suture requiring laparotomy. We report a case of a laparoscopic stitch and review the pertinent literature.

[Spontaneous rupture of uterine varices in the third trimester of pregnancy]. / Rupture spontanée de varices utérines au troisième trimestre de la grossesse.

We report a case of spontaneous rupture of a uterine varicosis in the third trimester of pregnancy resulting in massive peritoneal hemorrhage and maternal shock. This patient with an uncomplicated pregnancy presented symptoms suggestive of abruptio placenta with foetal distress. A caesarean section was performed identifying the cause and permitting the treatment of this syndrome. Since 1950, only 8 cases have been reported.

[Insulin dependent diabetes and pregnancy: evaluation of the insulin pump]. / Diabète insulino-dépendant et grossesse: évaluation de la pompe à insuline.

OBJECTIVE: To evaluate the effectiveness of continuous insulin infusion (insulin pump) on the materno-foetal morbidity during pregnancy in patients with insulin-dependent diabetes mellitus. METHODS: A retrospective study from 1980 to 1991. SITE. Gynecology-Obstetrics Unit, University of Caen. POPULATION: Eighty-one patients with insulin-dependent diabetes mellitus known to be affected before their pregnancy were followed in the unit from 1980 to 1991. This population was divided into two groups: in the first group, an insulin pump was installed before 15 weeks of amenorrhoea (n = 36) and in the second group, conventional treatment was given with three daily injections of insulin or with a pump installed after 15 weeks of amenorrhoea (n = 45). RESULTS: In the first group with the insulin pump before 15 weeks, there was a higher proportion of severe diabetes, the first consultation occurred earlier, there were half as many cases of neonatal jaundice and the length of hospitalization during the first trimester of pregnancy was longer. There was no difference in Apgar scores, cord pH, birth weight and the proportion of foetal macrosomia, length of the hospitalization in the neonatality ward, rate of malformation, infection, low blood glucose and calcium, transitive respiratory distress and neonatal polycythaemia, length of hospitalization of the mother during the second and third week postpartum, the rate of urinary infection, high blood pressure, hydramnios during pregnancy, delivery route, haemoglobin Alc or fructosamine during pregnancy. There was no perinatal death. CONCLUSION: Although there was no significant difference in the results, which may be explained by the higher number of severe cases of diabetes in the first group, the use of the insulin pump did not appear to improve control of blood glucose levels, and thus to improve the materno-foetal prognosis, except by the bias of earlier attentive management of the pregnancy which led to better outcome.

[Surgical laparoscopy and pregnancy. Eight cases]. / Coelioscopie opératoire et grossesse. A propos de 8 observations.

Eight cases of abdominopelvic surgery including 7 conducted uniquely by laparoscopy point out certain questions concerning diagnosis and management with this technique. These 8 cases included 6 cysts of the ovary, 1 appendectomy and 1 myomectomy. The consequences related to the operation or the anaesthesia and the foetal consequences were evaluated retrospectively. In particular, laparoscopic surgery induces certain pathophysiological modifications which remain to be studied.

[Cervical ripening with prostaglandin E2 in a scarred uterus during the third trimester of pregnancy. Report of 82 cases]. / La maturation cervicale par prostaglandine E2 sur utérus cicatriciel au troisième trimestre de la grossesse. A propos de 82 cas.

AIM: To study the feasibility, the results and the complications of cervical ripening using PG2 in scarred uterus in the third trimester of pregnancy. METHOD: A retrospective study of 82 cases of which 10 had ruptured membranes. The administration of 0.5 mgs of PG2 by the intracervical route after Beta-mimetic drugs by the intramuscular route. RESULTS: In 78% of the cases it was possible to improve the condition of the cervix so that labour could be induced or that it would start spontaneously. It was possible to deliver the baby vaginally in 67% of cases. There was no case of ruptured uterus. CONCLUSION: It seems possible that when there is a medical indication to induce labour to ripen the cervix using PG2 in a scarred uterus in the third trimester of pregnancy. The administration of beta-mimetic drugs for ripening and the use of tocometry to monitor labour seemed to be important precautions that have to be taken.

[Cervical cancer in the young woman]. / Le cancer cervical de la femme jeune.

OBJECTIVE: To study the frequency, the histological type, the stages, and prognosis of cancer of the cervix in women under 35 years of age or less. METHOD: A retrospective analysis of a series of 1,024 cases notes of which 63 dealt with young women. The therapeutic modalities are the same throughout the whole duration of the study from 1975-1988. RESULTS: There was no increase in the incidence of cancer in young women. The incidence of epidermoid cancer dropped. However, mixed adenosquamous tumours were more frequent. There is a predominance of stages I cancers. The survival taking all stages together is at 5, 10 and 15 years better in young women. All the same, taking stage by stage there is no difference in the prognosis.

[Feasibility of the laparoscopic sub-urethral sling procedure]. / Faisabilité de la fronde sous-urétrale coelioscopique.

OBJECTIVE: To evaluate the feasibility of the laparoscopic sling procedure, 44 patients 26 to 66 years old (average 45) with sphincter incompetence were included in this prospective series between 1993 and 1999. PATIENTS AND METHODS: Patient selection for a sling procedure was based on urodynamic findings (average closure pressure was 34 cm of water). The operative procedure is described. RESULTS: The follow up ranged from two to 66 months (average 27.6). Seven conversions into laparotomy had to be performed. 35 slings could be set successfully. Four of these slings had to be removed during the year following the procedure; two because of bladder neck erosion and two because of chronic bladder distension. The success rate of the 35 slings is 88.6%. The overall complication rate is 27% including five bladder injuries, 2 urether injuries and one hemorrhage. Ten of the twelve complications occurred in the 12 first patients and the complication rate decreased to 9% in the 32 last patients. Average hospital stay was 4 days. CONCLUSION: The laparoscopic sling procedure seems to be promising in the management of refractory urinary incontinence due to sphincter incompetence. But it is an advanced laparoscopic procedure for experienced laparoscopic surgeons, needing a long learning curve.

[Resistance to activated protein C and pregnancy: thromboprophylaxis with low molecular weight heparin]. / Résistance à la protéine C activée et grossesse: thromboprophylaxie par les héparines de bas poids moléculaire.

OBJECTIVE: The utilization, during pregnancy, of low molecular weight heparin (enoxaparine) for obstetric thromboprophylaxis for patients with activated protein C resistance, following Factor V Leiden mutation. STUDY DESIGN: Prospective study enrolling 10 pregnant patients heterozygote or homozygote for Factor V Leiden mutation. They all had familial or personal history of severe thrombotic disease and received 40 mg per day of enoxaparine. RESULTS: No thrombosis or hemorrhage were recorded during pregnancies or deliveries. All the infants were doing well. After birth, low molecular, weight heparin were continued between 6 to 12 weeks accordingly allelic status and history. We reviewed the literature on this subject. CONCLUSION: This series confirmed the efficacy, safety and tolerance of low molecular weight heparins which will probably become the next gold standard for obstetric thromboprophylaxis.

[The estimation of fetal weight by measurement of the adipose tissue of the extremities. Use in the diagnosis of hypotrophy]. / Estimation du poids foetal par la mesure de la graisse des membres. Application au diagnostic de l'hypotrophie.

OBJECTIVE: To investigate the accuracy of small for age fetuses diagnosis by a new method of fetal weight estimation, in comparison with some others models. A retrospective study. SUBJECTS AND METHODS: From a 232 fetuses population, whom age is known, ultrasound measurement have been performed (BPD, TBD, FL, AC and thigh circumference). Three physicians collaborated to data collection. All measurement have been done within a 3 days duration between measuring and birth in order to compare actual and calculated weight. There are 39 small fetuses coming from 10th percentile (17.5%), between then 24 from 5th percentile. RESULTS: Positive predictive value (PPV) of small for age diagnosis (from 10th P) by our model is 74% with a 74% sensibility and a 94% specificity. With Warsof estimation model, the PPV is only 47% with a 71% sensibility and a 83% specificity (p = 0.001). COMMENTS: Limbs subcutaneous fat ultrasound measurement improve considerably fetal weight estimation quality (mean error = 6% vs 10% for most of the classical models) and, as an extension, small for age fetuses diagnosis. The cutaneous and subcutaneous circumferences, between which is situated fat tissue have a better individual correlation to actual weight than abdominal circumference, usually considered as the best trophicity parameter. CONCLUSION: High positive predictive value show long term predictive detection possibility. It appears that this diagnosis could be done earlier with a better accuracy that the classical ultrasound biometry.

[Flecaine: drug of choice for supraventricular tachycardias with anasarca. A case report]. / La Flecaïne: un traitement de choix dans les tachycardies supra-ventriculaires avec anasarque. A propos d'un cas.

We report a case of fetal supraventricular tachycardia with intra uterine cardiac failure, treated with oral administration of flecainide acetate (Flecaine) to the mother. This treatment was rapidly effective. The fetus converted to sinus rythm in 5 days and the ascites had completely resolved in 10 days. We believe that flecainide acetate can be used as the "first line agent" for fetal supraventricular tachycardias with cardiac failure.

[Feasibility of bilateral sacrospinous ligament vaginal suspension with a stapler. Prospective studies with the 34 first cases]. / Faisabilité de la sacrocolpopexie vaginale bilatérale à l'agrafeuse. Etude prospective des 34 premiers cas.

OBJECTIVE: Evaluation of the feasibility of bilateral sacropinous ligament suspension with a stapler. Morbidity study and short term results. STUDY DESIGN: Prospective study from July 1994 to August 1996. RESULTS: Bilateral sacrospinous ligament suspension with a stapler was possible in 100% of cases and surgical technique is described. Our indications are stage III Bp and stage IV genital prolapses (according to the American Urogynecologic Society classification, 1996), with or without uterus, and when a Bologna's procedure is performed, in order to prevent enterocele. In 24 patients, the uterus was present. 20 vaginal hysterectomies and 4 conservative bilateral uterine suspensions were performed. The sacrospinous ligament suspension was associated to anterior colporrhaphy (in 74% of patients), repair of rectocele (82%), repair of enterocele (26%), posterior colpoperineorrhaphy (79%), bladder neck suspension (71%). No vascular injury nor post operative constipation was noted. In 2 patients, a small rectal laceration occurred, and in one patient one branch of the staple transfixed the rectal mucosa. Removal of the staple was easily performed without any post-operative complication. First results after an average 19 months follow-up (range 9 to 32) shows a perfect anatomic result in 77% of cases. We noted one recurrence of a vaginal vault prolapse; the patient underwent a second sacrospinous ligament fixation with good result. One patient had a stage II Aa cystocele post-operatively and three patients had a short vagina (< 6 cm). Patients who were continent before the sacrocolpopexy did not develop further urinary stress-incontinence. CONCLUSION: Bilateral transvaginal sacrospinous ligament suspension with a stapler facilitates the procedure. No post-operative constipation was noted with this method. Our first results are good. The cost of the stappler may limit its extensive use.

[Management of premature rupture of the membranes at term: how long to delay? Results of a prospective multicentric study in 713 cases]. / Rupture prématurée des membranes à terme: quel délai d'expectative? Résults d'une étude prospective multicentrique, à propos de 713 cas.

OBJECTIVE: The aim of our study was to define he best delay for management of spontaneous rupture of the membranes at term. MATERIALS AND METHODS: We conducted a prospective multicentric study in western France defining 3 groups of expectancy (6, 12 and 24 hours) to assess obstetrical, neonatal and maternal outcomes. RESULTS: We included 713 patients. There was no significant difference in neonatal and maternal morbidity between the 3 groups. The rate of cesarean section was statistically higher in the 6-hour group (12%). There was no statistical difference between 12 and 24 hours but the rate was lower in the 12-hour group (5.5 versus 7.9%). CONCLUSION: Based on our findings and a review of the literature, we have decided that in cased of premature rupture of the membranes at term, a 12 hour delay is best. At most two prostaglandin maturations can be performed in unfavorable cervixes.

[Tubal sterilization in mentally handicapped women]. / Stérilisation tubaire chez la femme handicapée mentale.

ETHICAL ISSUES: When performed for contraception purposes, tubular sterilization for mentally handicapped women poses important ethical issues, including patient's rights, body integrity, and the notion of informed consent. French law guarantees the respect and safety of all patients, but in everyday practice, patient's rights must be upheld by family and healthcare workers searching for the most adapted solutions for each individual situation. PROPOSITIONS: We present here our proposals for everyday practice. Our conclusions are based on an analysis of the notion of handicap as defined by the WHO and on the observed sexual activities of this type of patient. In this context, informed consent involves a number of subjective factors pointing out the difficulty encountered in providing dear comprehensible information. Finally we discuss the ethical issue of tubular sterilization which many consider to be a masked form of eugenism.