[Infectious spondylodiscitis after a laparoscopic sacrocolpopexy: about one case]. / Spondylodiscite après promontofixation coelioscopique : à propos d'un cas.

One case of spondylodiscitis, over a period of 18 months after a laparoscopic sacrocolpopexy with suture, was reported. After a needle aspiration of the disco-vertebral space retrieving Pseudomonas, adapted antibiotic treatment and immobilization permit favorable evolution. The clinical, biological and imaging with MRI favorable evolution, prompted not to disassemble the prosthetic material, however this option should be discussed at the outset when large abscess or vaginal fistula or unfavorable evolution with medical treatment. Fixation promontory must interest the prevertebral ligament and not the disc; using suture should be preferred to staples.

[Surgical management of pelvic organ prolapse in women: laparoscopic or vaginal sacrocolpopexy?]. / Chirurgie du prolapsus: coelioscopie ou voie basse ?

OBJECTIVE: To compare the safety and the efficacy of the laparoscopic and vaginal technique for the surgical management of pelvic organ prolapse, with systematic support of the three compartments and prosthetic reinforcements. PATIENTS AND METHODS: Retrospective study of 154 patients presenting a stage 3 or 4 prolapse on one of the three compartments. Laparoscopic procedures were performed with subtotal hysterectomy, double synthetic prosthesis attached to promontory, and douglassectomy. Vaginal procedures were performed with vaginal hysterectomy, anterior colporrhaphy with a hammock using porcine skin collagen implant fixed by transobturator passages, unilateral sacral colpopexy and posterior colporrhaphy. Monitoring was performed at six months and then annually. RESULTS: The laparoscopic technique requires a more important operating time, but a shorter hospitalization. The discovery of three carcinoma reinforces the idea of the interest of uterine radical surgery in these patients. The tolerance of prostheses by laparoscopy is safe. The biological prostheses, introduced vaginally, offer the same advantages. The anatomical results in the medium term (30 months) seem more favorable to laparoscopy than transvaginal approach, as well as functional results but they still need to better evaluated. DISCUSSION AND CONCLUSION: The two techniques must coexist, ideally without competing with each other but rather complementarily, as the overall rate of recurrence, requiring additional procedure does not exceed 2%. It is therefore important that surgeons, who support prolapse, have a good comprehensive training of the laparoscopic and vaginal techniques.

Menses, fertility and pregnancy after arterial embolization for the control of postpartum haemorrhage.

BACKGROUND: The long-term effects of uterine artery embolization for the control of postpartum haemorrhage on menses, fertility and future pregnancy evolution have not been assessed. METHODS: Between November 1993 and July 1999, 31 women with obstetric haemorrhage underwent arterial embolization. Four patients underwent a hysterectomy. Gynaecological information on 25 of the 27 patients who did not undergo hysterectomy was obtained by interview. RESULTS: All women had a return of normal menses. Nine of the 25 patients desired subsequent pregnancy and five patients became pregnant with normal delay of conception. Moreover, two other patients who did not plan another pregnancy became pregnant. A total of 10 pregnancies was studied, four ended during the first trimester. For the six others, the maternal evolution of the pregnancy was uneventful until term. No case of pre-eclampsia was observed. The ultrasonographic examinations revealed normal fetal growth and umbilical and uterine Doppler studies showed no anomaly. No repetition of obstetric haemorrhage was observed. All full-term, newborns were healthy, weighing from 3220 to 4100 g. CONCLUSION: Our results suggest that women who undergo arterial embolization for obstetric haemorrhage should expect to have a return of normal menses with preservation of future fertility and successful uneventful pregnancies.

Abnormal placentation and selective embolization of the uterine arteries.

OBJECTIVE: Abnormal placentation accounts for more than 50% of uterine artery embolization failure. The authors report their experience in this situation. STUDY DESIGN: Seven women presented with abnormal placentation. Uterine artery embolization was carried out in emergency or prophylactic control of postpartum bleeding. RESULTS: In five patients, control of postpartum hemorrhage was obtained without hysterectomy. In two cases with no placental removal and prophylactic procedures, hysterectomy and blood transfusion were not necessary. The manual removal of the placenta was achieved secondarily, respectively on the 25th and the 12th day. CONCLUSIONS: The success rate of uterine artery embolization for postpartum bleeding appears to be lower with abnormal placentation. In none of the cases with the placenta present was it possible to leave the residual placenta in place. However, embolization may permit a safe waiting period and spontaneous migration of the placenta. When the diagnosis is made before delivery, prophylactic uterine artery embolization without placental removal should be considered to reduce blood transfusion and preserve fertility.

Adnexal torsion: a report on forty-five cases.

OBJECTIVES: To evaluate the clinical findings, evolution of treatment and ovarian function following conservative therapy. STUDY DESIGN: A case series of 45 patients presenting with adnexal torsion between January 1989 and June 1999. All patients were surgically treated, either conservatively or radically. Patients who had received conservative treatment, interviewed by phone and underwent ovarian sonographic examination. RESULTS: Adnexal torsion is more frequent in young women with adnexal pathology. Conservative therapy by laparoscopy has gained increasing preference as a surgical procedure. It is safe and preserves ovarian function. CONCLUSIONS: Conservative therapy by laparoscopy is recommended to preserve ovarian function in young women.

False aneurysm of the uterine pedicle: an uncommon cause of post-partum haemorrhage after caesarean section treated with selective arterial embolization.

We report three cases of post-partum haemorrhage following caesarean delivery attributed to a false aneurysm of the uterine pedicle and treated with artery embolization. These lesion were probably post-traumatic in origin related to hysterotomy. Angiographic study of the anterior division of hypogastric arteries confirmed the diagnosis and embolization of the false aneurysm was successful in controlling the haemorrhage.

Plasma progesterone kinetics following surgical treatment of ectopic pregnancies.

OBJECTIVES: Comparative study of plasma progesterone and betaHCG kinetics following surgical treatment of ectopic pregnancy. STUDY DESIGN: Prospective study involving 62 patients with tubal ectopic pregnancies. Study of the kinetics of plasma progesterone and betaHCG, and the correlation coefficient between plasma progesterone and betaHCG levels during post-operative follow-up. RESULTS: Thirty-nine patients were treated by salpingostomy and 23 by salpingectomy. Analyzing the betaHCG kinetics according to treatment revealed that both curves were convergent on day 2. Progesterone kinetics differed greatly in that they appeared "parallel and confused". Analyzing the correlation between betaHCG and progesterone levels proved the absence of a significant link. CONCLUSIONS: Studying the kinetics of plasma progesterone after surgical treatment of ectopic pregnancies revealed a fast decrease in progesterone. Statistical analysis of the progesterone concentration showed that post-operative kinetics is fully independent from that of betaHCG. Progesterone therefore cannot be substituted to betaHCG for post-operative follow-up.

[Limits to arterial embolization treatment of severe postpartum hemorrhage]. / Facteurs d'échec de l'embolisation artérielle dans le traitement des hémorragies graves du post-partum.

OBJECTIVE: To assess the limits of arterial embolization in the management of serious postpartum haemorrhage (PPH). STUDY DESIGN: Retrospective study. PATIENTS AND METHODS: We examined the cases of 29 patients admitted to intensive care units of Rouen University Hospital for PPH between January 1994 and August 1999. Demographic, obstetrical and biological data, the required treatment and eventual side effects were collected and analysed using the appropriate parametric and non parametric tests. RESULTS: Arterial embolization was carried out on 15 patients (52%) with a success rate of 73%. Of the 14 other patients, 11 underwent conservative or radical surgery without further complications, three received medical treatment. No maternal death occurred; however, one patient transferred from a local hospital and already presenting haemodynamic instability suffered cardiac arrest before embolization. Arterial embolization was unsuccessful in four cases, two of which were cases of placenta accreta. These patients were older (p < 0.05) and all had a past history of curettage and/or caesarean section for preceding deliveries (p < 0.01). CONCLUSIONS: Emergency arterial embolization is a valuable therapy in case of PPH but can only be carried out in specialised units. Obstetrical antecedents would appear to constitute a major risk factor and transfer increases the morbidity rate.

[Evaluation of clinical competence in gynecology obstetrics: an innovative approach using the Objective Structured Clinical Examination]. / Evaluation au cours de la formation initiale de la compétence clinique en Gynécologie Obstétrique: approche innovatrice basée sur l'observation de la performance par l'examen clinique objectif et structuré (ECOS).

OBJECTIVE: The evaluation of medical student clinical competence in Obstetrics and Gynaecology using Objective Structured Clinical Examination (OSCE). MATERIAL AND METHODS: Development of OSCE with definition of an assessment of subject, choice of clinical stations sampling, identification of components of clinical competence to be evaluated, the level of performance required, development of specification table, editing of OSCE presentation page and assessment of praticability and results exploitation. RESULTS: Eleven station stimuli with simulated patient participation were carried out, 2 stations with a mannequin model and 1 questionnaire station. CONCLUSION: Our experience suggests OSCE feasibility for Obstetrics and Gynaecology during the initial course of education presents adequate psychometric characteristics. This gold standard can no longer be overlooked and should be considered as a useful tool to assess medical student competence. Nevertheless, OSCE remains to be further evaluated in France.

[Which initial tests should be performed to evaluate meno-metrorrhagias? A comparison of hysterography, transvaginal sonohysterography and hysteroscopy]. / Quelle exploration réaliser de première intention face aux méno-métrorragies? A propos d'une série prospective comparant l'hystérographie, l'hystérosonographie et l'hystéroscopie.

OBJECTIVE: Evaluate the feasibility and the value of hysterography, sonohysterography and hysteroscopy for investigation of abnormal uterine bleeding. Method. Longitudinal blind study of thirty-eight patients consulting for abnormal uterine bleeding during pre- and post menopause. All patients underwent an hysterography and transvaginal sonohysterography, in random order, followed by an hysteroscopy with histological sample. The results were compared with the histo-pathological examination that was used for reference diagnosis. Statistical study of sensitivity, specificity and Positive and Negative Predictive Value (PPV-NPV) of each investigation; rate of agreement by the coefficient of Kappa. RESULTS: The hysterography offers a PPV of 83% and a NPV of 100%. The interpretation errors were associated with the simple mucous hypertrophy interpreted as "hyperplasy". The limits correspond to a contrast agent allergy. The sonohysterography had a VPP of 89% and a VPN of 100%. The false positive is due to the difficulties of distinguishing the clots from the polyps. The limits correspond to the difficulties of cervix catheterization (13%). As regards the hysteroscopy, the VPP was 81.5% and the VPN of 75%. The interpretation mistakes were associated with mucous hypertrophy and the hyperplasy. CONCLUSIONS: The most useful examination for abnormal uterine bleeding, in the first instance, is transvaginal sonography with saline instillation. A complement by Doppler study would probably make it possible to limit the false positives.

Bladder exstrophy: gynecological and obstetrical characteristics with reference to three cases.

The authors report three cases of pregnancy in women treated for bladder exstrophy. Based on a review of the literature, and the follow-up of these cases, the aim of this study was to determine the prognosis of pregnancy, which is currently possible due to the progress in antibiotherapy and surgery. Nevertheless, these pregnancies need to be carefully followed-up, not only because of the complications that may occur to the mother and the infant, but also because of the type of delivery involved.

[Amniotic membrane graft in ocular surface disease. Prospective study with 31 cases]. / La greffe de membrane amniotique dans les pathologies oculaires de surface. Etude prospective à partir de 31 cas.

INTRODUCTION: Amniotic membrane's unique combination of properties including the facilitation of migration of epithelial cells, the reinforcement of basal cellular adhesion and the encouragement of epithelial differentiation [6] together with its ability to modulate stromal scarring and its anti-inflammatory and anti-bacterial activity has led to its use in the treatment of ocular surface pathology as well as an adjunct to stem cell grafts of the corneal limbus [6-4]. We report a prospective study of 30 patients so treated. MATERIAL AND METHODS: We studied 31 eyes of 30 patients subjected to amniotic membrane grafts between September 1999 and May 2000. There were 25 men and 5 women with an average age of 60.1 (range 25-86) years who were followed for a mean of 7.7 (range 4-11) months. 5 groups (A to D) were observed: A: 6 eyes. Small chronic ulcers without limbal involvement. B: 4 eyes. Ulcers of at least 75% corneal area or occupying 75% of the limbus. C: 9 eyes. Corneal burns. D: 8 eyes. Painful bullous corneal dystrophies unresponsive to other treatment. E: 4 eyes. Symblepharons. Amniotic membrane was placed on the corneal lesion, epithelial surface externally [6, 15], trimmed and sutured with interrupted 10/0 nylon, removed at one month. In two patients (11, 12) inflamed conjunctiva was recessed and amnion sutured to the recessed margin. For the bullous dystrophies we removed all the corneal epithelium and either sutured the amnion to peri-limbal conjunctiva (4 eyes) or to the limbus (4 eyes). For the symblepharons the conjunctiva was dissected to reform the fornix which was lined with amniotic membrane, sutured with 8/0 vicryl. Patients were reviewed regularity. RESULTS: Group A: All healed within 15 days, in most with dissolution of the amnion over 2-3 months although some persisted, covered with corneal epithelium. An eye with a Descemetocoele and one with a microperforation both healed. Vision improved more than two lines in 4 of 6 eyes. Group B: 2 of 4 eyes healed, one despite detachment of the membrane after 15 days. One eye was salvaged by tarsorrhaphy over a fresh keratoplasty after perforation of a neuroparalytic ulcer on failure of three successive amnion grafts. The final cornea vascularised despite an amnion graft for a meta-herpetic ulcer. Group C: 2 of 9 eyes had limbal damage in one quadrant but 7 had vessels in at least three-quarters of the circumference. One (15) also had a limbal autograft. 3 of 9 eyes healed satisfactorily with more than 2/10 improvement in acuity in each case. 2 showed further neovascularisation despite surface healing. One old chemical burn healed satisfactorily but vascularisation remained 5 eyes failed to heal with lysis of the graft, the patient who had a limbal autograft developed a vascular pannus, and in 4 eyes neovascularisation progressed to cover the entire cornea. Group D: 3 eyes settled with loss of symptoms but in 5 the graft detached within 15 days. All eyes where the membrane had been sutured to the conjunctiva beyond the limbus failed whilst 3 of 4 in which it had been sutured anterior to the limbus succeeded, leaving a persistent whitish membrane under the epithelium. Group E: We were able to reconstruct the cul de sac in 3 out of 4 eyes. In one patient with recurrent pterygium good ocular movement was restored, previously limited by scarring. One with associated ocular surface damage from a thermal burn failed by scarring of the cul de sac a month after surgery. DISCUSSION: Our best results were in persistent trophic ulcers of the cornea (Groups A and B) with a success rate of 80%, comparable to those of others [49, 37, 38]. The ready availability of amniotic membrane in our facility makes amniotic membrane transplantation the main secondary treatment for such lesions, especially because of the visual improvement we obtained. Because we did not observe any improvement in corneal thickness after this treatment we advise its early use before significant stromal lysis. The technique was not sufficient to control the effect of corneal anaesthesia in two eyes [40] or in chemical burns suggesting that amniotic membrane alone is insufficient to promote corneal healing in the absence of limbal stem cells. Nevertheless, three eyes did benefit. It has been suggested [13] that the anti-apoptotic function of amnion may prevent stem cell loss in such eyes [42], thus it appears logical to offer an amniotic membrane graft first, before stem cell transplantation, which may entrain complications in the donor eye if autografted [43] or because of the rejection risk of an allograft. It may be that an amniotic membrane graft simply becomes a holding procedure allowing time to settle the eye so as to allow secondary procedures to address the underlying cause of further damage. Our treatment of bullous dystrophy only succeeded on confining the graft to within the limbus, 3 out of 4 eyes becoming comfortable. By contrast we found amniotic membrane helpful in reconstructing symblepharons in the absence of local inflammation. CONCLUSION: Amniotic membrane grafting is a simple and straightforward surgical technique which should form part of the therapeutic arsenal for the treatment of ocular surface disease. Indications for the technique need further clarification for it is evident that it cannot correct all secondary pathology associated with limbal destruction. It is certainly preferable to conjunctival advancement and has proved useful in the reconstruction of the cul-de-sac.

[Missed diagnosis of postpartum hemorrhage]. / Les hémorragies non-diagnostiquées du post-partum.

OBJECTIVE: The purpose of this work was to search for the reasons why the diagnosis of post-partum hemorrhage may be missed. PATIENTS AND METHODS: We reviewed retrospectively the files 5,517 vaginal delivery patients cared for in our Gynecology and Obstetrics Unit at the Rouen University Hospital between January 1, 1997 and September 30, 1999. Among these patients, 90 (1.63%) developed anemia during the post-partum period with a 10-point fall in the hematocrit from the pre-delivery level, which corresponds to a 1 liter loss of blood, but for whom no diagnosis of hemorrhage was made. We compared this group with the population of patients who had had a diagnosis of hemorrhage. The chi-squared or Fischer's exact text were used where appropriate to compare means and calculate z. RESULTS: Significant risk factors were: primiparity, anemia before delivery, labor induction, locorregional anesthesia, use of ocytocin, long labor with a long active phase, fever during labor, episiotomy and prolonged delay between delivery and onset of suture. CONCLUSIONS: Missed diagnosis appeared to be related to use of visual assessment to determine the degree of bleeding, a very mediocre indicator, particularly when no means of blood collection or quantification is used. In addition, factors having an impact on the development of hemorrhage should be revisited with particular attention given to primiparous patients.

[Influence of the type of breech presentation on delivery in selected primiparous women at term]. / Influence du mode de la présentation dans l'accouchement du siège chez la primipare à terme sélectionnée.

OBJECTIVE: Study the effect of the type of breech presentation on the prognosis of delivery in selected primiparous women at term. PATIENTS AND METHODS: We reviewed retrospectively 146 breech presentations seen between January 1, 1993 and December 12, 1999 in our unit. We limited our study to primiparous mothers at term (> or = 37 weeks gestation) who had had a normal single fetus pregnancy and who had accepted a trial of labor. We analyzed the mode of labor termination, and maternal, fetal, ovular, obstetrical and neonatal features by type of breech presentation and by type of delivery. We collected data by manual search of the patients' registered files (AUDIPOG). The chi-squared and Fisher's tests were used as appropriate for statistical analysis. RESULTS: Spontaneous vaginal delivery was achieved in 10.3% of the cases and non-spontaneous vaginal delivery in 56.2%. Cesarean section during labor was required in 33.5%. There was no significant difference between frank breech presentation (27.4%) and incomplete breech presentation (72.6%). Maternal, fetal, ovular, obstetrical and neonatal features were not significantly different. CONCLUSIONS: Unlike data reported by others, our series did not demonstrate any significant feature predictive of obstetrical and neonatal prognosis irrespective of the type of breech presentation in selected primiparous women at term who had had a normal pregnancy.

[Waldmann disease and pregnancy]. / Maladie de Waldmann et grossesse.

Waldman disease, also called intestinal lymphangiectasis, is a protein-loosing enteropathy caused by anomalous intestinal lymphatic canals. The condition is transmitted by autosomal dominant inheritance. Diet therapy including medium chain triglycerides improves the disease course. The condition occurs in early childhood. We report a case observed in a pregnant woman with intestinal lymphangiectasis. She delivered a full-term infant and experienced no major complications.

[Technique of harvesting and preparation of amniotic membranes]. / Technique de prélèvement et de préparation des membranes amniotiques.

Amniotic membrane transplantation is a promising surgical technique for clinical management of ocular surface diseases. According to the first published results, the ease with which this highly available tissue can be prepared and preserved makes this technique very attractive. The aim of our study is to report procurement procedures and the preparation technique for amniotic membrane in accordance with the French tissue transplantation legislation.

[Endometrial imaging]. / L'endomètre: quelle imagerie?

The diagnostic value of endovaginal sonography in benign or malignant endometrial pathology is high, increased by sonohysterography. Sonohysterography is useful in the diagnosis of endometrial thickness and to determine further investigations. MRI is accurate in the uterine adenomyosis diagnosis and is the imaging modality of choice for the preoperative endometrial cancer staging.

[Management of cholestasis in pregnancy]. / Prise en charge d'une cholestase gravidique.

DIAGNOSIS: Pruritus in a pregnant women with healthy skin is suggestive of gravid cholestasis. The diagnosis can only be retained after ruling out viral or drug-induced hepatitis or gallbladder disease. The best markers are maternal serum transaminase and bile acid levels. FETAL RISK: The perinatal consequences of gravid cholestasis are minimal if reasonable premature delivery is accepted. THERAPEUTIC OPTIONS: Ursodesoxycholic acid is an interesting therapeutic option if pruritus is untolerable or if the diagnosis is made early in pregnancy. Injection of vitamin K prevents coagulation disorders.