[Immediate fetal-maternal morbidity of first instrumental vaginal delivery using Thierry's spatulas. A prospective continuous study of 195 fetal extractions]. / Morbidité maternofoetale immédiate de l'accouchement assisté par spatules de Thierry chez la primipare. A propos d'une série prospective continue de 195 extractions.

OBJECTIVES: To investigate the immediate fetal-maternal morbidity related to Thierry's spatula for first instrumental vaginal delivery. PATIENTS AND METHODS: We conducted a prospective observational study in Toulouse university hospital, including primiparas who vaginally delivered a live singleton cephalic infant>36 WG, between December 2005 and June 2006. Instrumental deliveries were performed using short spatulas in all cases. Outcome measures were: perineal complications (episiotomy, laceration and associated lesions, urinary retention, pain at H48), neonatal morbidity (cutaneous injuries, neonatal transfer, cord pH, Apgar score). Instrumental deliveries were compared with spontaneous vaginal deliveries (SVD). RESULTS: Six hundred and eight primiparas were included, distributed in 195 extractions (32%) and 413 SVD (68%). Spatulas allowed fetal extraction in all cases. Main differences between the two groups were: length of labour, occiput posterior position (12.8% for spatulas vs 1.7% for SVD; p<0.0001), episiotomy rate (97.9% vs 51.3%; p<0.0001), severe perineal lacerations (3.6% vs 0.2%; p=0.0007), post-partum morbidity (pain, hematoma, and urinary retention). No case of early severe neonatal complication was related to the use of the spatulas. DISCUSSION AND CONCLUSIONS: Perineal complications (severe lacerations) associated with spatulas are increased with regard to SVD, but comparable to that reported with forceps. The main disadvantage is the high frequency of episiotomy, which should not be systematic. Neonatal morbidity is reduced. Comparative studies (spatulas vs. other procedures) are needed to confirm these data, but spatulas remain a multipurpose instrument which should continue to be taught.

Paratubal endometrioid cystadenocarcinoma: case report and review.

BACKGROUND: Paratubal masses are common, but paratubal carcinoma is an extremely rare entity. CASE: We report a case of a 44-year-old nulliparous female who suffered from abdominal pain for three months. Abdominal and pelvic ultrasound revealed a 30 cm left adnexal mass originally. Laparotomy with bilateral salpingo-oophorectomy was performed. Final pathology indicated a heterogeneous tumor with benign, borderline, and endometrioid carcinoma areas. A repeat surgery was decided in order to complete hysterectomy, omentectomy, pelvic and paraaortic lymphadenectomy. Surgical staging did not reveal residual disease at pathological examination. After 36 months of follow-up, no recurrence has occurred. CONCLUSION: To our knowledge, no case of paratubal invasive endometrioid adenocarcinoma has previously been described. This case has been managed according to the recommendations of ovarian cancer, which seems to be an acceptable option.

Factors predicting the sentinel node metastases in T1 breast cancer tumor: an analysis of 1416 cases.

AIM: To determine the factors associated with the metastatic involvement of sentinel lymph node (SLN) biopsy in patients with early breast cancer. STUDY DESIGN: This was a retrospective study of patients with T1 invasive breast cancer who underwent SLN biopsy at Claudius Regaud Institute between January 2001 and September 2008. RESULTS: 1416 patients were recruited into this study. SLN metastases were detected in 368 patients (26%). Younger age, tumor size and location, histological type, nuclear grade, and lymphovascular invasion appear to be significant risk factors of SNL involvement. In multivariate analysis, tumor size, tumor location, histological type and lymphovascular invasion are significant factors. When the tumor size is >20 mm, the OR is 6.6 compared to a T1a tumor (3.145-14.175, p<0.001, confidence interval 95%). When the tumor is found in the inner quadrant, the risk of SLN involvement is reduced compared to external locations with an OR of 0.53 (0.409-0.709, p<0.001, confidence interval 95%). Non-ductal/lobular compared to infiltrative ductal cancer have a lower risk of SLN involvement with an OR of 0.423 (0.193-0.927, p<0.03, confidence interval 95%). Lymphovascular invasion increase the risk of positive SLN with an OR of 2.8 (1.9-4.1, p<0.001, confidence interval 95%). CONCLUSION: It appears reasonable to avoid axillary lymph node dissection in older patients with T1a tumors of good histopathological type and in the absence of lymphovascular invasion.

[Can we still perform instrumental rotations using Thierry's spatula? Preliminary study among primiparous]. / Peut-on encore réaliser des rotations instrumentales par spatules de Thierry? Etude préliminaire chez la primipare.

OBJECTIVES: To study immediate perineal and neonatal outcomes after instrumental rotational performed with Thierry's spatula among primiparous, and compare subsequent perineal tear with occiput posterior position delivery. MATERIALS AND METHODS: The study was performed from December 2005 to June 2006 at Paule-de-Viguier hospital (Toulouse university hospital) including all persistent occiput posterior vaginal deliveries among primiparous (49 patients). Mode of delivery was: 1) seven patients with spontaneous occiput anterior vaginal delivery (14.3%); 2) seven patients with rotational extraction using spatula with occiput anterior delivery (30.6%); 3) twenty-seven patients with instrumental extraction and occiput posterior delivery (55.1%). Maternal and fetal parameters were studied prospectively. RESULTS: Spatula was performed for failure of progress in 71.4% of cases (n=30) and for no reassuring fetal status in 28.6% of cases (n=12). In "rotational group", only one perineal tear was observed (Third degree) (6.6%) versus seven in "occiput posterior extraction group" (26%) with three severe perineal lacerations. Neonatal superficial lesions are frequent (26,6% after rotation versus 11.6% after occiput posterior extraction). None severe traumatic tears were observed. CONCLUSION: Instrumental rotation using Thierry's spatula seems to be less deleterious for maternal perineum than occiput posterior extraction, without increasing neonatal complications. Theses preliminary results have to be confirmed by more important prospective works.