Changes in haemostasis after laparoscopic surgery in gynaecology: contribution of the thrombin generation test.

Surgery induces immediate hypercoagulability by direct alteration of the vascular bed, release of procoagulant substances from the extravascular spaces and blood flow decrease, and delayed hypercoagulation in response to tissue damage which triggers inflammatory responses. Thus, the postoperative period represents a high-risk time for thrombosis. Recognition of high-risk individuals would make it possible to improve thromboembolism prevention. We studied in women undergoing laparoscopic surgery a series of markers known to be related to the thrombotic risk and confronted their results with those of a global test, the thrombin generation test (TGT) described by Hemker's group. Our results show that two groups of patients can be distinguished according to usual risk markers (PAI-1, TAT, body mass index): the higher risk group demonstrates higher initial TGT values, but also a postoperative decrease of the TGT values whose mechanisms remain to be defined.

[Difficult embryo transfers: contribution of echography]. / Transferts d'embryons difficiles: l'apport de l'échographie.

The aim of this retrospective study is to compare the results of embryo transfer in IVF without or after cervical dilatation, and trans-myometrial trans-vaginal transfer and after ultrasound-guided transfer. From 1989 to 1996 we have performed 4,355 embryo transfers to obtain 1,115 pregnancies. The results were 25.6% pregnancy by transfer and 10.9 embryos to start a pregnancy. During this time 281 transfers were appreciated as difficult or impossible and a cervical dilatation was done. We obtain 17.4% pregnancies by transfer with 16.5 embryos per pregnancy. We also practiced for the same indication 50 transmyometrial-transvaginal transfers. The result was 18% pregnancy by transfer and 16 embryos to start a pregnancy. In 1997 we have stopped cervical dilatations to prefer in these indications ultrasound-guided embryo transfer. 74 transfer were performed with this method to obtain 28.4% pregnancies per transfer and 9.9 embryos to start one pregnancy. This results are compared to a subgroup of women 38 years old or less, with a normal partner's sperm and in witch two embryos or more were transferred. At the end we think that the use of ultrasonography for embryo transfer is benefit in IVF program.

[Laparoscopic surgical repair of surgical complication of laparoscopy in gynecology. Experiences at the Paul Gellé de Roubaix Center from 1992 to 1995]. / Réparation coeliochirurgicale des complications opératoires de la coelioscopie en gynécologie. Expérience du pavillon Paul Gellé de Roubaix de 1992 à 1995.

UNLABELLED: From 1992 to 1995, 1565 laparoscopic operations were performed in Roubaix. We report on six complications. OBJECTIVE: To compare this figure with these of the French collaborative study done from 1987 to 1991 by seven departments known for their laparoscopic activity, including Roubaix. RESULTS: The trends are good. The rate of injuries was stable in spite of increasingly complex procedures. The largest portion of visceral and even vascular injuries were repaired by laparoscopy reducing by the same amount use of laparotomy. CONCLUSIONS: Strict adherence to safety guidelines and specific training of surgeons reduce the need of laparotomy for laparoscopic complication.

Monoamniotic twin pregnancies. Review of the literature, and a case report with vaginal delivery.

OBJECTIVE: To specify the process of the sometimes difficult diagnosis of monoamniotic twin pregnancies, as well as the best practise for delivery of this type of pregnancy. METHOD: Using their personal observation (a patient with a monoamniotic twin pregnancy, which presented a vaginal delivery at 35 weeks of gestation, two girls, in cephalic presentation, without particular problem, despite an entanglement of the cord and the existence of a knot), the authors established a review of the literature on this subject. RESULTS: Monoamniotic twin pregnancies represent a rare possibility. The prognosis is traditionally somber: 40-60% mortality, mainly due to pathologies of the cord. The review of the recent literature shows that most authors remain in favour of weekly ultrasound supervision from the 23rd week and of caesarean section in principle at 34 weeks (or from fetal pulmonary maturation). CONCLUSION: In the absence of funicular compression signs by colour-doppler, and under the cover of flawless obstetrical conditions, vaginal delivery can only be authorized for cases when both presentations are cephalic.

[Alternatives and access routes in hysterectomies. Are randomizations dangerous?]. / Alternatives et voies d'abord des hystérectomies. Les randomisations dangereuses?

Hysterectomy is a common gynaecological operation in Europe. Although the advantages of new minimally invasive procedures seem obvious, prospective randomised trials are essential for proper appraisal. We reviewed all randomised studies about routes for hysterectomy and comparison of conservative or radical surgery. This study points out the many deficiencies of such studies. Referred conclusions are then open to criticism. We concluded that new prospective studies should be performed, adapted to social, cultural and economic conditions in Europe.