EMC - Gynécologie-Obstétrique最新文献

Rubella usually is a mild disease with, however, serious consequences such as foetal death and a spectrum of birth defects, known as the congenital rubella syndrome. This syndrome may occur as a result of intrauterine infection, particularly during the first 4 months of pregnancy. The syndrome may affect multiple organ systems and common anomalies include cataract, deafness, congenital heart disease and mental retardation. During pregnancy, rubella serology is used to determine the immune status of the patient but it also allows diagnosis of primary infection. This diagnosis is essentially based on the detection of rubella-specific IgM but, if IgM antibody is always detected in recent primary infection, it can also be detected in other situations. Measurement of IgG avidity may help dating rubella. When primary rubella infection occurs during the first 4 months of pregnancy, prenatal diagnosis of foetal infection can be proposed. This diagnosis is based either on the detection of IgM antibody in foetal blood or on the detection of viral genome in amniotic fluid. Post-natal diagnosis of congenital infection is reliably performed by detecting specific-IgM antibody. In fact, if immunization programmes were thoroughly applied, congenital rubella should be eradicated in France since the RA 27/3 vaccine is very efficient and safe.

Laparoscopic radical hysterectomy has emerged as an optional surgical treatment for operable non bulky (less than 4 cm) cervical cancer with no evidence of node involvement in imaging studies (MRI and /or CT Scan). Minimal invasive surgery has been used in this area, for patient's benefits such as scar and pain reduction and short recovery. This procedure was initially time consuming and of questionable “radicality”. During the past decade some reports, on a limited number of patients, have shown the feasibility of radical resection by laparoscopic surgery, as well as an equivalent number of pelvic nodes harvested by laparoscopy and open surgery without compromising survival.

The human placenta is a mysterious organ between the mother and the foetus. It is an essential organ for gas and nutriments exchange leading to foetal growth and development. On the other hand, the placenta may be at the origin of severe maternal or foetal diseases. Before birth, the placenta is explored by ultrasounds, flow velocity and chorionic villous sample. After delivery, the placenta is an easily available specimen to understand perinatal diseases. The entire placenta should be grossly examined in the delivery room by the midwife and/or the obstetrician. Pathological examination of the placenta is indicated in case of maternal, foetal or placental abnormalities. This examination has to be integrated with the obstetrical and neonatal data. However, the placenta is usually under-evaluated and insufficiently used for the diagnosis of placental disease. The characterisation of placental diseases may provide crucial information for the etiological diagnosis of prematurity, intrauterin growth retardation, foetal demise, neurodevelopmental impairment. In case of twin pregnancy, the type of twinning can be identified and pathological aspects of twin pregnancy can be studied. The examination can identify placental conditions that can be recurrent or inherited in order to adequate treatment and preventive measures during subsequent pregnancies. Placental examination may have medicolegal aspect for example concerning the aetiology of long term neurodevelopmental sequelae. New clinicopathological entities such as inflammatory foetal response of the placenta and fetal thrombotic vasculopathy have been recently clarified. A pertinent placental examination integrated with a multidisciplinary approach with obstetricians and paediatricians should identify new clinicopathological entities and provide a better understanding of pathophysiological mechanisms in order to propose new treatments in severe and often recurrent perinatal diseases.

Circulating fetal DNA in maternal plasma and serum was first demonstrated by Lo et al. in 1997 and has become a useful tool for prenatal diagnosis less than five years later. There is more and more evidence that the trophoblatic cells act as the major source of this circulating fetal DNA. Contrary to fetal cells analysis in maternal blood which requires isolation and enrichment procedures, fetal DNA analysis is relatively easy to perform with the use of real-time PCR. Non invasive fetal sex and fetal RHD genotype determination are, to date, the two main clinical indications. Those newly offered possibilities have changed the management of pregnant women who are carriers for X-linked genetic disorders; prenatal diagnosis by choriovillous sampling could only be performed for male fetuses avoiding an unnecessary risk of fetal loss for female fetuses. Moreover, fetal RHD genotyping by maternal blood analysis could be useful in RhD-negative women at risk of immunization in order to adapt prophylactic anti-D injection.

Pre-implantation genetic diagnosis provides an alternative to prenatal diagnosis for couples who are at risk of having an offspring with a serious genetic disorder. This novel method is based on recent molecular techniques (PCR, FISH) that allow analyzing the genetic status of embryos obtained after in vitro fertilization. Only embryos free of the genetic disorder are transferred into the uterus. It is too early to establish the safety and accuracy of pre-implantation genetic diagnosis.

Recurrent miscarriage (RM) is defined as three or more consecutive pregnancy losses at less than 24 weeks of gestation; this condition affects 1% of fertile couples. RM is a clinical condition of heterogeneous aetiology; however, in 50% of the cases no cause is identified. Classification of RM is a crucial tool in the investigation, exploration and treatment of pathophysiological mechanisms. Uterine defects, chromosome and genetic abnormalities, hormonal and metabolic disorders, infectious causes, acquired and inherited thrombophilia, immunologic disorders, male and environmental factors are the principal causes of RM.

Uterine artery embolization is a radiological procedure that consists in occluding the perifibroid arterial plexus to induce fibroid ischemia. To date, with more than 50,000 women treated worldwide, embolization seems to be a valuable alternative to hysterectomy and multiple myomectomies particularly in women with severe menorrhagia. Embolization should ideally be performed in case of intramural or submucosal uterine fibroids. It must be preferably realized in case of multiple fibroids, be they intramural or submucosal (when hysteroscopic resection is not feasible). Complication rates are low if large calibrated microspheres are used to perform embolization and if pedunculated subserosal fibroids are excluded. In case of associated adenomyosis clinical recurrence seems more frequent. The role of embolization as an alternative to single myomectomy, particularly in young women who desire future pregnancy, remains a matter of debate and should be evaluated with clinical randomized trials. Multidisciplinary management is the key to a widened acceptance of uterine artery embolization in the management of uterine fibromas.

Prenatal diagnosis of aneuploidies is based on foetal karyotyping. Prenatal screening consists in targeting patients with an increased risk of chromosomal abnormality for whom amniocentesis will be proposed. Maternal marker screening for Down syndrome is based on an individual risk calculation obtained by weighting the risk due to maternal age by a factor linked to maternal serum markers. Four markers are currently used during the second pregnancy trimester: AFP, hCG or free β-hCG, and oestriol. In France, this screening has been organised since 1997 and is subject to strict regulation. The results of the 72 accredited laboratories are known at a nationwide level: screening is performed in 80% of pregnant women, 70% of trisomy 21 cases are detected for a 6.5% amniocentesis rate. Because maternal serum screening usually follows first-trimester nuchal translucency measurement, it would be interesting to combine the two methods instead of performing them sequentially. First-trimester maternal serum markers (free β-hCG and PAPP-A) are not currently used in France. The future consists of the use of combined tests, first- or second-trimester serum markers and nuchal translucency measurement.

45% to 89% of pregnant women experience nausea and vomiting. The treatment is nutritional (well accepted food, 4 to 6 meals per day). Pyridoxine (750 mg/day) is more effective on vomiting than on nausea. Antiemetic drugs (metopimazine, metoclopramide) are more or less efficient; some authors recommend homeopathic drugs or acupuncture. Persistent vomiting after 14 amenorrhea weeks suggests a psychological or an organic cause. There is no effective treatment for ptyalism. Constipation is first treated with an appropriate diet (fruits and both fresh and cooked vegetables for each meal); lactulose, vaseline oil and mucilage (ispaghul) or macrogol can then be used. Pyrosis occurs in late pregnancy, mainly when lying on the back and during night time: alginates are first prescribed and if they are not efficient enough, ranitidine or omeprazole can be used. In case of persistent pyrosis, oesophagoscopy may help detecting oesophagitis or hiatal hernia. Night cramps are highly painful: basic treatment is magnesium supplements for 2 to 3 weeks. Quinine (150 to 300 mg per dosing) is a symptomatic treatment and is not contraindicated. There is no effective treatment for the pelvic girdle relaxation that spontaneously recovers post partum. Lumbosacral pain is treated by lumbar lordose reduction: antalgesic drugs are not efficient. Massages and hydrotherapy reduce such pain. The treatment of congestive rhinitis is based on antihistaminic drugs: local vasoconstrictive drugs are contraindicated. In hypertrophic gingivitis, tooth brushing should be replaced by hydrojet. Epulis is uncommon and rarely requires surgery, except in abundant bleeding. Striae albae are common and there is no really effective treatment; moisturizing milks and creams can be applied to reduce dry skin.