EMC - Gynécologie-Obstétrique最新文献

Laparotomic abdominal myomectomy is a procedure undertaken essentially in child-bearing women with symptomatic myomas and who may not benefit from hysteroscopic or coelioscopic surgery. Such interventions may have peroperative complications such as important blood loss necessitating blood transfusion, or postoperative complications such as postoperative adherences. This underlines the importance of a preoperative assessment aimed at obtaining the best evaluation of the risks and benefits related to such intervention.

Pregnancy is possible for women after liver transplantation. However, these women have a higher risk of pre eclampsia, hypertension, small for gestational age and preterm delivery than the normal obstetric population. Pregnancy can be safely considered one year after the transplantation provided hepatic and renal functions are stable. Renal dysfunction is associated with a higher risk of foetal and maternal complication. Immunosuppressive medication should be continued. Pregnancy does not appear to alter hepatic graft function. Careful monitoring of these pregnancies is essential for favourable outcome.

Spontaneous or induced prematurity are leading causes of perinatal morbidity and mortality. Gestational age is the more important prognosis factor. Prevention and management of preterm labour are fundamental. Improvement of morbidity and mortality can be achieved by antenatal corticosteroid therapy and delivery in a maternity hospital adapted to the gestational age. The mode of delivery of premature infants is controversial. However, natural delivery seems to be privileged in case of vertex presentation. In breech presentation or in case of chorioamnionitis, caesarean section is preferred.

Endometriosis is a common condition often underestimated because of a tricky clinical diagnosis. Most frequent clinical presentations (dysmenorrhoea, dyspareunia, chronic pelvic pain) are very evocative if increased during menstruations. Endometriosis can also be revealed by urinary (dysuria, pollakiuria) or digestive (dyschezia, menstrual proctorrhagias, transit dysfunction) symptoms. Non-steroid anti-inflammatory drugs can be used as first-line medical treatment for sole dysmenorrhoea when the patient does not need contraception. In teenagers or very young women, provided there is no contraindication, estroprogestative oral contraception can be considered as alternative treatment. When symptoms are more severe or noncyclic, progestins chosen in 17α-hydroxy- or 19-Nor-progesterone-derivatives should be the first choice regarding their effectiveness, their low cost and their long-term good tolerance. GnRH agonists should only be considered when adequate pain relief is not obtained from the other treatment options or, for some authors, as a pre-operative therapy. For long-term treatment by GnRH agonist, hormone therapy should be associated to limit treatment side effects.

Myomectomy is a surgical procedure that allows preservation of the uterus in case of myomatous disease. Various surgical approaches may be considered. However, abundant peroperative haemorrhage may occur, resulting in complications such as incomplete surgery, modification of the surgical access, hypovolaemic shock, blood transfusion, and severe postoperative anaemia, necessitating aggressive treatment and transfusion, and delaying activity recovery. Such observations justify in seeking for means able to prevent peroperative haemorrhage. Several medical preoperative means have been strictly evaluated. The preoperative usage of gonadotrophin releasing hormone (Gn-RH) agonists seems to result, after a reduction of the uterine volume by myometrium vascular re-arrangements, in a reduction of peroperative haemorrhage; the results are still debated. Administrations of Gn-RH, misoprostol or antiprogesterone seem promising but further studies are necessary to confirmation. Preoperative embolization of the myoma could reduce peroperative blood loss but the use of this procedure in childbearing women is under evaluation. Peroperative means are available: chemical means such as vasoconstrictive or oxytocic agents, and mechanical means which temporarily interrupt the myometrial blood flow. Some have shown efficacy. As alternatives to surgery, techniques such myolysis – which induces in situ myoma destruction – necessitate further research, particularly regarding young childbearing women.

Complete anatomical survey of the foetus in the first trimester of pregnancy is possible, by transvaginal ultrasonography. Ideally, the ultrasonography should be performed between 12 and 14 weeks. At that time, a wide range of foetal congenital anomalies can be diagnosed, including defects of the central nervous system, heart, anterior abdominal wall, urinary tract, neck and skeleton. We studied 11,702 singleton pregnancies for which an ultrasonography was performed between 11 and 15 weeks at the Sonography and Foetal Medicine Unit of the CMCO in Schiltigheim/Strasbourg-France. We had a representative overview of the foetal abnormalities that could be observed in the first trimester, as most of these pregnancies were considered at high risk. 1313 abnormalities were suspected according to ultrasonographic examinations (11.2% of the studied population). Nuchal translucency, hygroma coli and Bonnevie-Ulrich syndrome were the most frequent abnormalities detected (more than 70%). Sensibility and specificity of the ultrasonographic investigations were evaluated. The first trimester ultrasonographic examination cannot detect all the malformations. However, it can detect the major ones and can define a high risk group that will need further assessment. It allows therefore early management. The anatomic ultrasonographic examination around 20 weeks gestation should also be performed, since a number of anomalies may not be evident at scanning during early pregnancy.

The latissimus dorsi myocutaneous flap is a very versatile and reliable flap. It is probably the oldest myocutaneous flap known, used most commonly in reconstructive surgery. In breast reconstructive surgery, its versatility and safety allows many designs for cutaneous islands. It can also be used for autologous reconstructions, but most often implant is required. Raising the flap is neither a hard nor a long surgery; difficulties depend more on the choice of the fitted implant, (with the incidence of periprothetic contraction in case of radiotherapy) and on the surgery required on the other breast. For all these reasons, good expertise of breast plastic surgery is necessary.