Impact of hydroxychloroquine on preterm delivery and intrauterine growth restriction in pregnant women with systemic lupus erythematosus: a descriptive cohort study.

OBJECTIVE: The aim of this study was to evaluate the effect of hydroxychloroquine (HCQ) on fetal preterm delivery and intrauterine growth restriction (IUGR) in a cohort of pregnant women with systemic lupus erythematosus (SLE). METHODS: Over an 11-year period (January 1, 2001 to December 31, 2011), all women with SLE and admitted to deliver after 22 weeks of gestation to Bordeaux University Hospital (France), were retrospectively enrolled in the present study. The population was then split into two groups based on the treatment they received: HCQ exposed (HCQ+) versus HCQ non-exposed (HCQ-) group. RESULTS: 118 pregnancies were included, 41 in the HCQ+ group and 77 in the HCQ- group. The rate of adverse fetal outcome was significantly lower in the HCQ+ group (p = 0.001), particularly in terms of preterm delivery, 15.8% versus 44.2% (p = 0.006), and IUGR, 10.5% versus 28.6% (p = 0.03). No adverse outcomes were reported in the HCQ+ group. CONCLUSION: HCQ reduces neonatal morbidity in women with SLE by significantly decreasing the rate of prematurity and intrauterine growth restriction.

Gynaecological endoscopic evaluation of 4% icodextrin solution: a European, multicentre, double-blind, randomized study of the efficacy and safety in the reduction of de novo adhesions after laparoscopic gynaecological surgery.

BACKGROUND: Gynaecological laparoscopic surgery outcomes can be compromised by the formation of de novo adhesions. This randomized, double-blind study was designed to assess the efficacy and safety of 4% icodextrin solution (Adept(®)) in the reduction of de novo adhesion incidence compared to lactated Ringer's solution (LRS). METHODS: Patients undergoing laparoscopic surgery for removal of myomas or endometriotic cysts were treated with randomized solution as an intra-operative irrigant and 1l post-operative instillate. De novo adhesion incidence (number of sites with adhesions), severity and extent were independently scored at a second-look procedure and the efficacy of the two solutions compared. The effect of surgical covariates on adhesion formation was also investigated. Initial exploratory analysis of individual anatomical sites of clinical importance was progressed. RESULTS Of 498 patients randomized, 330 were evaluable (160 LRS--75% myomectomy/25% endometriotic cysts; 170 Adept--79% myomectomy/21% endometriotic cysts). At study completion, 76.2% LRS and 77.6% Adept had ≥ 1 de novo adhesion. The mean (SD) number of de novo adhesions was 2.58 (2.11) for Adept and 2.58 (2.38) for LRS. The treatment effect difference was not significant (P = 0.909). Assessment of surgical covariates identified significant influences on the mean number of de novo adhesions regardless of treatment, including surgery duration (P = 0.048), blood loss in myomectomy patients (P = 0.019), length of uterine incision in myomectomy patients (P < 0.001) and number of suture knots (P < 0.001). There were 15 adverse events considered treatment-related in the LRS patients (7.2%) and 18 in the Adept group (8.3%). Of 17 reported serious adverse events (9 LRS; 8 Adept) none were considered treatment-related. CONCLUSIONS: The study confirmed the safety of Adept in laparoscopic surgery. The proportion of patients with de novo adhesion formation was considerably higher than previous literature suggested. Overall there was no evidence of a clinical effect but various surgical covariates including surgery duration, blood loss, number and size of incisions, suturing and number of knots were found to influence de novo adhesion formation. The study provides direction for future research into adhesion reduction strategies in site specific surgery.

[Methods and efficacy of medical and surgical treatment of non functional menorrhagia]. / Modalités et efficacité des traitements médicaux et chirurgicaux devant des ménométrorragies organiques.

OBJECTIVES: To assess the efficacy of therapies in menorrhagia related to atypical endometrial hyperplasia, polyps, myoma, adenomyosis and arteriovenous malformation of the uterus. MATERIALS AND METHODS: Medline and Cochrane contents were searched to June 2008. RESULTS: Atypical endometrial hyperplasia is classically treated by hysterectomy, but may temporarily regress under hormone therapy (progestins, Gn-RH agonists) in women of childbearing age. Hysteroscopic resection is the standard treatment for endometrial polyps. Recurrence of bleeding is reduced by combining it with endometrial ablation. Myoma-related menorrhagia can be treated by Gn-RH agonists for 3 months or levonorgestrel in utero (LNG-IUS). Hysteroscopic resection is the standard treatment of submucous myomas. Interstitial myomas can be treated by myomectomy, myolysis, uterine artery embolisation or occlusion, or hysterectomy. Laparoscopic myomectomy and uterine artery embolisation are effective, well tolerated, and the best researched. LNG-IUS is effective and well tolerated to treat adenomyosis-related menorrhagia. The effect of other conservative treatments of the uterus (endometrial ablation, uterine artery embolisation or occlusion) is limited, especially in case of deep and extensive adenomyosis. Uterine artery embolisation is the standard treatment for arteriovenous malformation. CONCLUSIONS: Numerous medical and technical innovations have been recently developed as conservative treatments for menorrhagia. However, hysterectomy remains the standard treatment of atypical endometrial hyperplasia and adenomyosis.

Decreased brain tryptophan availability as a partial determinant of post-partum blues.

BACKGROUND: The post-partum blues is a transient mood alteration affecting most women a few days after delivery. Its stereotypic pattern of symptoms and time course, peaking on post-partum day 3-5, is suggestive of biological determinants superimposed on psycho-social factors. This study was designed to evaluate the possible role of the serotonin system during this period through assessment of brain tryptophan availability. METHODS: Blood samples from 50 women were collected just before (D0) and 3 days after (D3) delivery. Based on plasma concentration of tryptophan, amino acids competing with tryptophan for transport across the blood-brain barrier and on their respective affinities for this transporter, a brain tryptophan availability index (BTAI) was calculated and its variation correlated with the intensity of post-partum blues evaluated through the Kennerley and Gath score at D3. RESULTS: The BTAI showed a -15% decrease between D0 and D3 (p < 0.01, paired t-test). This decrease was not supported by a drop in plasma tryptophan since its level rather increased (+19%). There was no evidence for change in placental indoleamine-2,3-dioxygenase activity since the variation in plasma l-kynurenine (+12%) paralleled the change in tryptophan level. The decreased BTAI appeared the consequence of a dramatic increase in plasma levels of most amino acids, particularly the competitor aminoacids leucine, isoleucine, valine and tyrosine, during the early post-partum. This decrease in brain tryptophan availability was concomitant to the post-partum blues, whose intensity significantly correlated with the amplitude of BTAI variation (Pearson's coefficient -0.283, p < 0.05). CONCLUSION: This study suggests that generalized, large amplitude metabolic and/or nutritional changes occurring in the early post-partum result in a transient decrease in brain tryptophan availability, partly accounting for the mood alteration referred to as the post-partum blues, a model for the triggering of puerperal mood disorder in vulnerable women.

[Endometrial hyperplasia: A review]. / Les hyperplasies de l'endomètre.

Endometrial hyperplasias can be divided into two categories based on the presence or absence of cytological atypia and further classified as simple or complex according to the extent of architectural abnormalities. They are usually diagnosed because of irregular bleeding in perimenopause. Hysteroscopy with a biopsy gives a more accurate diagnosis than transvaginal ultrasonography, sonohysterography, or blind curettage. Endometrial hyperplasias with no cytological atypia, regarded as a response to unopposed endogenous estrogenic stimulation, are normally treated with progestins. The intra-uterine route (levonorgestrel intra-uterine system) is more effective and better tolerated than the oral route. Either conservative surgery (endometrial resection, thermal ablation) or radical surgery (hysterectomy) in the case of other genital diseases is performed on women who did not respond to medical treatment. Endometrial hyperplasias with cytological atypia, considered as intra-epithelial neoplasias, are traditionally treated by hysterectomy. The absence of management protocols in the literature offers various treatment options and indications. Gonadotropin-releasing hormone agonists, danazol, or aromatase inhibitor are effective, but have adverse effects and are expensive. Endometrial ablation can be performed as a first line therapy in women suffering from bleeding related to hyperplasia without cytological atypia. Medical treatment may be offered to young women suffered from hyperplasias with cytological atypia and desiring pregnancy.

[Baby blues: characterization and influence of psycho-social factors]. / Le baby blues: caractérisation clinique et influence de variables psycho-sociales.

BACKGROUND: Within days following birth, most women are showing signs of mood changes, commonly named baby blues. Due to the frequency of this condition, baby blues is considered as a physiological state probably associated to biological modifications. Some studies have shown an existing link between the intensity of the baby blues and post-partum mood disorder. Therefore, it seems important to report and explore in more details the clinical background related the condition. The aim of this study was to demonstrate the possibility of a link between the intensity of the baby blues and some specific factors like maternal self-esteem, maternal childcare stress and social background, and also to define the symptoms of the baby blues from core dimensions in mood disorders. METHOD: Mothers were recruited few hours before giving birth in a teaching hospital. At the third day following birth, an appointment was made to obtain the necessary information (past medical history and social history) and history of previous mood disorders. The mood was evaluated from the scale of the intensity of baby blues from Kennerly and Gath (1989). Moreover, evaluations at day 3 and week 6 post birth of self-esteem in relation to motherhood (Maternal self-report Inventory from Shea and Tronick, 1988), stress in relation with the care of the baby (Childcare Stress Inventory from Cutrona, 1983) and the social support (Social Support scale from Bruchon-Schweitzer, 1998) were undertaken. RESULTS: 95 women were included in the final sample. The intensity of the baby blues was explained by the type of pregnancy (p=0.002), a low maternal self-esteem (p=0.025), high levels of stress in relation to the care of the baby (p=0.074). The basic clinical characteristic of the baby blues seems to be due to an increase in the emotional reaction with a sharp feelings, leading to a lability rather than an affect sad tonality. CONCLUSION: The baby blues seems to be a physiological process whereby the intensity is influenced by psychological factors. Consequently the diminution of self-esteem with motherhood and the increase of stress in relation to the care of the baby appeared to be significant factors in the intensity of the baby blues. Moreover, the clinical characteristics found in this study implies that the baby blues is more related to hypomania rather than to depression syndrome. This non-pathological state could be the first stage leading to a puerperal psychosis in predisposed women, which is mainly characterized by manic symptoms.

[Posthysterectomy prolapse: results of sacrospinous ligament fixation]. / Résultats de la sacro-spino-fixation dans le traitement des prolapsus après hystérectomie.

OBJECTIVE: To evaluate results of sacrospinous ligament fixation in the treatment of posthysterectomy prolapse. PATIENTS AND METHODS: Between September 1990 and September 2002, 92 women (mean age 64.8 years, range 45 to 92 years) underwent sacrospinous ligament fixation following total hysterectomy (82.6%) or subtotal hysterectomy (17.4%); 96.7% had a menopausal status, and 21.7% used hormone replacement therapy. 48.9% of the patients had a history of surgery for prolapse (and/or urinary incontinence), and 21.7% had associated symptoms of stress urinary incontinence. In all cases, sacrospinous ligament fixation was performed under visual control using conventional stitch. Sacrospinous ligament fixation was combined with the following procedures: anterior vaginal repair (n=31), additional incontinence surgery (n=11), cervical amputation (n=11), levator myorrhaphy (n=61). Main outcome measures were intraoperative complications, postoperative complications, anatomic and functional outcome. RESULTS: Complications were represented by 1 vaginal hematoma (related to sacrospinous fixation), 1 bladder injury, 1 ureteral injury, 3 acute urinary retentions. With a mean follow-up of 47 months (range: 12-156), 12 patients (13.5%) had failure of sacrospinous ligament fixation and 9 required additional procedures, during the first year of follow-up. 14 patients (15.7%) had postoperative cystocele, with 1 case of third-degree cystocele treated with sub-bladder prosthesis by the vaginal route. CONCLUSION: We noted low rates of major complications and sacrospinous ligament fixation in posthysterectomy prolapse appears to give satisfactory long-term results.

Screening for Chlamydia trachomatis, Neisseria gonorrhoeae, and Mycoplasma genitalium should it be integrated into routine pregnancy care in French young pregnant women?

Chlamydia trachomatis, Neisseria gonorrhoeae, and Mycoplasma genitalium screening during pregnancy is not performed routinely in France. We conducted the first prospective study in 1004 women attending for routine antenatal care to determine the prevalence and risk factors for these bacterial infections. The overall prevalence of C. trachomatis, N. gonorrhoeae, and M. genitalium infections was 2.5%, 0%, and 0.8%, respectively. In patients aged 18-24 years, the prevalence increased to 7.9% for C. trachomatis and to 2.4% for M. genitalium. C. trachomatis infection was associated with age ≤24 years or being single or having more than 5 sexual partners in a lifetime. M. genitalium infection was more frequent in patients aged ≤24 years or who had a history of abortion or their first sexual intercourse after 20 years of age. The high prevalence of C. trachomatis in pregnant women aged ≤24 years, mostly asymptomatic, suggests that systematic screening could be beneficial.

Post-partum blues and mild depressive symptomatology at days three and five after delivery, A French cross sectional study.

This cross-sectional work studies the prevalence of post-partum blues on days 3 and 5 after delivery and the links between post-partum blues and depressive symptomatology, using standardised interviews and rating scales (Kennerley and Gath Blues Scale. MADRS) to screen a consecutive series of 104 women on days three and five after a normal delivery. This study stresses the possibility of a difference between the symptomatology of a benign "classical" post-partum blues, and that of a more intense blues closer to the spectrum of depressive mood disorders and perhaps post-natal depression.

Trans fatty acids in adipose tissue of French women in relation to their dietary sources.

This study reports the fatty acid composition of subcutaneous adipose tissue in French women with special emphasis on the content of trans fatty acids originating from two main dietary sources, ruminant fats and partially hydrogenated vegetable oils (PHVO). Adipose tissue trans fatty acid levels from 71 women, recruited between 1997 and 1998, were determined using a combination of capillary gas chromatography and silver nitrate thin-layer chromatography. Results indicate that on average cis monounsaturates accounted for 47.9% of total fatty acids, saturates for 32.2%, and linoleic acid for 14.4%. Cis n-3 polyunsaturates represented only 0.7%. Total content of trans fatty acids was 2.32 +/- 0.50%, consisting of trans 18:1 (1.97 +/- 0.49%), trans 18:2 (0.28 +/- 0.08%), and trans 16:1 (0.06 +/- 0.03%). Trans 18:3 isomers were not detectable. The level of trans fatty acids found in adipose tissue of French women was lower than those reported for Canada, the United States, and Northern European countries but higher than that determined in Spain. Therefore, trans fatty acid consumption in France appears to be intermediate between that of the United States or North Europe and that of Spain. Based on the equation of Enig et al., we estimated the mean daily trans 18:1 acid intake of French women at 1.9 g per person. The major trans 18:1 isomer in adipose tissue was delta11 trans, as in ruminant fats. Estimates of relative contribution of trans fatty acid intake were 55% from ruminant fats and 45% from PHVO. This pattern contrasts sharply with those established for Canada and the United States where PHVO is reported to be the major dietary source of trans fatty acids.

A new method for the treatment of fibromas: interstitial laser hyperthermia using the Nd:YAG laser. Preliminary study.

Operative laparoscopy can replace hysterectomy in the treatment of submucous and subserosal uterine fibromyomas. Interstitial myomas are still treated using traditional methods. Using an Nd:YAG laser with a quartz fibre which diffuses the ray, we induced delayed necrosis of myoma secondary to the hyperthermia produced by this method-interstitial laser hyperthermia. We present an experimental study of fibromas from excised tissue. Optimal efficiency is achieved with continuous delivery at 5 W of power for 10 min. The temperature reaches 50 degrees C within a radius of 20 mm around the fibre. A clinical study was undertaken with the approval of the Ethics Committee. Seven patients suffering from symptomatic fibromas were treated by laparoscopy. Preliminary results at 12 months show that their symptoms have disappeared and the size of the fibromas has been reduced. A larger study is in progress.

Endometrial Nd-YAG laser ablation by hysterofibroscopy: long-term results of 137 cases.

OBJECTIVE: In our gynecology department, we have been performing endometrial laser ablation (ELA) under video control using a flexible hysteroscope since 1989. The aim of this study is to evaluate the long term results of our experience. STUDY DESIGN: We went back to the files of 137 patients treated between 1989 and 1993. These women (mean age 42 years) exhibited menorrhagia unamenable to medical treatments which had been developing for 28 months. Mean hysterometry was 9.8 cm. A hysteroscopy with ELA was performed. Our procedure lasts 19 min on average and uses 0.9 1 of glycocol. There were no perforations. Six patients presented a fever above 38 degrees C within the next 48 h; only one developed a true endometritis necessitating antibiotherapy. One patient who had received several GnRH agonist courses had a coagulation of the uterus and had to be hysterectomised. RESULTS: Nine patients were lost to follow-up; for the others, mean follow-up was 32 months. Seventeen women (13.3%) were hysterectomised, including the patient with a coagulation necrosis of the myometrium. In most cases, this was for undetected adenomyosis or fibromas evolving after hysteroscopy. Bleeding recurred in two other patients; they refused hysterectomy but should be counted as failures of this method. Among the 109 patients (85.1%) considered a success, 35 have had menopause since the procedure. CONCLUSION: ELA is a simple quick procedure which significantly reduces the number of hysterectomies. In addition, the economic value of ELA is beginning to be assessed in the literature. This long-term study should allow the indications to be better defined by eliminating patients with a high risk of failure and should lead to improved results.

Treatment of fibromas.

This study defines the current modes of treatment of patients with uterine fibromas with a review of the literature. Progesterone treatments appear to be principally used in cases of minor functional symptomatology and we discuss recent studies of mifepristone. GnRH agonists are particularly effective in preoperative treatment for conservative surgery. The indications and results of hysteroscopic resection and laparoscopic myomectomy are compared to those of classic myomectomy and hysterectomy. The indications for myolysis are discussed.

Breast cancer and in vitro fertilization. About 32 cases.

Because of the increased risk of breast cancer for infertile nulliparous women, the suspected promoter role of estradiol in mammary carcinogenesis and the high frequency of ovulation inducer treatments, it was interesting to focus on the risk of breast cancer after such a treatment. We reviewed 32 cases during a retrospective survey in Assisted Reproductive Techniques (ART) centers in France. Because of the small sample size and the few cases published so far, no statistical study could be made. However, many observations may have gone unnoticed or were not published. Two hypotheses can be proposed: (1) the facilitating role of stimulation on potential infra-clinical or un-diagnosed cancers; (2) the initiation of new cancers. Consequently, we propose to establish a register for the follow-up of treated women to monitor the advent of new cancers and to increase the follow-up of patients with other associated risk factors.

Management of septate uterus by flexible hysteroscopy and Nd:YAG laser.

OBJECTIVE: To evaluate the efficiency of flexible Nd-YAG laser hysteroscopic metroplasty. METHODS: We present a retrospective study of 17 patients treated for septate uteri between 1990 and 1995. The indication of hysteroscopy was recurrent abortion in nine cases and eight with primary infertility with indication of IVF in another five cases. We did not prescribe any pretreatment. A flexible hysteroscope with a 100-W Nd:YAG laser was used with glycine-controlled flow. The septum was divided by the laser after exploration of the cavity. We proposed a control office hysteroscopy 2 months after surgery to prevent uterine adhesions. RESULTS: There was no complication. Twelve patients conceived with 10 live births at term and two spontaneous abortions. Four are still infertile, two were lost from the study and two no longer desired pregnancy. Resectoscopic studies showed the same results. CONCLUSION: The advantages of this method are the excellent ergonomic properties of the fibroscope and the safety of the laser. We suggest that metroplasty does not improve the pregnancy rate but only the pregnancy outcome of these patients. However, for those with the indication of IVF the procedure seems useful in avoiding abortion.

[Sacrospinous colpopexy complications]. / Les complications de la sacrospinofixation.

OBJECTIVE: To evaluate complications of sacrospinous ligament fixation. DESIGN: Monocentric retrospective study. SETTING: Department of Obstetrics & Gynecology, La Conception University Hospital, Marcella. PATIENTS AND METHODS: Between January 1991 and September 2002, 277 women (mean age 64.9 years, range 37 to 92 years) underwent a sacrospinous ligament fixation; 91% had a menopausal status, and 15.5% used hormone replacement therapy. 33.2% of the patients had prior hysterectomy, 28.9% had a history of surgery for prolapse, and 18.8% had associated symptoms of stress urinary incontinence. In all cases, sacrospinous ligament fixation was performed under visual control using conventional stitch. Sacrospinous ligament fixation was combined with the following procedures: anterior vaginal repair (N =137), additional incontinence surgery (N =31), vaginal hysterectomy (N =137), levator myorraphy (N =203). MAIN OUTCOME MEASURES: Intraoperative complications, postoperative complications, long-term painful symptoms. RESULTS: Intraoperative complications were represented by 1 case of vascular wound and four rectal injuries. Main postoperative complications were vaginal haematomas (N =6) and abscesses (N =2). Long-term symptoms were perineal pain, sciatic neuralgia, and dyspareunia. DISCUSSION AND CONCLUSION: There was no surgical mortality, and we noted low rates of major complications. Sacrospinous ligament fixation assumes high priority in our therapeutic regimen.

[Cystic adenomatoid malformation of the lung, bilateral renal agenesis and left heart hypoplasia. An unusual association in Potter's syndrome]. / Malformation adénomatoïde kystique du poumon, agénésie rénale bilatérale et hypoplasie du coeur gauche. Une association inhabituelle dans un syndrome de Potter.

We describe an autopsy case of congenital cystic adenomatoid malformation of the lung (CCAM) associated with bilateral renal agenesis. Prenatal ultrasound examination showed additional left heart hypoplastic syndrome. A therapeutic abortion was induced at 23 weeks of gestation. The association CCAM-bilateral renal agenesis is a rare condition (5 cases previously described) which has to be known because of the mitigation effect of the CCAM on the oligohydramnios determined by bilateral renal agenesis. However, this instance is usually associated with oligohydramnios. The pathogenesis of polyhydramnios in isolated CCAM is discussed in regard with these data.

[Endometrial ablation by fiberoptic hysteroscopy and YAG laser]. / Endométrectomie par hystérofibroscopie et laser Yag.

The authors report the first cases of the use of operating fibre hysteroscopes with YAG laser to carry out endometrial ablation. Fiberoptic hysteroscopes were used and made it possible to carry out the procedure with much greater precision because of their mobility and flexibility. YAG laser rays are passed down an operating channel and can treat the whole of the endometrium in 20 minutes operating time. This treatment was suggested to 44 patients who had menorrhagia and did not respond to treatment with progestogens as an alternative to hysterectomy. There were 81.7% very good results, 11.3% good results and only 7% failures with a followup period of 3 to 20 months. There was no operative or post-operative complication either in the short or the longterm. This technique is a new one and not much used in France, but its advantages have been confirmed by several authors, especially in the United States.

[Fibrinolytic treatment with urokinase and streptokinase for recurrent thrombosis in two valve prostheses for the aortic and mitral valves during pregnancy]. / Traitement fibrinolytique par urokinase et streptokinase d'une thrombose récidivante sur double prothèse valvulaire aortique mitrale au cours de la grossesse.

The authors report a case of a patient who had two episodes of valvular thrombosis successfully treated with fibrinolysis using urokinase and streptokinase. They emphasise how efficient these treatments are in spite of the gravity of the initial picture and also point out the dangers and difficulties that can occur because of the risk of haemorrhage in pregnancy, and particularly during delivery and post-partum. They show once more that the treatment is harmless for the fetus. They conclude that using fibrinolytic treatment should be considered first when there is great danger to the patient, and the advantages and disadvantages of thrombolysis should be weighed up.

[Uterine necrosis after Nd-YAG laser ablation of the endometrium. A case report]. / Nécrose utérine après réduction d'endomètre au laser nd:YAG. A propos d'un cas.

Myometrial coagulation necrosis occurred after LH-RH analogue treatment and Nd:YAG laser reduction of the endometrium. This rare complication occurred in a patient with adenomyosis.