[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.

[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.

Real-time PCR quantification of human cytomegalovirus DNA in amniotic fluid samples from mothers with primary infection.

A real-time PCR assay was developed to quantify human cytomegalovirus (HCMV) DNA in amniotic fluid (AF) samples collected from 30 pregnant women with primary HCMV infection as detected either from HCMV-immunoglobulin G (IgG) seroconversion or by the presence of HCMV-specific IgG and IgM associated with a low IgG avidity. Clinical information available for each case included ultrasonographic examination and fetal or newborn outcome. HCMV infection of fetuses or newborns was confirmed for the 30 studied cases. AF samples were subdivided into three groups. In group A (n = 13), fetuses presented major ultrasound abnormalities, and pregnancy was terminated. In group B (n = 13), fetuses had normal ultrasound findings, the pregnancy went to term, and the newborns were asymptomatic at birth. In group C (n = 4), fetuses had no or minor ultrasonographic signs, and pregnancy was terminated. The HCMV DNA load values in AF samples were significantly higher in group A (median, 2.8 x 10(5) genome equivalents [GE]/ml) than in group B (median, 8 x 10(3) GE/ml) (P = 0.014). Our findings suggest that HCMV load level in AF samples correlates with fetal clinical outcome but might also be dependent on other factors, such as the gestational age at the time of AF sampling and the time elapsed since maternal infection.

[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.

[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.

[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.

[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.

[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.

[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.

Diagnosis of arachnoid cysts on prenatal ultrasound.

The aetiology and physiology of congenital arachnoid cysts are a source of controversy. We report a case where fetal cerebral ultrasonography shows an extraventricular sonolucent cystic formation after 20 weeks of pregnancy. Ultrasonography provides its topographic relations with adjacent brain structures and is also used to diagnose possible associated malformations. MRI confirms the ultrasonographic findings by investigating cerebral gyri. The rest of the examination involves detection of extracerebral anomalies and a karyotype study. Other differential diagnoses will be considered as a function of the embryological origin and topography of arachnoid cysts. The outcome of these arachnoid cysts depends on the age at the time of diagnosis, their size and their topography. The problem is that hydrocephalus, due to compression of the cerebrospinal fluid drainage pathways, may develop. Treatment, if necessary, is nearly always surgical.

Laparoscopic tubal anastomosis and reversal of sterilization.

Fallopian tube interruption is a common form of contraception worldwide. For a variety of reasons (e.g. change in marital status, wish for additional children, psychological factors), many of these women seek restoration of fertility. Laparoscopic tubal anastomosis is one of the newest of these procedures by which this can be achieved. Sixteen women underwent laparoscopic microsurgical anastomosis. We used a three-stitches technique with tubal cannulation adapted from methods described in the literature. Five pregnancies occurred, giving an overall pregnancy rate of 31.2%. Surgical outcome depends on the patient's age, the method of tube interruption and the length of Fallopian tube segments being anastomosed. In this study, the feasibility of laparoscopic tubal sterilization reversal is confirmed, as well as the benefits offered by laparoscopic procedures in terms of quality of life. Further improvement of surgical outcome will be achieved not only through better laparoscopic techniques but also through careful screening for surgical indications.

PIP: This study examined the reliability of laparoscopic tubal anastomosis, a commonly used birth control method. The study was conducted between January 1996 and December 1997 in 16 patients who underwent laparoscopic microsurgical tubal anastomosis. A technique requiring 3 stitches with tubal cannulation was used. Within a period of 6 months, there were 5 reported pregnancies, 1 ectopic and 4 ongoing. These showed a 31.2% overall pregnancy success rates. Mean age in the occurrence of pregnancies was 33.4 years. An association of infertility factors was found in 5 patients. Infertility factors included sperm abnormalities, tubal endometriosis, and salpingitis. From these findings, it was concluded that the surgical outcome depended on the patient's age, method of tube interruption and length of Fallopian tube segments to be anastomosed. Moreover, the study confirms the feasibility of laparoscopic tubal sterilization, as well as its offered benefits.

[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.

Laparoscopic douglasectomy in the treatment of painful uterine retroversion.

BACKGROUND: One of the etiologies of pelvic pain in women, often unrecognized, is the Masters-Allen syndrome, which was described in 1955 as the "universal joint cervix" syndrome. It has the following three elements: (1) etiology: obstetrics-related trauma; (2) clinical findings: uterine retroversion with hypermobile cervix following elongation or desinsertion of the uterosacral ligaments; (3) anatomy: visualization of a tearing of the posterior serosa and subperitoneal fascia of the ligamentum latum. METHODS: Forty-one laparoscopic Douglasectomies with uterosacral ligamentopexy were performed in the department of Gynecology at the University Hospital of Caen during the period between 1990 and 1995 in patients with painful retroverted uterus. The patient selection was made thanks to the "pessary test." The surgical endoscopic procedure, identical to the operation first promoted by Jamain and Letessier in 1976 by laparotomy, is described. RESULTS: Total pain relief was experienced by 31 patients (75%) and partial relief by five patients (5%). Two main complications occurred, requiring one laparotomy (bleeding from a pelvic varicose vein with a concomitantly occurring breakdown of the washing-aspiration system) and one second laparoscopy at day 15 (one case of hematoma below the peritonization revealed by pain). Twenty-three women became pregnant again, and had normal deliveries except for two cesareans, with no recurrence of pain. Douglasectomy is compared to alternative techniques in the literature. Other indications for Douglasectomy are discussed. CONCLUSION: Douglasectomy is the only definitive procedure for restoring normal anatomy of the pelvic floor in case of painful uterine retroversion occurring in a setting of Masters-Allen syndrome. Additionally, it provides for pathological analysis of the excised peritoneum. The results of this procedure are excellent when the indication is correctly set, particularly as concerns positive pessary testing.

Feasibility of and interest in laparoscopic assessment in recurrent urinary stress incontinence after Burch procedure performed by laparotomy.

BACKGROUND: The Burch colposuspension, performed by laparotomy or laparoscopy, remains one of the most popular operations for the treatment of genuine stress incontinence. The average failure rate is 10% in patients followed up for 5 years or more in the literature. The etiology of the failure is difficult to assess by clinical or urodynamic investigations; the failure may be due to weak sutures on the Cooper's ligaments or on the vagina, to excessive or insufficient elevation of the cervical neck, or to an incompetent urethral sphincter. METHODS: The authors performed five preperitoneal laparoscopies for recurrent urinary stress incontinence in women after a colposuspension performed by laparotomy in order to determine the etiology of the recurrence (between 1992 and 1995 at the Department of Gynecology of the University Hospital of Caen, France). RESULTS: Laparoscopic preperitoneal access was possible in all patients. No laparotomy had to be performed. One small bladder injury occurred during the dissection. It was sutured by laparoscopy. There were no postoperative complications. In one patient, both of the sutures had escaped. In two other patients both sutures were found in place, but urodynamics showed a decrease in closure pressure. In two other patients, complaining of dysuria (painful voiding and acute bladder distension) associated with urinary leakage, only the colposuspension on one side had failed, involving a lateral torsion of the bladder neck. CONCLUSION: Preperitoneal laparoscopy is feasible after a laparotomic colposuspension and gives a very interesting etiologic contribution to the recurrence of incontinence. It helps to choose the most appropriate procedure to treat these recurrent incontinent patients: a new colposuspension if the previous one has failed anatomically and a sling operation if it hasn't and if the sphincter is incompetent.