Is there a justification for hysterectomy in patients with borderline ovarian tumors?

OBJECTIVE: To determine the frequency of uterine involvement in patients with borderline ovarian tumors (BOT) and to evaluate the recurrence risk and survival after hysterectomy. MATERIALS AND METHODS: In two French hospitals: A tertiary referral centre (University hospital centre of Tours, France) and the Alliance community hospital of Tours (France), we reviewed data of consecutive women undergoing surgery for presumed stage I BOT between January 1997 and December 2012. Patients were divided into two groups: patients treated with fertility sparing surgery (group 1) and those treated with radical surgery (group 2). RESULTS: A total of 135 patients were evaluated. 35 had fertility sparing surgery, 81 had radical surgery with hysterectomy and 19 had previous hysterectomy for other reasons. There were more recurrent borderline ovarian disease and more ovarian invasive disease developed in group 1 (p = 0.02, p = 0.04, respectively). Hysterectomy affected favorably borderline disease-free survival, OR = 0.09 95%CI (0.005-0.69), p = 0.04, but perceived benefits may be related to bilateral salpingo-oophorectomy and not hysterectomy directly.

Dependence of human milk essential fatty acids on adipose stores during lactation.

The relationships between essential fatty acid (EFA) composition of colostrum, mature milk, and white adipose tissue (WAT) were examined on days 5 and 30 postpartum in 24 healthy French mothers. Fatty acid composition was assessed by capillary gas chromatography. In WAT, the proportion of individual polyunsaturated fatty acids (PUFAs) did not change during lactation and was greater (18:2n-6) or lower (18:3n-3, long-chain PUFAs) than values found in colostrum or mature milk (P < 0.04). The 18:2n-6 content and the ratio of 18:3n-3 to 18:2n-6 correlated between WAT and colostrum (r = 0.52 and r = 0.57, respectively) or mature milk (r = 0.64 and r = 0.65, respectively). These relationships agree with an expected qualitative effect of WAT fatty acid composition on interindividual variability of milk parent EFA content. The decrease in the long-chain PUFA content observed from colostrum to mature milk and the concomitant occurrence of a precursor-product relationship between the linoleate and its long-chain PUFA are consistent with the mobilization of a preformed long-chain PUFA pool during early lactation.

Low alpha-linolenic acid content of adipose breast tissue is associated with an increased risk of breast cancer.

Data derived from experimental studies suggest that alpha-linolenic acid may have a protective effect in breast cancer. Observations obtained from epidemiological studies have not allowed conclusions to be drawn about a potential protective effect of dietary alpha-linolenic acid on breast cancer, possibly because of methodological issues. This case-control study conducted in an homogeneous population from a central area in France was designed to explore the hypothesis that alpha-linolenic acid inhibits breast cancer, using fatty acid levels in adipose breast tissue as a biomarker of past qualitative dietary intake of fatty acids. Biopsies of adipose breast tissue at the time of diagnosis were obtained from 123 women with invasive non-metastatic breast carcinoma. 59 women with benign breast disease served as controls. Individual fatty acids were analysed by capillary gas chromatography. An unconditional logistic regression model was used to obtain odds ratio estimates whilst adjusting for age, menopausal status and body mass index (BMI). No association was found between fatty acids (saturates, monounsaturates, long-chain polyunsaturates n-6 or n-3) and the disease, except for alpha-linolenic acid which showed an inverse association with the risk of breast cancer. The relative risk of breast cancer for women in the highest quartile of adipose breast tissue alpha-linolenic acid level was 0.36 (95% confidence interval=0.12-1.02) compared with those in the lowest quartile (P trend=0.026), suggesting a protective effect of alpha-linolenic acid in the risk of breast cancer. The effects of dietary alpha-linolenic on the risk of breast cancer warrant further study.

Primary chemotherapy and radiosurgical breast-conserving treatment for patients with locally advanced operable breast cancers.

PURPOSE: The traditional surgical treatment for operable breast cancer larger than 3 cm is mastectomy. In order to avoid mutilating surgery, we administered primary chemotherapy to 80 patients with operable non metastatic large breast cancer T2 > 3 cm and T3, N0-N1. The purpose of the study was to evaluate the breast-conserving rate induced by this treatment strategy and determine if it is a safe alternative for women with locally advanced breast carcinomas that are responders to an induction chemotherapy. METHODS AND MATERIALS: The mean age was 50.1 years. Forty-three patients were T2 > 3 cm, 37 were T3. Twenty-six were N0 and 54 were N1. Mean tumor size was 5.4 cm. Patients were treated with three courses of the MVCF regimen (Mitoxantrone, Vindesin, Cyclophosphamide, and 5 Fluorouracil) every 4 weeks and then with a radiosurgical combination. RESULTS: The overall response rate to induction chemotherapy was 51% with 17.5% complete tumor regression. Twenty-one percent of the patients developed grade 3 or 4 chemotherapy toxic effects, all acceptable and reversible. Breast-conserving treatment was feasible in 42.5% (34/80). Twenty patients (25%) were treated with a radiosurgical combination (tumorectomy+radiation therapy), 14 (17.5%) with radiotherapy alone (external irradiation and brachytherapy). Age, tumor stage, histology, hormonal status, hormonal receptors rate had no influence on the frequency of the observed regressions. Isolated recurrences occurred in five patients, two conservatively treated and three treated with mastectomy. Metastatic relapses were observed in 20 patients (12% in the responders and 38.5% in the non responders to chemotherapy) (p < 0.02). Five-year actuarial survival was 73% and was significantly better for responders to the induction treatment. CONCLUSION: These results suggest that primary chemotherapy and radiosurgical breast conserving treatment is a safe alternative to mastectomy for patients with locally advanced operable breast cancer. The long-term benefit of this strategy must be evaluated in well designed controlled trials.

Uterine necrosis after arterial embolization for postpartum hemorrhage.

BACKGROUND: Selective embolization is an effective and reputedly safe method of managing pregnancy-related bleeding. However, we report an ischemic uterine necrosis after arterial embolization. CASE: The patient had heavy postpartum bleeding treated by embolization of the uterine arteries using polyvinyl alcohol particles (diameter 150-250 and 300-600 microm) and gelatin sponge pledgets. Her postoperative recovery was complicated by menorrhagia and pelvic pain. Because of the persistent menorrhagia and risk of infection, a hysterectomy was performed. Histopathology of the hysterectomy specimen revealed massive ischemic myometrial necrosis. CONCLUSION: This complication is most likely related to the small size of the particles used. In the management of postpartum bleeding by arterial embolization, the material of choice is gelatin sponge pledgets, and the use of small particles should be avoided.

Specific pruritic diseases of pregnancy. A prospective study of 3192 pregnant women.

BACKGROUND AND DESIGN: For a period of 1 year, all pregnant women presenting with itching were investigated by clinical, histologic, immunopathologic, and laboratory studies. Fifty-one of 3192 pregnant women were studied. RESULTS: We identified (1) two typical cases of herpes gestationis, with an approximate incidence of one in 1700 pregnancies; (2) 22 cases of pruritus gravidarum, including five cases with a polymorphous skin eruption, with an incidence of one in 145 pregnancies; (3) 25 cases of polymorphic eruption of pregnancy, including diseases without maternal or fetal side effects and without criteria defining herpes gestationis or pruritus gravidarum, with an incidence of one in 130 pregnancies; and (4) two cases of intercurrent disease (one scabies and one exfoliative dermatitis). CONCLUSION: Our study is a prospective homogeneous account of pruritic dermatosis of pregnancy. Our results show that the incidence of herpes gestationis is higher than is usually reported in the literature and that pruritus gravidarum must be considered in the presence of itching occurring during pregnancy, with or without skin eruption.

The DopFet system: a new ultrasonic Doppler system for monitoring and characterization of fetal movement.

To enable the investigation of fetal movement in a manner similar to fetal heart rate (FHR) monitoring we have developed an apparatus (the DopFet system) that consists of a pair of miniature sensors, a 2-MHz continuous-wave directional Doppler electronic module and a laptop personal computer. One of the sensors is aimed at the fetal limbs and the other at the thorax to detect heart and upper body movements. The signals are analyzed, presented in real-time and postprocessed by software developed by us. The postprocessing software computes a number of parameters (the DopFet parameters) describing fetal movement. These parameters can be divided into two categories: parameters that describe the quantity of fetal movement (i.e., number of movements) and parameters that describe qualitative aspects of fetal movement (i.e., average movement duration). Future studies using the DopFet system will be aimed at discovering which of these parameters or combination of parameters is the best indicator of fetal well-being. We present an example of a 0.5 h recording and the results of testing on 23 volunteer mothers. These results show good sensitivity of the system compared to real-time ultrasound (US). The system detects 96% of rolling movements, 100% of flexion movements and 97% of leg movements.

Assessment of the fetal PO2 changes by cerebral and umbilical Doppler on lamb fetuses during acute hypoxia.

The objective of the present study was to validate one or a combination of fetal Doppler parameters in order to assess acute fetal hypoxia in an ovine model. Acute hypoxia was induced by reducing umbilical, or maternal aortic flow (approx. 70%). A CW Doppler probe was fixed on the fetal cervical skin, facing the internal carotid artery and the fetal abdominal skin adjacent to the umbilical arteries. (The angle between Doppler beam and flow vector remained constant.) A "Doptek 3000" spectrum analyser was used to measure the maximal and mean Doppler frequencies. Heart rate (HR), umbilical blood flow (UBF), carotid blood flow (CBF), umbilical RI (URI), cerebral RI (CRI) and cerebroplacental ratio (CPR = CRI/URI) were calculated in real time. A catheter was inserted into the fetal femoral artery, for blood gas (PO2, PCO2 pH) and blood pressure (BP) measurements. After 1 min of aorta compression (70% aortic flow reduction), the URI increased by 10% (P < 0.05), and the UBF decreased by 10% (P < 0.05), but the CRI decreased by 20% (P < 0.02), and the CBF did not change significantly. Fetal PO2 and CPR fell down after 1 min (59% and 38%, respectively; P < 0.001), although strong fetal heart rate decelerations were observed. The blood pressure, PCO2 and pH did not change significantly during this test. Throughout the 12 min of cord compression (70% umbilical flow reduction) the URI increased (70% to 80% P < 0.001), and the UBF decreased (approx. 60%; P < 0.001), but the CRI decreased (approx. 25%; P < 0.01), and the CBF remained constant (+/- 5%; ns). Fetal PO2 and CPR all decreased during the compression (30% to 44% and 40% to 60%, respectively; P < 0.001). HR, pH and PCO2 did not change significantly. During cord compression the blood pressure did not change significantly. In both cases, the CPR decreased significantly (P < 0.001) with the PO2 in the same direction and with a comparable amplitude (-30% to -50%). Nevertheless, the drop in CPR was greater during cord compression than during aorta compression, probably because the compression of the cord induced a central hypovolemia in addition to the hypoxia. The CPR was found to be the hemodynamic parameter that followed most closely the PO2 acute changes. The amplitude of the variations of this parameter (-30% to -50%) were quite similar to those of the PO2 during the period of acute hypoxia.(ABSTRACT TRUNCATED AT 400 WORDS)

Bilateral ovarian removal during hysterectomy: what is done and what should be done.

OBJECTIVE: Discussion of the indications for bilateral removal of the ovaries at hysterectomy after the age of forty. DESIGN: A multicenter survey involving 50 university centres and regional hospitals was carried out. RESULTS: The majority of French Obs-Gyn carry out bilateral removal of adnexa when the patient is over fifty years old, rather than after forty years of age. DISCUSSION: Reducing mortality due to ovarian cancer is commendable, as is the reduction of morbidity due to ovarian cysts and pathology after hysterectomy, but it is necessary to evaluate the cost of prematurely induced menopause. CONCLUSION: The authors believe that an age limit of forty years is too low. A consensus has emerged for performing bilateral removal of the ovaries after the age of fifty in the absence of a history of pelvic adhesions and/or endometriosis. It is necessary to explore the condition of the ovaries during the laparotomy.

Fetal cerebral and renal Doppler in small for gestational age fetuses in hypertensive pregnancies.

UNLABELLED: The aim of the present work is to evaluate the hemodynamic disorders induced in several fetal vascular areas by maternal hypertension and to check the sensitivity and the specificity of the various Doppler parameters in the detection of small for gestational age (SGA) infants. The population consisted of 90 pregnant mothers aged 26.3 +/- 5.8 years with pregnancy-induced hypertension. Seventeen of them delivered moderate small for age babies (between the 10th and 5th centiles), without any neonatal complication. The opposition to flow in the fetal brain and kidney and in the placenta was evaluated using the Resistance Index (RI). The ratio of cerebral RI and umbilical RI, called the cerebroplacental ratio (CPR), was calculated and used as an indicator of fetal flow redistribution. The ability of CPR and renal RI to predict SGA at birth was evaluated; the sensitivity, specificity, positive predictive value, and negative predictive value for the CPR were 88.2%, 98.6%, 93.8% and 97.3%, respectively. The corresponding figures for the renal RI were 58.8%, 94.5%, 71.4% and 91%, respectively. Furthermore, in the SGA group, the abnormal renal RI values were both above and below the normal range, whereas the CPR values demonstrated consistent changes (always < 1). CONCLUSION: this investigation demonstrates that in pregnancy-induced hypertension (even with moderate growth retardation, and no neonatal complication), the diagnostic efficacy of CPR for predicting SGA at birth is very high and that of renal RI correlates very poorly with fetal growth.

Twenty-day cerebral and umbilical Doppler monitoring on a growth retarded and hypoxic fetus.

In one growth retarded and hypoxic fetus, the cerebral and umbilical hemodynamic changes were assessed (by Doppler), daily over 20 days. The fetal brain was investigated by magnetic resonance imaging (MRI) close to the delivery, and because the fetus died at delivery we performed an anatomical study of the fetal brain. The evolution of the fetal hemodynamics (day by day) was interpreted according to the MRI findings and the clinical findings. During the period of observation (under sustained hypoxia) the fetal deterioration was characterized by: (a) the progressive development of the oligohydramnios (190d), (b) the disappearance of the vascular reactivity (eight successive cerebral resistance index (RI) constant at 194d), (c) the occurrence of fetal heart rate decelerations (199d), and finally (d) the increase of the cerebral vascular resistances with reduction of the brain perfusion (204d). The anatomical study of the brain showed a periventricular congestion however the histology revealed hypoxic lesions like gliosis and a marked vasodilation of the anterior and middle cerebral arteries. Finally in addition to single Doppler measurements performed 1 week before delivery (for prediction of fetal outcome), one can suggest to use the 'loss of fluctuation of the cerebral RI' to identify the beginning of the period of very high risk for the fetus. Such hypothesis may have to be confirmed on a larger number of pathological pregnancies.

Abdomino pelvic irradiation after second-look laparotomy for stage III ovarian carcinoma.

OBJECTIVE: The purpose of this retrospective analysis of 34 patients with stage III ovarian carcinoma was to review results and morbidity of whole abdominal irradiation after surgery and chemotherapy. METHODS AND MATERIALS: All of the 34 patients had reached a complete clinical remission after first cytoreductive surgery and chemotherapy. After second-look laparotomy each patient underwent whole abdominal irradiation. Except for two patients with chronic myelosuppression, the dose administered was of 22.5 Gy to the abdominal cavity with a boost of 22.5 Gy added to the pelvis. RESULTS: Three and 5-year overall survival rates were 62% and 43%, respectively. Three and 5-year disease-free survival rates were 53% and 38%. Twenty-three patients (68%) developed local relapse or local disease progression. Metastasis occurred in five cases and were always associated with an abdominal cavity recurrence. Residual disease after first cytoreductive surgery appeared as a prognostic factor in univariate analysis. Patients with unresected residuum had a 5-year survival probability of 35% versus 83% for patients without residual disease. We observed 12% grade-3 intestinal toxicities and one fatal case of radiation enteritis. CONCLUSION: Despite its curative potential, the long term benefit of whole abdominal irradiation in the multimodality treatment of advanced ovarian carcinoma must be evaluated in well designed controlled trials.

[External cephalic version as a possible treatment of breech presentation]. / Il rivolgimento cefalico per manovre esterne come possibile trattamento della presentazione podalica del feto.

BACKGROUND: Breech presentation shows 3-4% incidence on every foetal presentation at the time of delivery and is more correlated than vertex presentation to a foetal risk of perinatal mortality (with a frequency from 2 to 5 times higher) and to foetal malformations, low weight at birth and prematurity. On the other hand, without a careful case selection, breech delivery has a higher risk of perinatal morbidity and mortality in comparison to cephalic presentation. It is estimated that perinatal mortality for breech presentation at term is about 4-5% for vaginal delivery and about 2-4% for caesarean section. In addition caesarean section has a higher maternal morbidity and a small but significant risk of perinatal mortality, therefore, external cephalic version (ECV) can be a good choice to increase physiological deliveries. The aim of the present study is to evaluate the real efficacy of this obstetric manoeuvre to decrease the frequency of breech presentation at delivery. METHODS: The study group included 67 patients (age 29.5 +/- 3.8) with foetal breech presentation at gestational age 35.8 +/- 1.9 weeks, recruited at the Department of Obstetrics and Gynaecology of the Pavia University. Every patient underwent ECV. The same physician has performed every ECV attempt using the forward roll technique, with previous tocolysis in 50 cases (rithodrine vs isoxsuprine). The following variables have been taken into consideration: amount of amniotic fluid, gestational age, kind of tocolysis, placental location, foetal back position, parity, breech variety and foetal adnexial complication at birth. RESULTS: ECV succeeded in 77.6% (n = 52) and failed in 22.4% (n = 15) of cases. No maternal or foetal complications, side effects and spontaneous breech version occurred and in 74.6% of cases (n = 50) a vaginal delivery was performed. In 25.4% of cases (n = 17) a caesarean section was performed (15 breech presentation, 1 foetal distress in labour and 1 cervical dystocia). Among variables examined related to successful ECV, it has been observed that the amount of amniotic fluid (chi 2 = 15.33; p < 0.0000), the kind of tocolysis (chi 2 = 10.04; p < 0.007) and the umbilical cord rounds (chi 2 = 3.98; p < 0.045) were distributed in a significantly different way, whereas gestational age (p < 0.045) was significantly higher in unsuccessful ECV. CONCLUSIONS: The results obtained suggest that ECV may be a good therapeutic approach for decreasing the percentage of breech presentation at delivery.

[Pentasa (mesalazine) and pregnancy]. / Pentasa (mésalazine) et grossesse.

We analysed the outcome of 11 pregnancies in women treated for inflammatory bowel disease with mesalazine (Pentasa) during part of or throughout pregnancy. There were 9 healthy babies, one spontaneous abortion (the woman had an uterine malformation) and one infant with multiple malformations (but the mother was not treated with mesalazine during organogenesis). Because of the relatively small number of pregnancies exposed to mesalazine (Pentasa) in this study, these data need to be confirmed by other studies.

[Retroperitoneal malignant fibrous histiocytoma]. / Histiocytome fibreux malin rétropéritonéal.

Malignant fibrous histiocytoma is the commonest soft tissue sarcoma of adults. The soft tissue of the extremities is the commonest primary site of malignant fibrous histiocytoma. It is much less common in the female retroperitoneum, leading to diagnostic errors. The clinical, radiographic and CT signs are non-specific. This tumor can only be diagnosed by histology. An initial complete resection is essential for successful treatment of the primary tumor. Radiation therapy is limited and chemotherapy has only been successful in a limited number of cases. This tumor has a poor prognosis. These lesions are relatively rare and consequently difficult to study. The authors report three cases and review the literature.

[Epithelial cancer of the ovary in adults: prognostic and therapeutic study of 95 cases]. / Le cancer épithélial de l'ovaire chez l'adulte: étude pronostique et thérapeutique de 95 cas.

The authors report 95 cases of ovarian carcinoma treated between 1st January 1975 and December 1986 in the department of gynecology and radiotherapy of hospital Bretonneau in Tours. The overall actuarial 5-year survival was 37.5%, for stage I 100%, stage II 51%, stage III 36%, stage IV 5%, grade I 88%, grade II 51%, grade III 18%. The authors stress the prognostic importance of histologic grade and the bad prognosis of small cell ovarian carcinoma with hypercalcemia. The authors propose a therapeutic attitude based on the results and a review of the literature.

[Changes in the utero-placental and fetal cerebral circulations induced by nicotine in the ovine fetus]. / Modifications des circulations utéro-placentaire et cérébrale foetales induites par la nicotine chez le foetus ovin.

Foetal and maternal circulations were studied in 5 gestating sheep given an intra-muscular nicotine injection (10 mg) daily for 65 days beginning on the 60th day of gestation. Six control sheep and 5 others given a placebo injection comprised the control group. Placental (Rp), cerebral (Rc) and uterine (Ru) vascular resistances were measured by Doppler at the following sites: umbilical arteries, foetal cerebral arteries, uterine arteries. Measurements were taken at 80, 100 and 130 days of gestation. The Doppler resistance indices were comparable in the control and placebo group. The cerebral Doppler resistance indices were comparable in the three groups at 80 and 100 days, but there was a significant increase at day 130 in the nicotine group (p < 0.01). This increase was in favour of reduced cerebral perfusion. The umbilical indices were slightly higher at 80 and 130 days in the nicotine group (p < 0.01). The cerebro-placental ratio (Rc/Rp) remained unchanged in the controls, but increased significantly in the nicotine fetuses (p < 0.05) confirming a redistribution of the fetal blood flow away from the brain. There was no significant difference in the uterine resistances at 80 and 100 days in the nicotine group (p < 0.01), but they increase between 100 and 130 days. In the control and placebo groups, delivery occurred at normal gestation dates. In these two groups, two lambs (10%) were stillborn. In the nicotine group, premature delivery occurred in two sheep and 8 of the 13 lambs (63%) were stillborn.(ABSTRACT TRUNCATED AT 250 WORDS)

[Refinement of a new Doppler sensor for studying fetal hemodynamic disorders (animal model)]. / Mise au point d'un nouveau capteur Doppler pour l'étude des perturbations hémodynamiques foetales (modèle animal).

Fetal Doppler techniques applied in the human have furnished information of the regional haemodynamics of fetal circulation but has in general been associated with haemodynamic data obtained by vessel puncture, i.e. arterial pressure or blood gases. With animal models, further data can be obtained in the course of induced pathologies or during dynamic test (hypoxia, drugs). Several studies on utero-placental haemodynamics have been conducted using electromagnetic sensors and implanted catheters. This type of technique is only possible for certain vessels (usually the cord vessels) and, for example, cannot be used to investigate the cerebral area. The aim of this work was to develop a Doppler sensor which could be implanted in utero on the fetus and would permit a real time measurement of the major fetal blood flows. The sensor was made of 2 continuous Doppler transducers (13 mm x 4 mm) with a 45 degrees inclinasion to the sensor surface and carried on a parallellopipedic support system measuring 20 mm x 6 mm. The active surface of the transducer has a silicone film covering. The sensor is placed on the skin of the fetus, facing the artery to be explored, and oriented towards capture of a quality signal. The sensor is then sutured to the skin and the coaxial leads of the 2 transducers are exposed through the skin of a pregnant ewe. The leads are connected to a Doppler control panel later after the operative period. Three sensors can be implanted simultaneously to monitor umbilical, cerebral and uterine blood flows.(ABSTRACT TRUNCATED AT 250 WORDS)

[Irradiation in the treatment of adenocarcinoma of the ovary. Retrospective study of 44 cases]. / L'irradiation dans le traitement des adénocarcinomes de l'ovaire. Etude rétrospective de quarante-quatre cas.

In order to better assess the place of radiotherapy in the treatment of ovarian carcinoma, the length of survival in 44 patients treated with irradiation has been examined. 44 patients, with nil or minimal (less than 2 cm) residual disease, were found among 92 patients with invasive ovarian carcinoma treated consecutively in our center from 1976 to 1986. Treatment included laparotomy for 42 patients. Debulking surgery was complete in 9 stage I and 10 stage II patients. Those patients also received abdominopelvic (16 cases) or pelvic (3 cases) irradiation. Residual tumour was left in the 25 remaining patients (2 with stage IIc, 18 with stage III, and 5 with stage IV) who further underwent various regimes of polychemotherapy (9 without and 16 with cisplatin) followed by second-look laparotomy. 25 patients had no (8 patients) or minimal (17 patients) residual disease after this second laparotomy and they underwent abdominopelvic irradiation. Overall 3-year survival was 68%, 3-year survival was 80% for stage I and II patients treated by radiotherapy after initial complete debulking surgery, and 58% for advanced stages treated by radiotherapy after chemotherapy and second-look laparotomy, 3-year survival was 71% for 18 patients with stage III. Tolerance for irradiation was significantly decreased after chemotherapy and this prevented a complete dose being delivered to 32% of the patients. A late severe complication was noted in only one case. For stage I or II our results are close to those already published by others.(ABSTRACT TRUNCATED AT 250 WORDS)

[Scarred uterus: is routine exploration of the cesarean scar after vaginal birth always necessary?]. / Utérus cicatriciel: la révision systématique de la cicatrice de césarienne après accouchement par voie vaginale est-elle toujours utile?

OBJECTIVE OF THE STUDY: To determine the risks and benefits of routine transcervical revision of previous cesarean uterine scar in patients with successful vaginal delivery. MATERIAL AND METHODS: Retrospective study, over a 10-year period, of a routine palpation practice in the two units of our Obstetric department. Then, a 30-month prospective study comparing, in each unit, two different attitudes toward uterine revision (routine exploration vs symptomatic patients exploration) was conducted. RESULTS: The retrospective part of our study led us to report 3 uterine ruptures (0.43% of all scarred uterus) and 14 dehiscences (2%) during the ten years. All uterine ruptures were sufficiently symptomatic in order to be suspected prior to scar exploration. No dehiscence needed surgical treatment. Some patients with bloodless dehiscence and no repair had subsequent vaginal deliveries with no scar separation found on uterine exploration. In the prospective part of our study, we found a significative difference in the occurrence of fever (18.9% vs 9.9%; p < 0.05) and antibiotic treatment (22.8% vs 12.7%; p < 0.05) between the two groups based on attitude toward uterine revision. CONCLUSION: These data suggest that transcervical revision of previous cesarean uterine scar should be performed only in symptomatic patients (persistent suprapubic pain, placental retention, excessive bleeding during labor or delivery) or when risk factors are present (prolonged labor, prolonged expulsive efforts, instrumental extraction).