[Autoimmune hepatitis and pregnancy: about a patient's three consecutive pregnancies]. / Hépatite auto-immune et grossesse: à propos de trois grossesses consécutives chez une patiente.

Spontaneous evolution of autoimmune hepatitis during pregnancy is not well known, nor are its consequences on pregnancy evolution. Immunosuppressive treatment during pregnancy is sometimes necessary but the long- and short-term consequences are unrecognized. We relate a patient's disease with autoimmune hepatitis and cirrhosis and three consecutive pregnancies with different obstetrical and medical complications.

[Breech presentation and vaginal delivery: evolution of acceptability by obstetricians and patients]. / Accouchement du siège par voie vaginale: évolution de l'acceptabilité par les obstétriciens et les patientes.

OBJECTIVE: To investigate the influence of obstetrician and patient respectively on mode of delivery in case of breech presentation at term. PATIENTS AND METHODS: This retrospective study included all women with a singleton pregnancy in a breech presentation delivered at term in a tertiary care maternity unit from January 1998 to December 2004. Mode of delivery was suggested by a score based on maternal age, parity, obstetrical past history, radiopelvimetry and cephalopelvic confrontation. The obstetrician was free to follow or not the score indication and patient's informed consent was required concerning the mode of delivery. Our main outcome measurements were mode of delivery and neonatal parameters. RESULTS: Two hundred cases were identified. Elective cesarean section increased progressively (from 52% in 1998 to 80% in 2004 [P=0,002]). Neonatal status and proportion of score in favour of vaginal birth remained stable during the study period. The rise in cesarean section rate was mainly due to patient's request (P=0,001) whereas the trend of obstetrician in favour of cesarean did not reach significance (P=0,3). DISCUSSION AND CONCLUSION: The rise of elective cesarean section for term breech delivery in a maternity unit using a predefinite score is mainly induced by patient's request. This evolution has no effect on neonatal status.

Trauma and endometriosis. A review. May we explain surgical phenotypes and natural history of the disease?

OBJECTIVE: The study was performed to evaluate whether trauma is an initial event of development of endometriosis. METHOD: Using Medline database from January 1960 up to December 2014, a systematic review was made of all published studies using the keywords trauma, healing, injury, infection, hyperperistaltism, stretch and endometriosis, adenomyosis and trauma. Studies and review articles written in French and/or in English related to the topic were included and reviewed independently by two authors. RESULTS: The role of trauma is well-established for endometriotic lesions diagnosed in surgical scars. Various traumas including delivery, uterine curettage or incision, intraperitoneal hemorrhage, or occult pelvic inflammatory diseases could be involved to explain other localizations of the disease. Many data suggested that the healing process, particularly growth factors and the associated estrogen production, may facilitate the implantation and the growth of ectopic endometrial cells. After the initial, a traumatic event, the phenotype of the disease would depend on the tissue in which the endometriotic lesion grows. CONCLUSIONS: The present literature review may support a potential role of a trauma as an initial event of endometriosis.

[About a case of uterine per-partum rupture, 37months after resection of a rectovaginal endometriosis nodule]. / À propos d'un cas de rupture utérine per-partum, 37 mois après une résection d'un nodule recto-vaginal d'endométriose.

Endometriosis is a common condition in women, whose main repercussions are painful symptoms. In addition, it was shown that endometriosis was a major cause of infertility and various obstetric complications could be related to this pathology. Uterine rupture is a rare but serious complication whose incidence tends to decrease with the screening of women at risk, however, its fetal, maternal morbidity and mortality causes remains important. We were confronted with a case of posterior uterine rupture in a patient of 36 years, primipare term exceeded in immediate postpartum period. The patient's primary antecedent of uterine surgery torus was responsible for infertility endometriosis. The outcome was favorable for the mother, after a surgical treatment by laparotomy, and for the child. In the literature, two cases have been reported of uterine rupture after endometriosis surgery, which is why we found it interesting to report this rare case. Given the increase in surgical management of this disease, it seems relevant to ask whether, in the future, we should be more vigilant in monitoring pregnancy for these women.

[Neonatal morbidity after conservative management followed by systematic delivery at thirty-four weeks of gestation in preterm rupture of membranes]. / Morbidité néonatale après attitude d'expectative suivie d'une naissance systématique à 34 semaines d'aménorrhée en situation de rupture prématurée des membranes.

OBJECTIVE: To evaluate the neonatal morbidity and its risks factors in case of uncomplicated preterm rupture of membranes managed conservatively with subsequent planned delivery at 34 weeks of gestation. PATIENTS AND METHODS: We studied retrospectively 42 consecutive neonates systematically delivered at 34 weeks of gestation after more than 48 hours of conservative management for uncomplicated preterm rupture of membranes. Conservative management was conducted in a single tertiary care center and consisted in corticotherapy and in antibiotherapy (amoxycilline during 7 days). We evaluated the neonatal mortality rate, the incidence of infection, respiratory distress, neurological disorders, and we looked for their prenatal risks factors. RESULTS: Forty-two neonates were included. The median gestational age at rupture was 31.1 weeks of gestation (from 25 to 33.9 weeks). The median duration of expectant management was 20 days (from 2.4 to 65 days). We observed 7 cases of neonatal infection but no septic failure, 18 cases of respiratory distresses among which 9 required a tracheal intubation for a mean duration of 3.7 days, no perinatal encephalopathy (5 cases of subependymal haemorrhage) and no neonatal death. We isolated one single risk factor that was the lowest gestational age at rupture in case of subsequent respiratory distress (29.6 vs 31.9 weeks; P=0.02). DISCUSSION AND CONCLUSION: Neonatal morbidity in this population consisted mainly in respiratory distresses with an increased incidence when gestational age at rupture decreased.

[Obstetrical prognosis of labour induction with mifepristone after 41 weeks of gestation]. / Pronostic obstétrical du déclenchement artificiel du travail au-delà de 41 semaines d'aménorrhée en fonction de la réponse à la mifépristone.

OBJECTIVE: To compare the mode of delivery in two groups of patients selected by their response after induction of labour with mifepristone. PATIENTS AND METHODS: We studied retrospectively 89 cases of labour induction with viable children after 41 weeks of gestation. Bishop scores were less than 6. Patients were given 200 mg of mifepristone per day for 48 h. They were retrospectively divided into group 1 (spontaneous onset of labour or premature rupture of membranes before the third day) and group 2 (not in labour by that date). RESULTS: The mean Bishop score at inclusion was 3.1 +/- 1.3. Among the 51 patients (53.9%) in group 1, one required prostaglandins and we performed 10 cesarean sections. In group 2, the mean Bishop score at the 3rd day was 4.4 +/- 1.3 (P < 0.0001). Twenty-four patients required prostaglandins (P < 0.0001) and we performed 17 cesarean sections (P = 0.01). The number of cesarean sections increased with the dose of prostaglandins (P = 0.025). We observed no maternal or fetal complications. DISCUSSION AND CONCLUSIONS: Mifepristone was successful in inducing labour spontaneously in over 50% of pregnancies after 41 weeks of gestation. In the other group, the probability of vaginal delivery was reduced especially when high doses of prostaglandins were required. After the use of mifepristone, we suggest to shorten the duration of prostaglandin administration (two applications of 2 mg dinoprostone) before performing cesarean section.

[Laparoscopy and gynecologic cancer: is it still necessary to debate or only convince the incredulous?]. / Coelioscopie et cancer en gynécologie? Faut-il encore débattre ou seulement convaincre les incrédules?

Many papers suggested that laparoscopic treatment of cancer could be achieved and taught safely. Although cases reports about trocar site metastasis and national survey about inadequate management of early ovarian cancer suggested that laparoscopic management of cancer may be dangerous. The current literature may be summarized as follows. An inadequate surgical management performed by laparoscopy as well as by laparotomy may worsen the prognosis of an early ovarian cancer. If the abdominal wall is protected with a bag and the tumour is not morcellated, the incidence of trocar site site metastasis is about 1%. Animal studies demonstrated that the laparoscopic management of cancer has both advantages and disadvantages. Preliminary results from prospective randomised trials in the treatment of colon cancer suggested that the survival rate is similar after laparoscopy and after laparotomy. The risk of dissemination appears high when a large number of malignant cells are present in patients operated using an increased abdominal pressure and a CO2 pneumoperitoneum. These data suggest that laparoscopic treatment of gynaecologic cancer is not dangerous if an adequate surgical technique is used. However morcellation of suspicious solid tumours, treatment of adnexal tumours with external vegetations but without peritoneal dissemination and of bulky lymph nodes should be considered as contra-indications to CO2 laparoscopy, puncture of an ovarian tumour with intracystic vegetations is a high risk situation which should be avoided whenever possible.

[Prevention of peritoneal adhesions]. / Prévention des adhérences péritonéales.

Peritoneal adhesions are a major problem for health and economy. An adequate and atraumatic surgical technique is essential in the prevention of peritoneal adhesions. Laparoscopic microsurgery should be developed and promoted. The following conclusions can be proposed about the treatments available Adequately designed clinical studies are too rare. Future studies are necessary to obtain information on pregnancy and pain as primary outcomes. Cost implications of adhesion prevention treatments also have to be addressed.

[Predictors of failed trial of labor in obese nulliparous]. / Facteurs prédictifs d'échec de l'intention de voie basse chez la primipare obèse.

OBJECTIVES: To identify predictors of failed trial of labour (TOL) in obese nulliparous at term. PATIENTS AND METHODS: Retrospective study about 213 nulliparous with a body mass index (BMI) greater than 30kg/m(2) who delivered a vertex singleton after 37 weeks of gestation (WG). Planned caesarean sections were excluded. Maternal, sonographic, per-partum and neonatal characteristics were analyzed according to the mode of entry into labor and delivery route. Univariate and multivariate logistic regression analysis were performed. RESULTS: The cesarean delivery rate was 28%. Induction of labor (aOR=4.3 [1.8-10.7]), prolonged pregnancy (aOR=10.8 [1.7-67.6]), macrosomia (aOR=5.6 [1.1-27.3]), meconium-stained amniotic fluid (aOR: 2.57 [1.03-6.42]), use of trinitrine (aOR=5.5 [1.39-21.6]) and neonatal head circumference greater than 35cm (aOR=3.1 [1.2-8.0]) were predictors of failed TOL. There was no significant correlation between failed TOL and preconceptional BMI. Univariate analysis revealed an association between excessive weight gain and failed TOL. DISCUSSION AND CONCLUSION: Predictors of failed TOL are the same in obese and non-obese women. Preconceptional BMI does not predict failed TOL in this nulliparous obese population.

[Interest of a structured laparoscopy training in a simulation center: survey of resident's point of view]. / Intérêt d'un enseignement structuré de la cœlioscopie en centre de simulation : enquête d'opinion auprès des internes.

OBJECTIVE: Assess residents satisfaction within their participation to a short and structured training to laparoscopy, gathering theoretical and practical issues. METHODS: This course was divided in two periods of 3days including an individual prospective evaluation. For each period, the residents have answered to three questionnaires trying to evaluate their experience in laparoscopy and their short term and medium term satisfaction. RESULTS: Three hundred residents from different French university hospitals have been involved in this study. After 4years, half of them were not satisfied with their chirurgical studies. Thirty-seven percent of them never attended to any surgical procedure as main operator. The training course has answered to their expectation for 95% of the residents and 85% said they now feel more confident about laparoscopy then before. According to 76% of them, it should be a compulsory and systematic training course and for 75%, they should be tested regarding their laparoscopy skills level during the resident studies period. The training on animals is the more efficient for 86% of them. CONCLUSIONS: Due to the increasing number of residents and to the legal time for rest, the time spent in the operative room has decreased. People also do not accept easily the training made on true patients. Intensive and tested training are useful and answer to residents needs. They could be systematically integrated in their global curriculum.