[Management of malignant gliomas diagnosed during pregnancy]. / Prise en charge des gliomes malins découverts au cours d'une grossesse.

INTRODUCTION: Glioma is seldom diagnosed during pregnancy. In this situation management presents difficult problems for both neuro-oncologists and obstetricians. We report four cases and discuss the management of this unusual situation. CASE REPORT: The first patient was admitted to hospital at 29 weeks' gestation because of a generalized seizure and a right hemiparesis. MRI showed a left fronto-insular lesion. A stereotactic biopsy was obtained and revealed an anaplastic oligodendroglioma. With corticosteroids the patient remained stable until cesarean delivery at 36 weeks. In post-partum additional treatment with chemotherapy was started. The second patient was hospitalized at 26 weeks' gestation because of cranial hypertension, right hemiparesis and aphasia. MRI showed an important left fronto-parietal lesion. Partial resection was performed at 28 weeks. Histology revealed a glioblastoma multiforme. With corticosteroids the patient remained stable until cesarean delivery at 33 weeks. In post-partum additional treatment with radiotherapy and chemotherapy was started. The third patient was admitted to the hospital at 12 weeks' gestation because of cranial hypertension. MRI showed a left frontal lesion. A subtotal resection was done at 13 weeks. Histology revealed a glioblastoma multiforme. Two weeks after surgery the patient's neurological condition worsened and in agreement with the patient a therapeutic abortion was decided. Afterwards additional treatment with radiotherapy and chemotherapy was started. The last patient received combined treatment with radiotherapy and chemotherapy for local recurrence of a mesencephalic high-grade glioma. A posteriori it was discovered that the patient was at 4 months' gestation during this treatment. Cesarean delivery was done at 36 weeks. The child was normal at birth and is still in good health 5 years later. CONCLUSION: The management of gliomas diagnosed during pregnancy should not be different from the standard management of gliomas in young non-pregnant adults. Pregnant women because of their young age can have a long survival. Their pregnancy should not prevent them from receiving the best treatment for their glioma. Treatment will depend upon clinico-radiological presentation, histology, gestational age and the patient's desires. Generally speaking, surgical resection of high-grade gliomas should not be delayed during pregnancy. Progress in anesthesia and neurosurgery have greatly reduced the risks for the foetus. After delivery, if the delay between surgery and delivery is too long it is possible to begin cerebral radiotherapy during pregnancy. After the first trimester of gestation this treatment can be given without any important risks for the child.

[Cystic fibrosis and pregnancy: report of a twin pregnancy and review of the literature]. / Mucoviscidose et grossesse: á propos d'un cas de grossesse gémellaire et revue de la littérature.

We report here the first published case of twin pregnancy in a woman with cystic fibrosis. This situation will become more and more common because the increased life expectancy of patients with cystic fibrosis and the development of medically assisted procreation. Conception of this twin pregnancy was medically assisted in a cystic fibrosis woman with moderate pulmonary disease. This observation is in accordance with several recent reports dealing with single pregnancies: morbidity, mortality and degradation of lung function have not been found to increase. The only effect of cystic fibrosis on pregnancy is an increased risk of preterm delivery. There is thus no systematic contraindication to pregnancy among women with cystic fibrosis provided that they are given attentive care by a multidisciplinary team. Genetic counselling and prenatal diagnosis also have an important role to play.

[The administration of micronized progesterone in the treatment of threatened premature labor]. / L'administration de progestérone micronisée au cours du traitement de la menace d'accouchement prématuré.

A randomised double-blind placebo-controlled trial concerning the treatment of threatened premature labour was undertaken using the following methodology: beta-mimetics were given intravenously to all patients (44) and micronised progesterone or the placebo were prescribed orally after randomisation (22 patients in each group). The mean index of prolongation of pregnancy was similar in both groups. However, the mean duration of the intravenous infusion and the mean dose of beta-mimetics administered intravenously were significantly lower in the oral progesterone group (p less than 0.01). Similarly, there was a significant (less than 0.05) decrease in the mean duration of hospitalisation. The cost and risks of treatment are thus significantly reduced when beta-mimetics and oral progesterone are used in combination.

[Echographic guided puncture of ovarian cysts. Possibilities and limitations]. / Ponction échoguidée des kystes de l'ovaire. Possibilités et limites.

Ultrasound-guided puncture is a simple and easy to perform procedure. It would seem to be a good idea to suggest simple puncture as a first intention in cases of an image of ovarian cyst. In theory, the advantages are obvious: a puncture is performed, the liquid is analyzed and an appropriate treatment is administered. Coelio-surgery could surely be avoided in cases of functional cysts and perhaps in some non-malignant ovarian cysts. In fact, it must be remembered that a cancer of the ovary in its early stages may have the appearance of a banal cyst, and that puncture does not allow pathological examination. Cytological examination is insufficient to totally rule out malignancy or to allow detailed histological diagnosis. There is, therefore, a risk of leaving in place the pocket of a cyst which may be organic and which may recur or even develop. For these reasons, ultrasound-guided puncture can be undertaken only in pre-selected patients and in the context of a specific protocol: 1) The ultrasound image of the cyst must be liquid, anechoic, unilocular (or bilocular with a fin wall), with no vegetation, the serum level of CA 125 must be low; 2) it the puncture liquid is oily, tarry or viscous, a celioscopy must be carried out as soon as possible, only a yellow-colored liquid can justify waiting; 3) the analysis of the cyst fluid is not always determinant, and the cytology findings are conclusive only if positive. A high 17 beta-estradiol level suggests a functional cyst.(ABSTRACT TRUNCATED AT 250 WORDS)

The use of micronized progesterone in the treatment of menace of preterm delivery.

The results of a study concerning the treatment of acute menace of preterm labor are given: beta-mimetics were administered intravenously in all cases (44) and micronized progesterone or placebo was administered orally after classical double-blind randomization (22 cases in each group). The mean index of pregnancy prolongation was the same in both groups. However the mean duration of the intravenous perfusion and the mean quantity of beta-mimetics administered intravenously were significantly reduced in the progesterone group (P less than 0.01). The mean duration of hospital stay was also significantly reduced (P less than 0.05). Cost and risks are finally significantly lessened.

[The management of pregnant women presenting with genital HPV infections]. / Conduite à tenir chez la femme enceinte présentant une infection génitale à HPV.

The number of genital HPV infections has increased these past few years and, at present, 1 to 3% of pregnant women are infected. Before all treatment, a precise evaluation of the lesions is essential. The condylomata acuminata, and the plane condylomata associated or not to a slightly atypical lesion can be treated by CO2 laser spraying. This treatment is not recommended in cases of severe dysplasia because of possible adjacent micro-invasion. The questionable conization during the first trimester is not recommended after the latter. Systematic prophylactic caesarian section is indicated only in voluminous and diffuse florid condylomata which have not been treated or which persist after treatment.

[Gynecological surgery under local anesthesia]. / Chirurgie gynécologique sous anesthésie locale.

Local anesthesia allows interruptions of pregnancy until the 16th week; it also permits endo-uterine exploration, conization and treatment of synechiae. In terms of the breast, local anesthesia is indicated for the excision of palpable lesions, benign a priori, regardless of their size or location. The risk of overdose and vascular crossing is lower than with general anesthesia. It reduces hospital stay to a few hours but must be performed in a well-equipped operating suite in case of a possible complication.

[Cesarean section before the end of 32 weeks of amenorrhea]. / Les césariennes avant 32 semaines révolues d'aménorrhée.

The authors report the results of 59 caesarean operations in which 74 children were born before the end of the 32nd week of amenorrhoea. The gross mortality was 21.9% and the corrected mortality 18.5%. 7.9% of the infants had major neurological sequellae and 8.6% mild sequellae. 65.2% are alive and well with normal psychomotor development. The follow-up has been between 1 and 5 years. The factors that influence survival and the indications for caesarean section at this time are reviewed and discussed.

[Severe postpartum hemorrhage]. / Les hémorragies graves de la délivrance.

The authors report 95 cases of post-partum haemorrhage estimated at one litre or more seen in the Department of Obstetrics between 1979 and 1982 for 11 662 deliveries. Classical treatment combining artificial delivery or uterine manual evacuation-oxytocics led to the arrest of bleeding in 73 cases. Severe haemorrhage persisted in 22 cases, including 13 patients who were found to be suffering from a coagulopathy. Treatment of these severe forms is based upon: local haemostasis (in the presence of inertia, prostaglandins must be used before surgery) and correction of the coagulation disorder by substitution therapy providing the missing factors.

[Treatment of cancer of the uterine cervix by surgery alone]. / Le traitement du cancer du col utérin par la seule chirurgie.

The authors report a series of 434 patients with invasive cancer of the uterine cervix treated with primary surgery. The results are equivalent to those reported by others who treated cervix cancer with radiotherapy. Post-operative radiotherapy did not improve the results except in the most advanced forms (pT2b, pN1 or 2) when it increases the disease-free interval without altering the survival probability at 5 years. For the clinical stages I, IIA and IIB proximal (infiltration of the parametrium limited to the proximal part) surgery is the elective treatment. In stage IIB distal and for "operable" Stages III and IV, a combination of chemotherapy-surgery and radiotherapy is suggested.

[Laparoscopic sterilization under local anesthesia]. / La sterilisation per coelioscopique sous anesthesie locale.

PIP: Laparoscopic sterilization with local anesthesia is almost never done in Europe at present. The authors were moved to undertake use of local anesthesia in an effort to reduce hospital stays to meet the needs of some patients and to put the few available hospital beds to maximal use. The anesthetist sees all patients before the procedure. An electrocardiogram, chest X-ray, and blood work are done. A perfusion of isotonic glucose serum is installed for the procedure, and local anesthesia is achieved with xylocaine 1% with a vasoconstrictor to prevent too rapid diffusion of the xylocaine. The steps in the procedure are the administration of the paracervical block, establishment of the pneumoperitoneum by the posterior vaginal route using C02, administration of cutaneous abdominal anesthesia using the same mixture, anesthetizing of the tube with lidocaine 4%, and sterilization, which may be done by thermocoagulation or mechanical means. Only 9 sterilizations under local anesthesia have been performed by the authors. The total duration of the procedure is about 20 minutes. The pneumoperitoneum has been well tolerated by patients if it does not exceed 2 liters. Only 1 patient was unfit for discharge on the evening of the procedure. The risk of the procedure is decreased because there is no general anesthesia, but some cooperation from the patient is required.^ieng