Early detection of hospitalized patients with COVID-19 at high risk of clinical deterioration: Utility of emergency department shock index.

BACKGROUND: The COVID-19 outbreak has put an unprecedented strain on Emergency Departments (EDs) and other critical care resources. Early detection of patients that are at high risk of clinical deterioration and require intensive monitoring, is key in ED evaluation and disposition. A rapid and easy risk-stratification tool could aid clinicians in early decision making. The Shock Index (SI: heart rate/systolic blood pressure) proved useful in detecting hemodynamic instability in sepsis and myocardial infarction patients. In this study we aim to determine whether SI is discriminative for ICU admission and in-hospital mortality in COVID-19 patients. METHODS: Retrospective, observational, single-center study. All patients ≥18 years old who were hospitalized with COVID-19 (defined as: positive result on reverse transcription polymerase chain reaction (PCR) test) between March 1, 2020 and December 31, 2020 were included for analysis. Data were collected from electronic medical patient records and stored in a protected database. ED shock index was calculated and analyzed for its discriminative value on in-hospital mortality and ICU admission by a ROC curve analysis. RESULTS: In total, 411 patients were included. Of all patients 249 (61%) were male. ICU admission was observed in 92 patients (22%). Of these, 37 patients (40%) died in the ICU. Total in-hospital mortality was 28% (114 patients). For in-hospital mortality the optimal cut-off SI ≥ 0.86 was not discriminative (AUC 0.49 (95% CI: 0.43-0.56)), with a sensitivity of 12.3% and specificity of 93.6%. For ICU admission the optimal cut-off SI ≥ 0.57 was also not discriminative (AUC 0.56 (95% CI: 0.49-0.62)), with a sensitivity of 78.3% and a specificity of 34.2%. CONCLUSION: In this cohort of patients hospitalized with COVID-19, SI measured at ED presentation was not discriminative for ICU admission and was not useful for early identification of patients at risk of clinical deterioration.

[Lobular intra-epithelial neoplasia: atypical lobular hyperplasia and lobular carcinoma in situ]. / Néoplasies lobulaires intra-épithéliales: hyperplasie lobulaire atypique et cancer lobulaire in situ.

OBJECTIVE: To review main knowledge about lobular intra-epithelial neoplasia with special interest for daily practice management. MAIN RESULTS: Intra-epithelial lobular neoplasias (ILN) are non invasive proliferations within the terminal ducto-lobular unit of monomorphic loosely cohesive small cells. A lack of expression of the E-cadherin adhesion molecule is often observed as in invasive lobular breast cancer. ILN are infrequent, however, a rise in incidence partly, due to the generalization of mammographic screening, is observed. Actually ILN are usually asymptomatic and diagnosed after breast biopsy for unspecified microcalcifications. ILN are associated with an increased risk of breast cancer that persists over 20 years after the initial diagnosis. The average risk is 4.2 % for the ipsilateral breast and 3,5 % for the controlateral breast. However, a great variability in the risk estimation is observed between the studies. There is no consensus on how to treat ILN. Surgical options have varied from biopsy to bilateral mastectomy. Current tendency is favouring lumpectomy.

[Operative termination of pregnancy between 12 and 14 weeks' gestation: influence of the operator's experience]. / Particularités techniques de l'IVG instrumentale entre 12 et 14 semaines d'aménorrhée: influence de l'expérience de l'opérateur.

OBJECTIVE: To assess the feasibility of operative termination of pregnancy between 12 and 14 weeks of gestation and the role of the operator's experience in physicians previously unfamiliar to this technique. MATERIALS AND METHODS: A prospective study of 251 operative terminations of pregnancy, from July 1st, 2001 to January 31st, 2002, and from May 1st, 2002 to October 31st, 2002, in order to assess the role of operator's experience. 104 terminations between 12 and 14 weeks were compared to 147 terminations at earlier gestational ages. All patients received cervical ripening with 400 mcg oral misoprostol 3-4 hours before operation performed under general anesthesia. Evaluation criteria were: duration of operation, need for use of forceps, and complications: uterine perforation, cervical laceration, bleeding > 500 ml and need for blood transfusion. RESULTS: There was no difference in the rate of operative complications between terminations before and after 12 weeks. The duration of operation was slightly longer after 12 weeks than before (12.9 +/- 6.7 min versus 11.1 +/- 2.8 min.; p < 0.05). Forceps use was 0.7% before 12 weeks, 20% between 12 and 13 weeks, and 59% between 13 and 14 weeks (p < 0.01). There was no difference in the complication rate or in the need for forceps according to the operator's experience. The perceived difficulty in cervical dilatation was higher in early experience than in experimented operators (19.6% versus 5.2%; p < 0.05). CONCLUSION: Operative termination of pregnancy is technically feasible beyond 12 weeks without dramatic increase in operative complications. Technical skill can be acquired in a short time interval.

[Surgical site infections after cesarean section: results of a five-year prospective surveillance]. / Infections de site opératoire chez les patientes césarisées: bilan de 5 années de surveillance.

AIMS: To determine the incidence of surgical site infections and to identify risk factors for infections. METHOD: A prospective study of surgical site infections (SSI) after cesarean section was carried out from September 1997 to September 1998 (pilot study) and from January 2000 to August 2003, using the methodology of the American National Nosocomial Infection Surveillance System. Follow up of women was performed by midwives until discharge and during the post-natal visit. Suspected surgical site infections were confirmed by surgeons and infection control practitioners. The microbiological file of each patient was edited 30 days after cesarean section. Risk factors were analyzed using a logistic regression model. RESULTS: During the pilot study, infection rate was estimated at 3.2%. At multivariate analysis, factors independently associated with an increased risk of SSI were ASA score > 1, performance of cesarean section in a room not dedicated to this activity, and use of an open urine drainage system. During the following years (2000-2003), infection rates progressively decreased to reach 1.9% in 2003. Infections included superficial wound infections (involving skin and subcutaneous tissue) (47%), deep wound infections (involving deep and soft tissue (fascia and muscle) (20%) and organ/space infections (i.e. endometritis, pelvic abscess) (33%). Infections occurred after patient discharge in 47.5% of cases and diagnosis was based only on clinical findings in 30% of cases. Infected patients were hospitalized longer (median: 6 days) than non infected patients. CONCLUSION: Prospective surveillance of SSI led to better awareness of infectious problems among health care workers, to identification of risk factors and evaluation of health procedures. Surveillance contributed to a decrease in nosocomial infections.

[Preoperative concurrent radiation therapy and chemotherapy for operable bulky carcinomas of uterine cervix stages IB2, IIA, and IIB with proximal parametrial invasion]. / Association concomitante préopératoire de radiothérapie et de chimiothérapie dans les cancers du col utérin opérables de stades IB2, IIA et IIB proximal de gros volume.

PURPOSE: To evaluate preliminary results in terms of toxicity, local tumour control, and survival after preoperative concomitant chemoradiation for operable bulky cervical carcinomas. PATIENTS AND METHODS: Between December 1991 and October 2001, 42 patients (pts) with bulky cervical carcinomas stage IB2 (11 pts), IIA (15 pts), and IIB (16 pts) with 1/3 proximal parametrial invasion. Median age was 45 years (range: 24-75 years) and clinical median cervical tumour size was 5 cm (range: 4.1-8 cm). A clinical pelvic lymph node involvement has been observed in 10 pts. All patients underwent preoperative external beam pelvic radiation therapy (EBPRT) and concomitant chemotherapy during the first and the fourth radiation weeks combining 5-fluorouracil and cisplatin. The pelvic dose was 40.50 Gy over 4.5 weeks. EBPRT was followed by low-dose-rate uterovaginal brachytherapy with a total dose of 20 Gy in 17 pts. After a rest period of 5-6 weeks, all pts underwent class II modified radical hysterectomy with bilateral lymphadenectomy. Para-aortic lymphadenectomy was performed in eight pts without pathologic para-aortic lymph node involvement. Twenty-one of 25 pts who had not received preoperative uterovaginal brachytherapy underwent postoperative low-dose-rate vaginal brachytherapy of 20 Gy. The median follow-up was 31 months (range: 3-123 months). RESULTS: Pathologic residual tumour or lymph node involvement was observed in 23 pts. Among the 22 pts with pathologic residual cervical tumour (<0.5 cm: nine pts; >or=0.5 to 1 cm: 10 pts), seven underwent preoperative EBRT followed by uterovaginal brachytherapy vs. 15 treated with preoperative EBRT alone (P = 0.23). Four pts had pathologic lymph node involvement, three pts had vaginal residual tumour, and four pts had pathologic parametrial invasion. The 2- and 5-year overall survival rates were 85% and 74%, respectively. The 2- and 5-year disease-free survival (DFS) rates were 80% and 71%, respectively. After multivariate analysis, the pathologic residual cervical tumour size was the single independent factor decreasing the probability of DFS (P = 0.0054). The 5-year local control rate and metastatic failure rate were 90% and 83.5%, respectively. Haematological effects were moderate. However, six pts had grade 3 acute intestinal toxicity. Four severe late complications requiring surgical intervention were observed (one small bowel complication, three ureteral complications). CONCLUSION: Primary concomitant chemoradiation followed surgery for bulky operable stage I-II cervical carcinomas can be employed with acceptable toxicity. However, systematic preoperative uterovaginal brachytherapy should increase local tumour control.

[Operable stage IB and II cancer of the uterine neck: retrospective comparison between preoperative utero-vaginal curietherapy and initial surgery followed by radiotherapy]. / Cancer du col utérin stades IB et II opérable: comparaison rétrospective entre curiethérapie utérovaginale préopératoire et chirurgie première suivies d'une radiothérapie.

PURPOSE: To identify prognostic factors and treatment toxicity in a series of operable stages IB and II cervical carcinomas. PATIENTS AND METHODS: Between May 1972 and January 1994, 414 patients (pts) with cervical carcinoma staged according to the 1995 FIGO staging system underwent radical hysterectomy with (n = 380) or without (n = 34) bilateral pelvic lymph node dissection. Lateral ovarian transposition to preserve ovarian function was performed on 12 pts. The methods of radiation therapy (RT) were not randomised and depended on the usual practices of the surgical teams. Group I: 168 pts received postoperative RT (64 pts received vaginal brachytherapy alone [mean total dose (MD): 50 Gy], 93 pts had external beam pelvis RT (EBPRT) [MD: 45 Gy over 5 weeks] followed by vaginal brachytherapy [MD: 20 Gy], and 11 pts had EBPRT alone [MD: 50 Gy over 6 weeks]. Group II: 246 pts received preoperative utero-vaginal brachytherapy [MD: 65 Gy], and 32 of theses 246 pts also received postoperative EBPRT [MD: 45 Gy over 5 weeks] delivered to the parametric and the pelvic lymph nodes with a midline pelvic shield. The mean follow-up was 106 months. RESULTS: The 10-year disease-free survival (DFS) rate was 80%. From 75 recurrences, 35 were isolated locoregional. Multivariate analysis showed that independent factors decreasing the probability of DFS were: both exo and endocervical tumour site (p = 0.047), lymph-vascular space invasion (p = 0.041), age < or = 51 yr (p = 0.013), 1995 FIGO staging system (stage IB1 vs stage IIA, p = 0.004, stage IB1 vs stage IB2, p = 0.0009, and stage IB1 vs stage IIB with 1/3 proximal parametrical infiltration, p = 0.00002), and histological pelvic involved lymph nodes (p = 0.00009). Methods of adjuvant RT did not influence the probability of DFS (group I vs group II, p = 0.10). The postoperative complication rate was 10.2% in group I and 8.9% in group II (p = 0.7) but the postoperative urethral complication rate necessitating surgical intervention with reimplantation was lower in group I than in group II (0.6% vs 2.3%, respectively, p = 0.03). The 10-year rate for grade 3 and 4 late radiation complications according to the LENT-SOMA scoring system was 10.4%. EPRT significantly increased the 10-year rate for grade 3 and 4 late radiation complications (yes vs no: 22% vs 7%, respectively, p = 0.0002). CONCLUSION: In our series, the methods of adjuvant RT (primary surgery vs preoperative uterovaginal brachytherapy) do not seem to influence the prognosis of the stage IB, IIA, and IIB (with 1/3 proximal parametrical involvement only) cervical carcinomas. The postoperative EPRT applied according to histopathological risk factors after surgical treatment increases the risk of late radiation complications.

[Endometrial adenocarcinoma treated with combined radiotherapy and surgery: 437 cases]. / Adénocarcinome de l'endomètre traité par association radiochirurgicale: à propos de 437 cas.

PURPOSE: To identify prognostic factors and treatment toxicity in a series of operable endometrial adenocarcinomas. PATIENTS AND METHODS: Between November 1971 and October 1992, 437 patients (pts) with endometrial carcinoma, staged according to the 1988 FIGO staging system, underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy without (n = 140) or with (n = 297) pelvic lymph node dissection. The chronology of RT was not randomized and depended on the usual practices of the surgical teams. Group I: 79 pts received preoperative uterovaginal brachytherapy (mean total dose [MD]: 57 Gy). Group II: 358 pts received postoperative RT (196 pts received vaginal brachytherapy alone [MD: 50 Gy], 158 pts had external beam pelvis RT [EPRT] [MD: 46 Gy over 5 weeks] followed by vaginal brachytherapy [MD: 17 Gy], and 4 pts had EPRT alone [MD: 46 Gy over 5 weeks]). The mean follow-up was 128 months. RESULTS: The 10-year disease-free survival rate was 86%. From 57 recurrences, 12 were isolated locoregionally. Multivariate analysis showed that independent factors decreasing the probability of disease-free survival were: histologic type (clear cell carcinoma, p = 0.038), largest histologic tumor diameter > 3 cm (p = 0.015), histologic grade (p = 0.008), myometrial invasion > 1/2 (p = 0.0055), and 1988 FIGO staging system (p = 9.10(-8)). In group II, the addition of EPRT did not seem to improve locoregional control. The postoperative complication rate was 7%. The independent factors increasing the risk of postoperative complications were FIGO stage (p = 0.02) and pelvic lymph node dissection (p = 0.011). The 10-year rate for grade 3 and 4 late radiation complications according to the LENT-SOMA scoring system was 3.1%. EPRT independently increased the 10-year rate for grade 3 and 4 late radiation complications (R.R.: 5.6, p = 0.0096). CONCLUSION: EPRT increases the risk of late radiation complications. After surgical and histopathologic staging with pelvic lymph node dissection, in a subgroup of intermediate risk patients (stage IA grade 3, IB-C and II), postoperative vaginal brachytherapy alone is probably sufficient to obtain a good therapeutic index. Results for patients with stage III tumor are not satisfactory.

Adenocarcinoma of the endometrium treated with combined irradiation and surgery: study of 437 patients.

PURPOSE: To identify prognostic factors and treatment toxicity in a series of operable endometrial adenocarcinomas. METHODS AND MATERIALS: Between November 1971 and October 1992, 437 patients (pts) with endometrial carcinoma, staged according to the 1988 FIGO staging system (225 Stage IB, 107 Stage IC, 4 Stage IIA, 35 Stage IIB, 30 Stage IIIA, 6 Stage IIIB, and 30 Stage IIIC), underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy without (n = 140) or with (n = 297) pelvic lymph node dissection. The chronology of adjuvant RT was not randomized and depended on the usual practices of the surgical teams. Seventy-nine pts (Group I) received preoperative low-dose-rate uterovaginal brachytherapy (mean dose [MD]: 57 Gy). Three hundred fifty-eight pts (Group II) received postoperative RT. One hundred ninety-six pts received low-dose-rate vaginal brachytherapy alone (MD: 50 Gy). One hundred fifty-eight pts had external beam pelvic RT (MD: 46 Gy) followed by low-dose-rate vaginal brachytherapy (MD: 17 Gy). Four pts had external beam pelvic RT alone (MD: 47 Gy). The mean follow-up from the beginning of treatment was 128 months. RESULTS: The 10-year disease-free survival rate was 86%. From 57 recurrences, only 12 were isolated locoregional recurrences. The independent factors decreasing the probability of disease-free survival were as follows: histologic type (clear-cell carcinoma, p = 0.038), largest histologic tumor diameter >3 cm (p = 0.015), histologic grade (p = 0.008), myometrial invasion > 1/2 (p = 0.005), and 1988 FIGO staging system (p = 9.10(-8)). In Group II, the addition of external beam pelvic RT did not seem to independently improve vaginal or pelvic control. The postoperative complication rate was 7%. The independent factors increasing the risk of postoperative complications were stage FIGO (p = 0.02) and pelvic lymph node dissection (p = 0.011). The 10-year rate for Grade 3 and 4 late radiation complications according to the LENT-SOMA scoring system was 3.1%. External beam pelvic RT independently increased the rate for Grade 3 and 4 late complication (RR: 5.6, p = 0.0096). CONCLUSION: Postoperative external beam pelvic RT increases the risk of late radiation complications. After surgical and histopathologic staging with pelvic lymph node dissection, in subgroup of "intermediate-risk" patients (Stage IA Grade 3, IB-C and II), postoperative vaginal brachytherapy alone is probably sufficient to obtain a good therapeutic index. Results for patients with Stage III tumor are not satisfactory.

Precarity and pregnancy in Paris.

OBJECTIVE: Our purpose was to assess to what extent the absence of health insurance (Social Security) contributes to poor pregnancy outcome. STUDY DESIGN: A prospective, population-based study compared the perinatal outcome of women without Social Security (n=243) to a contemporaneous control group (n=243) and to a group of women (n=32) with Social Security but presenting another risk factor for precarity (a judicial child-mother separation sentence). RESULTS: Prenatal consultations were less frequent and initiated later for women without Social Security than for controls. There was no difference between these two groups concerning maternal morbidity (premature labour, hypertension, gestational diabetes, post-partum complications) or maternal mortality, no difference for the mode of delivery and the rate of low birth-weight, foetal death, and neonatal morbidity (hypoglycaemia, hypocalcemia, anaemia, jaundice, infection and transfer to intensive care unit). The rate of prematurity was not significantly higher in the group without Social Security compared to the control group (11.1% versus 6.2%, P=0.08). However, in the group with Social Security and a court sentence of child mother separation, the rate of fetal growth retardation, prematurity, home delivery, caesarean section, neonatal drug deprivation syndrome and transfer to an intensive care unit was significantly higher compared to the two other groups (P<0.01). CONCLUSION: In our study, absence of Social Security during pregnancy is not a major determinant of poor pregnancy outcome, whereas other factors of precarity seem to be more influential.

Nicardipine versus salbutamol in the treatment of premature labor. A prospective randomized study.

OBJECTIVE: To compare the tocolytic action and the side effects of nicardipine to those of salbutamol in patients presenting premature labor in order to propose nicardipine as a promising alternative to salbutamol in the treatment of premature labor. STUDY DESIGN: Ninety patients admitted to the Saint-Antoine Hospital (Paris, France) for premature labor were included in this prospective randomized open study comparing nicardipine and salbutamol. Each study group included 45 patients. RESULTS: The mean term of delivery in the nicardipine group was 38.4 +/- 1.7 and 37.6 +/- 2.1 weeks in the salbutamol group (P < 0.05). The percentage of deliveries after 37 gestational weeks was higher with nicardipine (P < 0.05). The birthweight of infants was 3131 +/- 488 g with patients treated with nicardipine and 3019 +/- 494 g with the salbutamol group (NS). The Apgar scores were identical in the two groups at 1 and 5 min. There was no statistically significant difference in the number of neonates admitted into intensive care nor the premature infant center between the two groups. Nicardipine reduced the systolic and diastolic blood pressure whereas there was no change in the salbutamol group. Maternal pulse rate was significantly increased in the salbutamol group (P < 0.01) and was unchanged in the nicardipine group. The most common side-effects with nicardipine were headaches, and with salbutamol, tremors and palpitations. CONCLUSIONS: Nicardipine is a tocolytic agent as effective as salbutamol in the treatment of premature labor. The use of nicardipine is an interesting alternative to salbutamol, especially in cases of hypertension, diabetes or maternal cardiopathy.

[Agenesia of the canal of Arantius. A case report]. / Agénésie du canal d'Arantius. A propos d'un cas.

Looking for the etiology of hydramnios which became symptomatic at 21 weeks' gestation ultrasonography revealed a hepatic vascular abnormality without other symptoms. The suspected diagnosis was agenesis of the ductus venosus with creation of a high grade arteriovenous shunt between the umbilical vein and the inferior vena cava. Agenesis of the ductus venosus may be one expression of the different possible systemic-portal-umbilical abnormalities. Physiological consequences vary according to the type of substitutive anastomoses.

Synthesis of glycosaminoglycans by human cervical fibroblasts in culture: effects of prostaglandin E2 and cyclic AMP.

OBJECTIVE: To study the mechanism of action of prostaglandin E2 (PGE2) and its analogue sulprostone leading to production of glycosaminoglycans (GAGs) in the human uterine cervix. STUDY DESIGN: We analysed the effects of PGE2 and its analogue sulprostone upon production of adenosine 3',5'-monophosphate (cAMP), in human cultured fibroblasts. We also studied the effects of PGE2, sulprostone and a cAMP analogue (8-Bromo-cAMP), on the incorporation of [3H]glucosamine into GAGs in human cervical fibroblasts in culture. RESULTS: Following treatment with PGE2 (10(-4)-10(-6) M), we observed a significant increase in the production of cAMP from 96.3 +/- 8.4 pmol/10(6) cells without phosphodiesterase inhibitor 3-isobutyl-methylxanthine (IBMX) to 325 +/- 63 pmol/10(6) cells with 10(-4) M IBMX (Spearman correlation test; P < 0.05). Under the same conditions, the effects of sulprostone (10(-6) M) were limited (from 8.1 +/- 1.5 to 51.3 +/- 14.1 pmol/10(6) cells without and with IBMX, respectively; not significant). Both PGE2 and 8-bromo-cAMP (from 10(-12) to 10(-4) M) increased [3H]glucosamine uptake into GAGs (Spearman correlation test; P < 0.05). Sulprostone (10(-12)-10(-4) M) was unable to reproduce such an effect even after a 24 or 48 h treatment. CONCLUSION: Since firstly, PGE2 acts through EP1, EP2 and EP3 specific receptors, whereas the action of sulprostone is only mediated by EP1 and EP3, and secondly EP2 receptor is coupled with cAMP production, we conclude that cAMP is involved in mediating the action of PGE2 upon GAG synthesis by human cultured cervical fibroblasts.

Termination of 2nd and 3rd trimester pregnancies with mifepristone and misoprostol.

OBJECTIVE: The purpose of this study was to evaluate our use of the association of mifepristone and misoprostol for terminating second and third trimester pregnancies. STUDY DESIGN: One hundred and six patients undergoing termination of pregnancy between January 1993 and June 1995 in our center were studied. Each patient received 600 mg of mifepristone followed 24 h later by 400 microgrammes of misoprostol every 6 h. RESULTS: The average interval from the first administration of misoprostol to expulsion was 12.5 +/- 7.5 h (interval markedly decreased to 9.6 +/- 6.3 h in cases of intrauterine fetal death). CONCLUSION: The efficacy of the association of mifepristone and misoprostol is comparable with that of current regimens with grealer ease of utilization and at a much lower cost.

PIP: A clinical study of 106 second- and third-trimester induced abortions conducted at a hospital in Paris, France, confirmed the feasibility of a combined mifepristone-misoprostol regimen. All women were hospitalized and administered 600 mg of mifepristone, followed 24 hours later by 400 mcg of misoprostol every 6 hours until fetal expulsion. Medical reasons for pregnancy termination included fetal morphological abnormalities (34.9%), intrauterine death (26.4%), chromosome anomalies (16.9%), and maternal indications (19%). The average gestational age was 22.1 weeks (range, 15-41 weeks). The average expulsion interval was 12.5 +or- 7.5 hours (range, 30 minutes-38 hours). This interval was significantly shorter in multiparas, second-trimester pregnancies, and cases of fetal death. Mild side effects (e.g., vomiting, hyperthermia, and diarrhea) were noted in 34 patients (32%); there were no major complications. The mean length of hospital stay was 4.1 +or- 2.5 days. The efficacy of this regimen is comparable to that of regimens involving other abortifacient agents, but with the added advantages of greater ease of utilization and lower costs.

Treatment of symptomatic polyhydramnios with indomethacin.

Polyhydramnios carries a poor fetal prognosis with an expected neonatal death rate of nearly 30%. Approximately one-fourth of this perinatal mortality is a result of the effects of prematurity. The poor outcome with usual management of polyhydramnios led us to introduce the therapeutic use of prostaglandin synthetase inhibitors so as to decrease amniotic fluid volume and to prevent premature labor. Twenty-two women (20 singleton and two twin pregnancies) were included in a retrospective study from 1983 to 1992. Indomethacin was given at a dose of 3 mg/kg/day. Treatment was started at 28.2 +/- 3.8 weeks of amenorrhea and discontinued after 35 weeks. We observed a significant effect of indomethacin on amniotic fluid volume and avoided severe preterm delivery in all patients. Mean gestational age at birth was 37.5 +/- 1.6 weeks of amenorrhea (range 35.5-39 weeks). We did not observe any maternal or neonatal side effects of indomethacin therapy. However, we reported three neonatal deaths out of 24 infants: two related to undiagnosed fetal anomalies (one Nager syndrome and one cerebral malformation) and one related to umbilical cord entanglement in a monoamniotic twin pregnancy. Since our first report, several open studies supporting our data have been published. However, although indomethacin appears to be effective in the treatment of polyhydramnios, our goal is to analyze efficacy and side effects, so as to define conditions of clinical use.

[Mifepristone and misoprostol in therapeutic abortions]. / Mifépristone et misoprostol dans les interruptions médicales de grossesses.

OBJECTIVES: To report our experience with the mifepristone and misoprostol combination in second and third trimester medically induced abortion. TYPE OF STUDY: Prospective study without control group between January 1993 and december 1994. STUDY SITE: Saint-Antoine Hospital, Paris. PATIENTS: Fifty-three patients admitted for a medically induced abortion. RESULTS: Induction-to-abortion mean time was 12.9 +/- 7.5 hours (time distinctly decreased in fetal death: 8.3 +/- 4.4 hours). CONCLUSION: The combination of misoprostol with mifepristone has equivalent with the other protocol used for therapeutic pregnancy termination, is less expensive (25 to 100 times) and finally is simple and non-invasive.

[Cervical pregnancy: conservative treatment with primary embolization of the uterine arteries. A case report. Review of the literature]. / Grossesse cervicale: traitement conservateur avec embolisation première des pédicules utérins. A propos d'un cas. Revue de la littérature.

Ectopic pregnancies are rarely located in the cervix. In most (50-70%) of the cases, haemostatic hysterectomy is usually performed. We attempted an original approach for ectopic pregnancies located in the cervix which allowed preservation of the uterus. The uterine arteries are embolized before evacuation of the pregnancy and haemostasis of the loge with a balloon probe. In the literature, the incidence has been reported at 1 cases/20,000 births. Past history of curetage is a favouring factor. Echography facilitates diagnosis. When possible, conservative treatment may involve surgery (arterial ligature, endocervical haemostasis), drug therapy (methotrexate) and radiography (arterial embolization).

Nicardipine versus metoprolol in the treatment of hypertension during pregnancy: a randomized comparative trial.

OBJECTIVE: To compare the effects of treatment with nicardipine and metoprolol in patients with hypertension during pregnancy. METHODS: One hundred pregnant patients with mild or moderate hypertension followed at the Centre Hospitalier Intercommunal de Créteil (France) were randomly allocated to treatment with either nicardipine or metoprolol. Changes in maternal blood pressure (BP), laboratory indices, umbilical Doppler velocimetry, and neonatal outcome were compared by means of Student t test, chi 2 test, and analysis of variance. RESULTS: Nicardipine decreased maternal systolic and diastolic BP more than metoprolol (P < .001). Umbilical artery resistance was lower in nicardipine-treated patients (P < .001). Plasma uric acid and creatinine concentrations were increased less markedly in the nicardipine group (P < .05 and P < .01, respectively). The incidence of cesarean delivery for fetal distress was lower in the nicardipine group (P < .01). There was a trend toward higher birth weights in the nicardipine group but no significant difference in neonatal outcome. CONCLUSION: Nicardipine is more effective than metoprolol in decreasing maternal BP; neonatal outcome is not significantly different.