Evolution of middle cerebral artery peak systolic velocity after a successful laser procedure for iatrogenic twin anemia-polycythemia sequence.

We report a case of twin anemia-polycythemia sequence (TAPS) treated by laser at 24 + 5 weeks' gestation, 7 weeks after a first laser procedure for twin-to-twin transfusion syndrome at 16 + 6 weeks. This management led to the birth of two healthy neonates by Cesarean section at 36 weeks. In this case, weekly measurement of the middle cerebral artery peak systolic velocity allowed us to monitor the twins after both laser treatments and, more specifically, to detect TAPS. Following delivery, placental injection showed a minuscule coagulated arteriovenous anastomosis. Intrauterine transfusion is generally chosen to manage TAPS, but the choice of therapy must consider gestational age, technical difficulties and disease severity. The laser procedure cannot be used as a curative treatment for TAPS in all cases. We propose a decisional algorithm to help clinicians select the appropriate treatment.

[Prenatal breastfeeding information: survey in Pays de Loire, France]. / Information prénatale sur l'allaitement maternel : enquête en Pays de Loire.

OBJECTIVES: The main aim of this study was to evaluate how well expectant mothers were informed on breastfeeding by healthcare professionals. The secondary objective was to determine the factors associated with the initiation of breastfeeding. POPULATION AND METHODS: The survey was conducted in a group of 500 women who had delivered at the Angers Hospital (France), based on a questionnaire filled out by the postpartum women during their hospital stay. RESULTS: The rate of breastfeeding was 61.2%. More than a quarter (26.9%) of the women did not receive any prenatal breastfeeding information. The survey showed that 77.8% of the women had been informed of breastfeeding advantages for infants and 51.5% of breastfeeding advantages for themselves. Only 27.5% had received the advice of exclusive breastfeeding for 6months. Only 5.2% had been informed of the uselessness of breast preparation during pregnancy and a minority had been informed of correct and incorrect breastfeeding contraindications. Only 15.4% of fathers had been involved in a discussion on infant feeding practices during prenatal consultations. Only 4.8% of the women had come to prenatal classes on breastfeeding with a relative. The maternal factors positively associated with breastfeeding initiation were age between 25 and 34 years, non-French origin, a high socioeconomic status, being married, having been breastfed, and having previous experience with breastfeeding. Breastfeeding initiation was negatively associated with maternal smoking. All the factors concerning prenatal breastfeeding information in women were associated with the choice of breastfeeding. CONCLUSION: This study pointed out the populations at risk of not breastfeeding. Breastfeeding information given to pregnant women by healthcare professionals may influence them on whether or not they choose to breastfeed their newborn. However, this survey showed that women are insufficiently informed on prenatal breastfeeding. Therefore, prenatal breastfeeding information should be improved.

[Determination of nosocomial infection incidence in mothers and newborns during the early postpartum period]. / Les infections nosocomiales chez la mère et l'enfant: à propos d'une enquête d'incidence portant sur 804 accouchements.

BACKGROUND: We wished to determine the incidence of nosocomial infections in the mother and the newborn during the early postpartum period. MATERIAL AND METHODS: Over a three-month period, the same investigator collected 50 different clinical and microbiological, standardized data related to infectious diseases in parturients and their newborns. RESULTS: Data were collected on 804 deliveries. The overall rate of nosocomial infection was 2.9% (23/804). For vaginal deliveries, the rate was 1.9% (12/615) and for deliveries by Cesarean section, the rate was 5.8% (11/189). Of 745 newborns followed until discharge from hospital, 0.7% (5/745) had a nosocomial infection. CONCLUSION: These results are in line with previously published rates of nosocomial infections, which varied between 0.2% to 2.3% for vaginal deliveries, 1.6% to 18.9% for Cesarean section, and 0.2 to 4% in newborns. Regular surveys of the incidence or the prevalence of nosocomial infections are necessary to monitor the effectiveness of educational programs, aimed to reduce hospital acquired infections.

[Healthcare networks: involvement of various healthcare professionals]. / Les réseaux de soins: multidisciplinarité et équipe.

Diabetes is a very representative model of chronic disease requiring a partnership between various healthcare professionals. The organisation of healthcare networks allows a global care improvement. For the "Midi-Pyrénées" area, the diabetes network associates physicians and other healthcare professionals, working in their private - practice or in clinics or hospitals. The priority of this network was to develop therapeutic patient education, outdoors and indoors. The use of a specific communication system will be unavoidable, as a basis for medical files, evaluation, and permanent updates for the network members. Current projects concern a regional organization for chronic foot ulcers care, coronary heart disease and diabetes during pregnancy. These various care domains suppose the collaboration with other regional networks.

[Leiomyosarcoma of the renal vein]. / Le léiomyosarcome de la veine rénale.

The authors report a new case of leiomyosarcoma of the right renal vein, marked by a rapidly fatal course within 9 months, despite the initial absence of metastasis. This exceptional vascular tumour (only about thirty cases have been published) must be distinguished from primary renal leiomyosarcoma and retroperitoneal leiomyosarcomas involving adjacent structures. This difficult diagnosis was suggested by preoperative CT and angiography. Leiomyosarcomas of the renal vein generally have an unfavourable outcome in the medium term. The prognosis is related to the localized nature of the tumour and the risk of local and distant recurrence. Limited tumour resection is rarely sufficient and radical nephrectomy is usually necessary, possibly associated with a vascular procedure on the inferior vena cava in the case of contiguous extension.

[Treatment of pain due to unwanted lactation with a homeopathic preparation given in the immediate post-partum period]. / Traitement de la douleur de la montée laiteuse non souhaitée par homéopathie dans le post-partum immédiat.

Dopaminergic agonists, such as Parlodel((R)), are now widely used to inhibit lactation. However, some countries, such as the United States, no longer use these drugs in this indication because of their sometimes serious adverse effects. In this context, the authors tested a homeopathic treatment designed for parturients unable or not wanting to breastfeed. The APIS MELLIFICA 9 CH and BRYONIA 9 CH combination was chosen for its anti-inflammatory and analgesic effects. 71 patients were included in this double-blind placebo-controlled study. All received basic treatment comprising naproxen and fluid restriction. A significant improvement of lactation pain (main criterion of the study) was observed in parturients treated with homeopathy (p<0.02 on D2 and p<0.01 on D4). A similar effect (p<0.05 on D4) was observed for breast tension and spontaneous milk flow. No significant difference was observed for the other criteria of the study. The homeopathic combination studied was therefore effective on the pain of lactation and should be integrated into the therapeutic armamentarium.

A randomized, multicenter, controlled trial using intravenous pulses of methylprednisolone in the initial treatment of simple forms of giant cell arteritis: a one year followup study of 164 patients.

OBJECTIVE: (1) To evaluate the corticosteroid sparing effect of an initial intravenous (i.v.) pulse of methylprednisolone (MP) in the treatment of simple forms of giant cell arteritis (GCA). (2) To analyze corticosteroid response, steroid related side effects, and GCA complications. METHODS: Patients received a 240 mg i.v. pulse of MP followed by 0.7 mg/kg/day oral prednisone (Group 1) or 0.7 mg/kg/day prednisone without an i.v. pulse (Group 2, controls), or a 240 mg i.v. pulse of MP followed by 0.5 mg/kg/day prednisone (Group 3). Corticosteroid dosage was reduced after normalization of 2 biological inflammatory variables to obtain half-dosage after 4 weeks in Groups 1 and 2 and 20 mg/day after 2 weeks in Group 3. Tapering was systematically attempted from the 6th month of treatment. RESULTS: One hundred sixty-four patients were included in the trial (1992-96). Cumulative doses of corticosteroids after one year were identical for all groups (p = 0.39). No significant differences were observed in the time required for normalization of C-reactive protein, corticosteroid resistance (13.5%), and corticosteroid related side effects (39% of patients; p = 0.37). Corticosteroid resistant patients received larger doses and showed a high risk of GCA related complications (p = 0.02). CONCLUSION: MP pulses have no significant longterm, corticosteroid sparing effects in the treatment of simple forms of GCA and should be limited to complicated forms. Moreover, corticosteroid resistance is a real risk factor for GCA complications.

[Cervical adenocarcinomas: diagnostic, prognostic and therapeutic aspects in a 49 case-control study]. / Aspects diagnostiques, pronostiques et thérapeutiques des adénocarcinomes du col utérin: à propos d'une série de 49 cas.

OBJECTIVES: The aim of this study was to search for potential diagnostic, therapeutic and prognosis differences between a series of 49 adenocarcinomas of the cervix and a matched series of epidermoid carcinomas. METHODS: Forty-nine adenocarcinomas were treated between 1978 and 1992 and retrospectively compared to a series of 98 paired epidermoid carcinomas. RESULTS: The adenocarcinoma incidence is 5.4%. There was no significant difference for age distribution, parity, or hormonal status. There was also no significant difference for clinical features. Stage I appeared more frequently in the adenocarcinoma group (stage I: 69.4%, stage II: 14.3%, stage III: 14.3%, stage IV: 2%). Stage I are also more frequently found in the adenocarcinoma group (69.4% versus 42. 9%, p< 0,05). Combined radio-surgical treatment was proposed more often for the adenocarcinoma group (respectively radio-surgery combination 73%, radiotherapy alone 18%, surgery 9%); in the epidermoid carcinoma group, combined radio-surgical treatment and radiotherapy were the usual treatment (46%); surgery alone appeared in third rank place (8%). Adenocarcinoma pelvic recurrences appeared more frequently (28.6% for adenocarcinoma group versus 13.3% for epidermoid group p< 0.05), while distant recurrence was the same (12. 2% for adenocarcinoma group versus 11.2% for epidermoid group, p< 0. 05). Five years overall survival rate was worse for the adenocarcinoma group (52% versus 63.7%, p< 0.05) but the difference was not significant for the disease free survival rate. Only for stage Ib, there are also more pelvic recurrences (35.4% versus 13.1%, p< 0.05), more distant recurrences (9.6% versus 2.6%, p< 0.05), and lower overall survival for adenocarcinomas (58.7% versus 88.5%, p< 0. 01). CONCLUSION: The incidence of adenocarcinomas is slightly increasing (absolute value in our experience) and the low stages seem to be more frequent in our experience probably by staging inaccuracy. Adenocarcinoma prognosis seems to be worse because of its poor radio-sensitivity. It seems necessary to optimize clinical staging and therapeutic protocols excluding radiotherapeutic approach, including surgical purposes or radio-surgical associations if unfavorable histological features or tumoral enlargement (T> 3 cm) are found.

[Metrorrhagia during the second trimester of pregnancy: obstetrical and perinatal outcome. A retrospective study including 85 cases]. / Métrorragies du deuxième trimestre de la grossesse: devenir obstétrical et périnatal.

OBJECTIVE OF THE STUDY: To examine pregnancy outcome in patients with second-trimester vaginal bleeding and to determine a relationship between presumed etiology and perinatal outcome. MATERIAL: and methods: A retrospective study performed in Toulouse La Grave CHU between January 1993 and December 1997 including 85 cases of vaginal bleeding from 15 to 27 week's amenorrhea (90 fetuses). Results are compared to overall deliveries during the same period (14941 deliveries). RESULTS: Mean age at diagnosis is 29.8 years (SD: 5.3 years). Vaginal bleeding in the midtrimester concern 0.57% of deliveries. Abnormal ultrasonographic findings are observed in 73% of patients (placenta previa, subchorionic hematoma, placental abruption) and 81% were hospitalized (mean hospital duration: 18 days). Perinatal mortality was 17.04% and preterm delivery rate 30.6% (vs 11% in the overall patients). Perinatal complications are significatively increased compared with the overall population especially if ultrasonographic examination was abnormal. Second-trimester placental abruption had the worse prognosis. On the other hand, perinatal outcome was comparable when the origin of bleeding was unknown and ultrasonographic examination normal. 41% patients underwent cesarean section. CONCLUSION: Preterm delivery, perinatal mortality and morbidity are increased in patients with second-trimester vaginal bleeding. The risk is higher when abnormalities are detected at ultrasonography making ultrasonography a useful tool for predicting perinatal outcome.

Intra-uterine fetal death following maternal varicella infection.

The association of varicella and pregnancy is very rare since 90% of women of reproductive age are immune. In the literature, a fetal varicella syndrome has been described characterized by multiple congenital malformations. We report here a case of intrauterine fetal death following maternal varicella at 17 weeks amenorrhea, with virological proof of fetal contamination. Because of the rarity of this association and by the same token of the fetal contamination during maternal varicella, the management during pregnancy rests essentially on a valid ultrasonic surveillance.