[Abortion law in France]. / Interruption volontaire de grossesse : le cadre juridique français.

The French law of 17 January 1975 relative to abortion, called Veil law decriminalized abortion. Since intervened many legislative changes that now allow completion of the surgical or medical abortion. This text provides an update on legislative developments and case law for practice.

[Induced abortion: Guidelines for clinical practice - Text of the Guidelines (short text)]. / L'interruption volontaire de grossesse : recommandations pour la pratique clinique ­ Texte des recommandations (texte court).

OBJECTIVE: Develop recommendations for the practice of induced abortion. MATERIALS AND METHODS: The Pubmed database, the Cochrane Library and the recommendations from the French and foreign Gyn-Obs societies or colleges have been consulted. RESULTS: The number of induced abortions (IA) has been stable for several decades. There are a lot of factors explaining the choice of abortion when there is an unplanned pregnancy (UPP). Early initiation and choice of contraception in connection to the woman's life are associated with lower NSP. Reversible contraceptives of long duration of action should be positioned fist in line for the teenager because of its efficiency (grade C). Ultrasound before induced abortion must be encouraged but should not be obligatory before performing IA (Professional consensus). As soon as the sonographic apparition of the embryo, the estimated date of pregnancy is done by measuring the crown-rump length (CRL) or by measuring the biparietal diameter (BIP) from 11 weeks on (grade B). Reliability of these parameters being±5 days, IA could be done if measurements are respectively less than 90mm for CRL and less than 30mm for BIP (Professional consensus). A medical IA performed with a dose of 200mg mifepristone combined with misoprostol is effective at any gestational age (EL1). Before 7 weeks, mifepristone followed between 24 and 48hours by taking misoprostol orally, buccally sublingually or eventually vaginally at a dose of 400 ug possibly renewed after 3hours (EL1, grade A). Beyond 7 weeks, misoprostol given vaginally, sublingually or buccally are better tolerated with fewer side effects than oral route (EL1). It is recommended to always use a cervical preparation during an instrumental abortion (Professional consensus). Misoprostol is a first-line agent for cervical preparation at a dose of 400 mcg (grade A). Aspiration evacuation is preferable to curettage (grade B). A perforated uterus during an instrumental suction should not be considered as a scarred uterus (Professional consensus). IA is not associated with increased subsequent risk of infertility or ectopic pregnancy (EL2). The pre-abortion medical consultations does not affect, most of the time, the decision to request an IA. Indeed, a majority of women is quite sure of her choice during these consultations. Acceptability of the method of IA and satisfaction appears to be larger when they are able to choose the abortion method (grade B). There is no relationship between an increase in psychiatric disorders and IA (EL2). Women with psychiatric histories are at increased risk of mental disorders after the occurrence of an UPP (EL2). In case of instrumental abortion, oral estrogen-progestogen contraceptives and the patch should be started from the day of the abortion, the vaginal ring inserted within 5 days of IA (grade B). In case of medical abortion, the vaginal ring should be inserted within a week of taking mifepristone, oral estrogen-progestogen contraceptives and the patch should be initiated on the same day or the day after taking prostaglandins (grade C). In case of instrumental abortion, the contraceptive implant may be inserted on the day of the abortion (grade B). In case of medical abortion, the implant can be inserted on the day of mifepristone (grade C). The copper Intrauterine Device (IUD) and levonorgestrel should be inserted preferably on the day of instrumental abortion (grade A). In case of medical abortion, an IUD can be inserted within 10 days following mifepristone after ensuring by ultrasound of the absence of intrauterine pregnancy (grade C). CONCLUSION: The implementation of these guidelines may promote a better and more homogenous care for women requesting IA in our country.

Nonsurgical treatment of heterotopic pregnancy: a report of six cases.

OBJECTIVE: To evaluate nonsurgical management of heterotopic pregnancy. DESIGN: Retrospective case series. SETTING: Department of Obstetrics and Gynecology (Antoine Béclère Hospital, Clamart, France, Paris-Sud University). PATIENTS: Six women with heterotopic pregnancy who conceived in four cases after ovulation induction. INTERVENTION: Transvaginal ultrasound (US)-guided aspiration/injection of potassium chloride (KCl) was performed in three cornual pregnancies with alive embryo. Expectant management was realized in three other cases. The regression was followed by serial US examination. MAIN OUTCOME MEASURES: Early and late complications related to the procedure, outcome of intrauterine pregnancy (IUP). RESULTS: Five of six patients were treated successfully (3 with KCl and 2 after expectant management). Three of these five patients had a spontaneous vaginal delivery, and two abortions occurred in the remaining two patients. Salpingectomy had to be performed in one case 10 days after medical treatment. This twin pregnancy ended with an abortion at 23 weeks of amenorrhea. Four cornual heterotopic pregnancies were treated successfully. No complication occurred after the initial management. CONCLUSION: Ultrasound permits a reliable and early diagnosis of heterotopic pregnancy. In such cases nonsurgical management is an efficient alternative with a good IUP prognosis.

Thrombophilia and fetal growth restriction.

OBJECTIVE: Genetic thrombophilia may represent a new risk factor for obstetrical complications. The aim of the study was to determine which subgroups may be associated with genetic thrombophilia for small for gestational age infants (SGA). METHODS: A case-control study was performed in three different maternity wards in Normandy. Cases (n=203) were women who had pregnancies complicated by unexplained SGA infants defined as a birth weight below the 3rd centile and control subjects (n=203) were women who had infants with birth weight > or =10th centile. Patients were tested in the immediate postpartum period and 2 months later for factor V Leiden mutation, and prothrombin 20210A mutation. Frequencies of these mutations were observed in different subgroups of SGA infants depending on pregnancy or neonatal outcomes usually associated with intrauterine growth restriction (IUGR), and were then compared with the overall prevalence for these mutations detected in the control group. RESULTS: Prevalences for factor V Leiden mutation (or=2.58; 95% confidence interval: 0.83-8.04), prothrombin 20210A mutation (or=2.03; 95% confidence interval: 0.51-8.01), were comparable between cases and controls (4.9% versus 1.9% and 2.9% versus 1.4%, respectively). Frequencies for these two polymorphisms significantly increased in subgroups of SGA infants with a normal Pourcelot index (13/133 versus 7/203; P=0.04), a gestational age > or =37 weeks of gestation (15/143 versus 7/203; P=0.01), a vaginal delivery (11/117 versus 7/203; P=0.04), a birth weight > or =2000 g (12/121 versus 7/203; P=0.03), no admission to paediatric ward (11/116 versus 7/203; P=0.01), a low Ponderal index <2.5(e) centile (6/45 versus 7/203; P=0.04), and normal head circumference >10th centile (7/53 versus 7/203; P=0.01) in comparison with the control group. CONCLUSIONS: An association was found between polymorphisms for factor V Leiden and prothrombin, and asymmetrical intrauterine growth restriction with immediate favourable neonatal outcomes.

Obstetric patients treated in intensive care units and maternal mortality. Regional Teams for the Survey.

OBJECTIVE: To ascertain the frequency of serious diseases in pregnant women. STUDY DESIGN: A population based survey was performed in France. The cases were all the women admitted for treatment in intensive care unit (ICU). The severity of the cases was measured with the simplified acute physiology score (SAPS) the lethality and the rate of still birth. RESULTS: 435 obstetric patients were included. The estimated frequency of severe diseases was 310 S.D.36 per 100,000 live births. The most frequent diagnose that motived admission in ICU was hypertensive diseases. The lethality rates differed greatly between specific disorders. The lethality rate was lower when scheduled maternity was located in a teaching hospital. CONCLUSION: Regarding these results it appears that the majority of obstetric patients with severe diseases are referred to suitable care, but a small proportion of women who had to change their type of care registered a significant higher lethality.

Selective percutaneous coronary arteriography: an experience with 600 procedures.

Six hundred selective percutaneous coronary angiographies have been performed, using the Judkins technique. The procedure was well tolerated even by critically ill patients. Considering the low risk (mortality: 1.7%), the relatively infrequent complications (2.7%) and the value of the information obtained, selective coronary arteriography is a prerequisite to any meaningful surgery.

Congenital arteriovenous fistula of the internal mammary vessels: report of a case and review of the literature.

The case of a congenital arteriovenous fistula of the internal mammary vessels in a 41 year-old woman has been reported, and the pertinent literature briefly reviewed. These rare lesions may become apparent only relatively late in life. The accompanyiny signs are often misleading. In view of the uncertain long-term outlook, surgery seems indicated.

The late post-operative patency rate of aorto-coronary venous grafts.

Long-term aorto-coronary venous graft patency has been examined in a consecutive series of 47 patients (average: 1.6 graft per patient) after a mean follow-up period of 5 years and 9 months (44-108 months) post surgery. Overall patency rate was 71% (52/73 grafts), with the best results for LAD grafts 85% (27/32). Seventy-seven percent of the patients experienced lasting relief from angina. Significant improvement of LV ejection fraction was observed in cases with patent grafts.

Effect of low left ventricular ejection fractions on the outcome of primary coronary by-pass grafting in end-stage coronary artery disease.

Advanced ischemic heart disease (HID) with very low left ventricular ejection fraction (LVEF), pulmonary hypertension (PHT) with or/without left ventricular aneurysm (LVA) are criteria for defining end-stage coronary artery disease (ESCAD). Coronary artery by-pass grafting is often denied to these patients. Between January 1990 and December 1993, 91 patients with ESCAD, significant 2 or 3-vessel disease (stenosis > or = 70%) and LVEF < or = 25% underwent primary CABG at our institutions. The mean age was 62.5 +/- 8.0 years (41-81), 89% were men. Eighty-one patients were in preoperative NYHA (New York Heart Association) functional class 3 and 4. Mean LVEF was 21.3 +/- 3.8% (10-25). Mitral regurgitation (MR) was present in 39/91 (43%). The systolic pulmonary artery pressure (PAP) was 33.2 +/- 17.1 mmHg (11-75) and the wedge pressure was 19.0 +/- 10.8 mmHg (5-47). Twenty-two patients had significant PHT with a systolic PAP > or = 40 mmHg. The overall perioperative mortality was 14.3% (13/91). Low postoperative cardiac output occurred in 33 patients, requiring intraaortic balloon support in 13. Gastrointestinal complications occurred in 6 patients and neurological events in one. Fifteen patients had additional left ventricular aneurysm repair. There was a good correlation between LVEF and PAP (r = 0.782). Surprisingly, in a subset of patients with preoperative PHT and LVEF < or = 25% the mortality rate was only 4.6% (1/22). Other perioperative complications did not differ.(ABSTRACT TRUNCATED AT 250 WORDS)

[Stenosis of the left coronary trunk. Apropos of fifteen cases]. / Les sténoses du tronc coronaire gauche. A propos de quinze cas

Stenosis of the left main trunk was revealed by selective coronary angiography in 15 patients among the 567 who were investigated (2.6%). No case of total occlusion was observed. There was no fatality due to the procedure. As a rule other coronary vessels also show atheromatous lesions. Five patients were not operated: 3 died (60%) after a mean survival period of 14 months following angiography. Among the 10 others who underwent surgery there was no operative mortality, but 2 patients died in the postoperative period (20%). The 8 survivors have been followed for a period ranging from 8 to 61 months (mean: 36 months). All are still alive and much improved clinically. Once the diagnosis of left main trunk stenosis has been established, early surgery should be considered.

[Value of echocardiography in the diagnosis of Uhl's disease. Apropos of a case in an adult]. / Intérêt de l'échocardiographie dans le diagnostic de la maladie de Uhl. A propos d'une observation chex l'adulte.

Uhl's anomaly, or paper thin right ventricle is a rare congenital malformation which may present with variable degrees of hypoplasia. The most severe forms are encountered in infants and children, but a less serious form occurs in adolescents and adults which, clinically. There are a number of echocardiographic features common to both diseases but paper-thin right ventricle may be distinguished by the finding of premature opening of the pulmonary value. The increased atrial contraction in these patients with right ventricles of reduced compliance is directly transmitted to the pulmonary artery, leading to end diastolic opening of the pulmonary value before tricuspid closure. The case presented underlines the value of M mode echocardiography in the diagnosis of Uhl's anomaly and in the differential diagnosis with Ebstein's anomaly.

[Interventricular septum. Angiographic and echocardiographic correlations]. / Septum interventriculaire. Corrélations angiographiques et échocardiographiques.

The diastolic thickness of the interventricular septum was measured by echocardiography and by biventricular angiography in 48 patients (40 male, 8 female) with age ranging between 15 and 67 years (average 44.4 years). These patients were classified in four groups according to clinical and paraclinical parameters:--normal subjects (29 cases),--patients with concentric hypertrophy (5 cases),--patients with asymmetrical septal hypertrophy without obstruction (4 cases),--patients with hypertrophic cardiomyopathy with obstruction under basal conditions or under stress (10 cases). Biventricular cineangiography was performed in 70 degrees left anterior oblique projection after measuring the intracavitary pressures. Analysis was performed by projecting the film and reproducing one or several diastolic frames on paper. Septal thickness was measured at the two levels suggested by Redwood. The septum was then divided into 5 parts and the thickness measured at the corresponding 4 levels. The values obtained were then corrected for magnification artefact. Qualitative comparison of the results obtained by echocardiography and angiocardiography showed a good correlation in 35 cases (73%) and less significant correlations in the other 13 cases (27%). The poorest correlations were observed in the groups of patients with concentric or asymmetrical hypertrophy without obstruction. Of these 13 cases, angiography confirmed the clinical diagnosis in 6 cases. In the remaining 2 cases, echocardiography and angiocardiography gave divergent diagnoses which also differed from the clinical diagnosis. The quantitative correlations between the echocardiographical and angiocardiographic measurements of diastolic septal thickness were quite satisfactory in most patients. The correlation improved when the echocardiographical measurement was compared to an average of the 4 angiographical measurements; (R = 0,74; p < 0.001). The correlation was poorer in groups 2 and 3 in patients with concentric or asymmetrical hypertrophy without obstruction. The disadvantages and limitations of these two methods are discussed. Possible ambiguity in the identification of segments of the septum measured by the two methods may be a significant factor especially in cases of asymmetrical hypertrophy.

[Permeability of venous aortocoronary bypass 5 years later]. / Perméabilité à 5 ans des pontages veineux aorto-coronariens.

47 consecutive patients who had undergone aorto-coronary venous bypass surgery (mean: 1.6 graft per patient) have been investigated after a mean follow-up period of 5 years and 9 months (range: 44-108 months). 52 grafts out of 73 were found to be patent (71 p. 100), the best patency rate being shown by grafts on the LAD artery (27/32 = 85 p. 100). Long-term graft patency may be associated with an improved left ventricular ejection fraction; 77 p. 100 of the total patients experienced a lasting clinical benefit from the operation.

[Percutaneous selective coronarography. Apropos of 600 cases]. / La coronarographie sélective percutanée. A propos de 600 examens

600 selective coronary angiographies were performed in 559 patients, using Judkins preformed transfemoral catheters. One fatality was deplored (mortality: 0,17 p. 100). 15 cardiac complications were observed 2,5 p. 100), 10 of which were severe but rapidly corrected arrhythmias. Among these 559 patients 495 were clinically cases suffering from probable or certain coronary heart disease. 88 p. 100 of this group were men. Selective coronary angiography revealed stenosis with decrease of at least 50 p. 100 of the lumen in over 80 p. 100 of the cases. The anterior descending was the most frequent site of stenosis. In the majority of cases, and especially in men, two or several vessels were diseased. There is some relationship between the development of collateral circulation and the extension of coronary disease. In one third of the cases, ventricular function, assessed by measurement of the ejection fraction was impaired.

[Angiographic study of the dynamics of the interventricular septum]. / Etude angiographique de la dynamique du septum interventriculaire.

The interventricular septum was studied by biventricular angiography in 52 patients divided into 4 groups: the first group consisted of 14 normal subjects; the second of 10 patients with hypertension (9 cases) or aortic stenosis (1 case); the third, of 19 patients with echocardiographic asymmetric septal hypertrophy, and the fourth, of 9 cases of cardiomyopathy with dilatation. The following parameters were measured: septal thickness at 4 different points and mean septal thickness, the height (long axis) and surface of the septum in diastole and systole. The percentage variation was calculated. There were no significant differences between Group I and II; there was a significant difference (p less than 0,01) in the variations of septal thickness of the upper segments between Group I and III. This difference remained significant (p less than 0,05) for the variations of mean thickness between Group I (-38%) and Group III (-18%). There was also a significant difference (p less than 0,05) in the variation of height between Group I (23%) and Group IV (9%). None of the variations of septal surface reached the threshold of statistical significance between the four groups. Biventricular angiography can therefore demonstrate certain abnormalities of septal motion. In asymmetric septal hypertrophy, the variations in thickness are significantly less pronounced than in normal subjects but the motion in the longitudinal axis does not differ significantly. In cardiomyopathy with dilatation, however, the variation in septal height is the most affected parameter.

[Postpartum septic arthritis. Two case reports]. / Arthrites septiques du post-partum. A propos de deux cas.

Nongonococcal septic arthritis can occur during the postpartum period. We report two cases, one involving the wrist and the sacroiliac joints and the other the pubic symphysis. The difficulty of initial diagnosis in the postpartum period is emphasized. This pathology is uncommon and may begin insidiously. The sacroiliac joint is particularly at risk for postnatal sepsis, but its deep localization hinders investigations. Besides the classical obstetrical infectious assessment (blood cultures, urine culture, vaginal sample, white blood cell count and CRP) and radiological investigations, joint puncture is needed to isolate the causal infectious agent. Joint immobilization in combination with major 3-month antibiotic therapy is usually successful, generally with no sequellae.

[Medical and ethical problems posed by the prenatal diagnosis of distal absence of a limb]. / Problèmes médicaux et éthiques posés par le diagnostic anténatal d'une amputation distale d'un membre.

Eight cases of distal amputation of limb are reported. The diagnosis were made by ultrasound scans at 18-25 weeks of amenorrhea. In all cases, according to the French law, our team of fetal medicine refused the therapeutic terminations of pregnancy requested by the parents. The therapeutic terminations of pregnancy were achieved by another unit of fetal medicine in France, or in another country. These reported cases address many questions about the aim of fetal medicine (therapeutic terminations of pregnancy or treatment of infants), the place of the parents request in the decision, the different decision arguments, and the variations in the decision between different fetal medicine crew facing to similar prenatal diagnosis.

[Factors predictive of uterine rupture after operative hysteroscopy]. / Facteurs prédictifs de rupture utérine obstétricale après hystéroscopie opératoire.

OBJECTIVES: To identify factors predictive of uterine rupture after operative hysteroscopy. When these factors are present, to search for means to prevent a later uterine rupture. Lastly to specify criteria allowing extraction of the fetus before rupture. PATIENTS AND METHODS: Dramatic description of a case of uterine rupture, in a patient who presented a history of uterine perforation secondary to operative hysteroscopy and retrospective analysis of 12 similar observations reported in the literature. RESULTS: Two types of situations must be differentiated: uncomplicated hysteroscopic resection of a polyp or sub-mucous fibroid does not seem to modify the obstetrical outcome; metroplasty for uterine malformation, complex synechia resections, and uterine perforations using monopolar current section are high-risk situations predictive of uterine rupture during pregnancy. CONCLUSION: Uterine ruptures secondary to operative hysteroscopy are rare but serious. They can occur before onset of labor, and compromise vital maternofetal outcome. Risk factors can be identified, but nothing can prevent natural history towards uterine rupture during pregnancy. The obstetrician's vigilance in this context must be extreme searching for the least clinical sign in favor of a pre-rupture of the uterus. Furthermore, systematic caesarean is not justified.

[Gestational age and fetal lung maturity]. / Age gestationnel et maturité pulmonaire foetale.

In order to assess the lung maturity of the fetus, a biochemical analysis using two reliable, simple and rapid methods (FLM-TDX Abbott and determination of phosphatidylglycerol (PG) have been carried out on 166 amniotic fluids taken by amniocentesis. The patients were particularly pregnant women presenting disorders such as diabetes (n = 41), premature rupture of the membranes (n = 30), hypertension (n = 20), intra uterine growth retardation (n = 13) and gemellar pregnancies (n = 27). The lung maturity of the fetus has been considered as mature (no risk of any hyaline membrane disease: HMD) when the phospholipid rate is higher than 50 mg/g albumin (FLM-TDX Abbott), associated or not with the presence of PG (PG positive). The latter phospholipid was present only in women whose pregnancy was about 35 weeks. Besides, our results show a very large disparity of the phospholipid rates (FLM-TDX) in the amniotic samples for an identical gestational age. Values from 9 to 124 for pregnancies with term of 31 weeks, and from 21 to higher than 160 for those of 38 weeks. In infants born not later than 48 hours after the amniotic punction (n = 30), four of them presented an HMD. The FLM-TDX values were less than 30 for three cases and equal to 52 for the fourth. The term of these newborns was 37 weeks or more for three of them, and 31 weeks for the last one. Our study confirm that the TDX-FLM Abbott is useful to assess the fetal lung maturity and does not correlate with the gestational age.

[Chorioangioma of the placenta. Echographic, radiologic and anatomo-pathologic correlations]. / Le chorioangiome placentaire. Corrélations échographiques, radiologiques et anatomo-pathologiques.

Chorangioma, one of the most frequent placental tumors, is associated with an important perinatal morbidity and mortality. We describe the case of a pregnant woman in whom this tumor was diagnosed during a routine obstetric investigation. The originality of our report is a strong and clear correlation between echographic, radiologic and histopathological findings. To avoid its obstetric and perinatal dramatic complications, we review the main echographic patterns allowing an early diagnosis of chorangioma.