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.

Fetal pulse oximetry: correlation between changes in oxygen saturation and neonatal outcome. Preliminary report on 39 cases.

Arterial oxygen saturation of the fetus during labour (SPO2) measured with a fetal pulse oximeter was compared to the neonatal condition measured by umbilical vein pH and Apgar score. Changes in oxygen saturation (index of desaturation) during the second stage of labour were also compared to neonatal outcome. Fifty-five patients with abnormal fetal heart rate pattern during labour had a continuous monitoring of fetal oxygen saturation using the Nellcor N-400 pulse oximeter. SPO2 measurement during the last 10 min of labour was significantly correlated to umbilical vein pH and to 1-min Apgar score (P = 0.022 and P = 0.025, respectively). A much higher correlation was found between the index of desaturation and umbilical vein pH at birth and with 1-min Apgar score (P = 0.002 and P < 0.001, respectively). When considering the lower value of umbilical vein pH at birth to be 7.20, and the normal value of SPO2 during labour to be > or = 40% (negative test), we observed a 100% negative predictive value of oximetry. If these results are confirmed in a larger series of patients, analysis of the changes in fetal arterial oxygen saturation during labour (index of desaturation) could be a good indicator of the condition of the newborn. A normal SPO2 value during labour could be reassuring in case of abnormal fetal heart rate.

Alternative to surgery of treatment of unruptured interstitial pregnancy: 15 cases of medical treatment.

OBJECTIVE: To evaluate medical treatment of interstitial pregnancy. METHODS: This series was a retrospective study of medical treatment of interstitial pregnancies which was managed in two French Departments of Obstetrics and Gynecology (Bichat public Hospital. Paris and A. Béclère public Hospital, Clamart, France). Fifteen patients with clear evidence of an unruptured interstitial pregnancy were treated by injection of methotrexate (MTX) or potassium chloride (KCL) without surgery since January 1988. The diagnosis was established either by sonography and laparoscopic confirmation in eight cases or by only transvaginal ultrasound in seven cases. Three out of 15 cases in this series, had a heterotopic pregnancy who were treated by transvaginal ultrasound-guided injection of KCL. Others received systemic MTX injection in four cases, and local MTX injection in eight cases under either laparoscopy or transvaginal ultrasound guidance. Four different protocols of MTX (Ledertrexate) administration was performed in this series with time: at the beginning of our experience, MTX1 protocol, 15 mg i.m. daily for 5 days was used; and after MTX2 protocol, 1 mg/kg body weight i.m. daily for 4 days; MTX3 protocol, 1 mg/kg body weight intratubal associated with 1 mg/kg body weight i.m. daily for 3 days; and now MTX4 protocol, only intratubal 1 mg/kg body weight is especially used. The success was defined as declining serum human chorionic gonadotropin (hCG) to undetectable levels, and no further surgical management was required. Outcome of subsequent fertility was also evaluated. RESULTS: Complete resolution was obtained in 13 (86.6%) out of 15 interstitial pregnancies. Two out of 15 patients, with medical treatment's failure required secondary surgery. No severe side effects of medical treatment were observed. Follow-up hysterosalpingography was performed in 12 patients showing 91.7% tubal patency on the side of interstitial pregnancy. Outcome of intra-uterine pregnancy of the three patients who had heterotopic gestation, was two miscarriages and one delivery at term. Out of the other 12 patients in this series, nine became pregnant within 1 year: eight pregnancies at term, and one induced abortion. At present, among the last three patients, two have no desire to conceive. CONCLUSION: Our results suggest that unruptured interstitial pregnancies now can be managed with local MTX administration of 1 mg/kg body weight under transvaginal ultrasound or under laparoscopy procedure. This approach is particularly attractive in these patients, where the only alternative to therapy is laparotomy with cornual resection.

Epithelial ovarian carcinoma of low malignant potential.

OBJECTIVE: The aim of this study was to evaluate the interest of sonographic features, serum marker tumors and conservative treatment especially by laparoscopic approach of epithelial ovarian tumors of low malignant potential (or borderline tumors). STUDY DESIGN: Thirty-four patients with 40 epithelial ovarian tumors of low malignant potential treated at Bichat Claude Bernard hospital were reviewed. Of these patients, 29 had preoperative sonographic control (85.2%), 19 (55.8%) had pretreatment serum CA 125 determination, 17 (50%) serum CA 199 determination and 19 CEA serum levels. Twenty patients (58.8%) had serous tumor and 14 (41.2%) had mucinous tumor. Six out of the 20 serous lesions were bilateral. Of the patients 31 (91%) had a stage I disease, one had stage II (3%) disease and two had stage III (6%) disease. Nine patients (26.5%) had laparotomic management, 25 (73.5%) had first laparoscopic management with seven laparoconversions (28%). RESULTS: The majority of borderline tumors (67.7%) exhibited multilocular aspects and seven patients had benign features (unilocular smooth sonolucent). Seven out of the 19 CA 125 serum levels were up to 35 U/ml; 4/17 CA 199 serum levels were above 40 U/ml but the CEA serum levels were always normal. Eighteen patients (52.9%) had radical surgery and 16 patients (47.1%) had conservative surgery including 7 cystectomies. Seven patients (20.6%) had subsequent laparotomic treatment, (five after laparoscopic management, one after laparoconversion management and another one after laparotomic surgery) and no residual disease was found. Fourteen patients (41.1%) had preoperative cyst rupture (13 during laparoscopic management). Four recurrences in stage I disease occurred; one after unilateral salpingo-oophorectomy, three after cystectomy but only one recurrence was in ipsilateral ovary. All four recurrences were diagnosed by sonographic control and one was associated with CA 125 serum level elevation. Ten laparoscopic second look were negative. CONCLUSION: No specific sonographic aspect exists for borderline tumors but it is the best way to detect recurrence. The preoperative CA 125 serum levels was elevated in 36.8% of patients. The conservative treatment including laparoscopic procedure in borderline ovarian tumors appears to have a high risk of peroperative rupture but the rate of recurrence is similar to laparotomic treatment.

[Role of endoscopy in surgery for urinary incontinence]. / Place de l'endoscopie dans la chirurgie de l'incontinence urinaire.

In France, approximately 2 or 3 million women suffer from urinary incontinence. A consensus has been reached about the safety of treatment of genuine urinary stress incontinence by retropubic colposuspension (Burch procedure). The cure rate for the abdominal Burch procedure is 85% after 5 years. Since 1991, laparoscopic retropubic colposuspension has been advocated for the treatment urinary stress incontinence. The procedure can be performed either by laparoscopic intraperitoneal or extraperitoneal approaches or by associated laparoscopic and vaginal routes. The feasibility of laparoscopic colposuspension has been proved. Indeed, a series including 578 patients, showed a laparoconversion rate of 3.6%. The most frequent complication of colposuspension is bladder injury. The majority of cystotomics were treated laparoscopically. The follow-up in this series is relatively short. After one year, the success rate was 96%. However, these results must be confirmed by other series with longer follow-up and by prospective randomized studies.

[Practical use of sulprostone in the treatment of hemorrhages during delivery]. / Utilisation pratique du sulprostone dans le traitement des hémorragies de la délivrance.

OBJECTIVE: To assess intravenous use of sulprostone (Nalador), a prostaglandin E2 analogue, is case of post-partum haemorrhage due to uterine atonia. MATERIALS AND METHODS: A retrospective study on 315 cases of post-partum haemorrhage (PPH) from 1st January 1990 to 31st December 1992 in Baudelocque maternity. In 91 cases of PPH due to uterine atonia, usual oxytocin drugs were not sufficient and intravenous sulprostone was used. Characteristics of the patients, mode of sulprostone administration, side effects and treatment failures are reported. RESULTS: One or two dose of 500 micrograms were sufficient in 71% cases. Mean perfusion rate was 8.3 micrograms/mn. Success of treatment was 89% with few side effects (5.5%). No serious complication due to sulprostone was observed. Risk of treatment failure was 8.3 times greater when the delay between diagnosis of uterine atonia and sulprostone administration was more than 30 mn. CONCLUSION: Prostaglandins treatment, and particularly sulprostone, could be used more frequently and earlier in case of PPH due to uterine atonia. Further controlled studies are necessary to know if they should be used as a first line treatment instead of oxytocin in this indication.

[Preliminary study of the use of fetal pulse oximetry during labor]. / Etude préliminaire sur l'utilisation de l'oxymétrie de pouls foetal pendant le travail.

OBJECTIVE: To assess continuous monitoring of fetal blood oxygen staturation (SpO2) during labour using a fetal pulse oxymeter. STUDY DESIGN: Preliminary results obtained with the Nellcor N-400 fetal pulse oxymeter at the Maternité Port-Royal-Baudelocque between November 1992 and November 1993 in cases of abnormal fetal heart rate are presented. We analyzed: the correlation between SpO2 during labour and cord vein pH as well as Apgar score, the correlation between changes in SpO2, expressed as a desaturation index, and cord vein pH as well as Apgar score. The negative predictive value of oxymetry was assessed. RESULTS: We found a significant positive correlation between the last SpO2 measurement during labour and umbilical vein pH as well as 1 minute Apgar score. We observed a highly significant correlation between the index of desaturation and cord vein pH as well as 1 minute Apgar score. No neonatal pH below 7.20 was observed when SpO2 was > or = 40% during labour. The negative predictive value of oxymetry was 100% in this short series of patients. CONCLUSION: If these results were confirmed in a larger series of patients, a normal SpO2 value during labour could be reassuring in case of abnormal fetal heart rate.

[Distal tubal surgery: a critical review of 104 laparoscopic distal tuboplasties]. / Chirurgie de la trompe distale. Analyse critique d'une série de 104 plasties tubaires distales coeliochirurgicales.

MATERIALS AND METHODS: Between January 1988 and June 1993, laparoscopic distal tuboplasty was carried out on 104 patients. The mean age of the patients was 32 years: the duration of infertility was 3.2 years; infertility was primary for 44 patients (42.3%) and secondary for 60 patients (57.7%). The patients were classified according to the French cooperative tubal scoring system: stage 1: 21 patients, stage II: 49 patients, stage III: 22 patients, stage IV: 12 patients; 37 patients underwent a fimbrioplasty (35%) whereas 67 patients underwent a neosalpingostomy (65%). No complications were observed either during or after the operation. All patients were discharged two or three days after the operative procedure. Antibiotic and antiinflammatory treatments were systematically administered post-operatively. RESULTS: Thirty-four patients obtained intrauterine pregnancies (32.5%) and 5 patients obtained ectopic pregnancies (4.8%); 76% of the intrauterine pregnancies were obtained within the 1st postoperative year. The pregnancy outcome was directly correlated to the tubal scoring system. Intrauterine pregnancy rate decreased with the severity of the tubal damage: stage 1: 12/21 (57%), stage II: 19/49 (38.7%), stage III: 3/22 (13.6%), stage IV: 0/12. CONCLUSION: Laparoscopic surgery represents the first-choice treatment of distal tubal occlusion in stage I and II. In stage IV, IVF should be suggested immediately. In stage III, the choice of treatment is more difficult: the main prognostic factor might be the tubal mucosal appearance.

[Ethnic predisposition of the severity of HELLP syndrome. Retrospective study of 12 cases including 5 during post-partum]. / Prédisposition ethnique de la sévérité du HELLP syndrome. Etude rétrospective de 12 cas dont 5 survenus en post-partum.

HELLP syndrome is characterized by association of haemolysis (H), elevated liver enzymes (EL), and low platelets (LP). From 1989 to 1991, we studied retrospectively 12 cases of HELLP syndrome cases that occurred during the third trimester for 7 cases and during post-partum for 5 cases. 83% of patients (10/12) were black people (African or Creole). The most frequent sign of HELLP syndrome during pre- and post-partum was epigastric or dorsal pain, present in 91% of the cases (11/12) and in all cases of preeclampsia. Aggressive treatment was always performed, leading to 12 births: 7 of the 12 children were hypotrophic for gestational age. There were no maternal or neonatal deaths. Post-partum HELLP syndrome occurred 28.8 hours (mean) after delivery. Whether HELLP syndrome occurred during pre- or post-partum, laboratory findings returned to normal levels after equivalent delays: platelets 57 hours, ASAT 68 hours and ALAT 65 hours.

[Retroperitoneal liposarcoma. Disclosure by anemia and prolonged fever]. / Liposarcome rétropéritonéal. Révélation par une anémie et une fièvre prolongée.

We report the case of a 79-year old woman with a retroperitoneal liposarcoma. The condition was discovered because of the association, in a woman of that age, of anaemia and persistent fever. The diagnosis was suggested by computed tomography. Treatment was exclusively surgical. Liposarcomas usually affect men in their sixth decade. Postoperative radiotherapy improves the quality of life but does not prolong survival. Metastases are frequent, and death usually occurs in the year that follows discovery.

[Current indications for medical treatment of ectopic pregnancy]. / Indications actuelles du traitement médical de la grossesse extra-utérine.

Today, the early diagnosis of ectopic pregnancy (EP) is made possible by the assay of plasmatic hCG and the improvement of trans-vaginal sonography. These different tests lead to diagnose the EP before the ruptured stage. Therefore, the medical treatment is today a logical alternative to the surgical one. The medical treatment is mainly based upon the use of methotrexate (MTX). The logical indications for EP medical treatment are: early EP without peritoneum effusion, with hCG < or = 5000 mUI/ml, without embryonic cardiac activity at sonography. The medical therapy by intramuscular injection of MTX at 1 mg/kg gives a success rate of 91.8% similar to the success rate of intra tubal injection of MTX under sonographic control.

[Treatment with methotrexate of 4 interstitial, unruptured pregnancies]. / Traitement par le méthotrexate de quatre grossesses interstitielles non rompues.

Successful treatment of four, non ruptured, cases of interstitial pregnancy are reported. Treatment consisted of in situ injection of methotrexate during coelioscopy. Dosage was 1.5 mg methotrexate per kilogram body weight. Negative plasma beta hCG levels were obtained 9 to 22 days after conservative medical treatment. No clinical or biochemical side effects were observed. Of two patients had no radiologically demonstrable cornual abnormality on the hysterosalpingographies effected at the 3 months evaluation after ascertained interstitial pregnancy, one have normal pregnancy. Two further patients had normal uneventful pregnancies 12 to 15 months later. Treatment of interstitial pregnancy by way of one in situ injection of methotrexate seems to be the currently preferred alternative to classical surgery.

[Percutaneous needle colposuspension to Cooper's ligament: 63 cases]. / Colposuspension percutanée à l'aiguille au ligament de Cooper: à propos d'une série de 63 cas.

OBJECTIVE: To evaluate the feasibility, safety and results of a new procedure of treatment of genuine urinary stress incontinence : needle percutaneous colposuspension to Cooper's ligament. STUDY DESIGN: From June 1994 to December 1995, 63 patients had a needle percutaneous Cooper's ligament colposuspension for stress urinary incontinence (USI). The mean age of the patients was 48 years (range : 32 to 80). Fourteen patients were menopausal (22,2 %). The mean parity was 2,7 (range 0 to 10). According to Blaivas and Olsson classification of USI, 6 patients had type 0, 32 type 1, 22 type 2 and 3 type 3. Fifty-eight patients had preoperative urodynamic control. RESULTS: The procedure was performed in 63 patients (100%). The mean operative time was 20 minutes (range 15 to 30). Peroperative complication: hemorrhagic in one case (1,5%). Postoperative complication rate was 12,7% including seven urinary infections. The mean follow-up of the patients was 8 months (range: 6 to 17). By subjective parameters, 55 patients were cured (87,3%). Only 38 patients had postoperative urodynamic control including the 8 patients with failure of the procedure. Among these 8 patients, 1 had clinical failure with normal urodynamic control, 2 had vesical instability and 5 had a persistence of USI confirmed by urodynamic control. CONCLUSION: Needle percutaneous colposuspension to Cooper's ligament appears as feasible and safe technique to cure USI. The interest of this new procedure of colposuspension is its fixation to the Cooper's ligament using the vaginal approach. Preliminary results are good, however longer follow-up is necessary to validate this new technique.

[Upper genital tract infections in women infected with HIV: epidemiologic, diagnostic and therapeutic aspects]. / Les infections génitales hautes chez la femme infectée par le VIH : particularités épidémiologiques, diagnostiques et thérapeutiques.

Fifty seven women hospitalized in the gynecological department of Bichat-Claude Bernard hospital in Paris for pelvic inflammatory disease (PID) proven by laparoscopy from sept. 1992 to nov. 1994 had a serological diagnosis of HIV infection. Three of them (5,2%) were positive (HIV+). Previous publications have shown from 4% to 17% in the USA and as much as 32% in Abidjan. However this prevalence is arising each year. PID in HIV+ seems to have more often a poor symptomatology but require more surgical treatments. Postpartum endometritis in HIV+ were also studied. From 1989 to 1994, we observed 109 delivery in HIV+ patients. Numerous infectious diseases occurred but endometritis were not significantly elevated. Three american studies in HIV+ failed to show an increased risk of postpartum endometritis but a fourth larger study achieved in Abidjan, showed a significantly higher risk of endometritis, associated with decreasing levels of CD4. HIV+ women are at increased risk of upper genital tract infection and could profit from obstetrical antibioprophylaxis.