EMC - Gynécologie-Obstétrique最新文献

Adenomyosis is a frequent gynecological disorder that affects women above 40 years of age and is responsible for nonspecific symptoms. Imaging is required to establish the diagnosis, the extension of the disease and to rule out other associated diseases. Transvaginal ultrasound is the initial imaging modality. The reported sensibility and specificity vary between 50-89 % and 53-89 % respectively, depending on the coexistence of other disorders. Pelvic MRI can be proposed in case of doubtful diagnosis, with a high sensitivity (78-89 %) and specificity (67-93 %). The most important distinction must be made with leiomyoma. Specific ultrasound and MRI signs have to be sought to correct the diagnosis since therapeutic strategies differ, especially among patients who wish pregnancy.

Fetal growth is a complex and multifactorial phenomenon that depends on environmental and genetic factors. Fetal growth is controlled by maternal, placental and fetal factors. Fetal growth is closely related to placental growth and requires continuous nutrient supply adapted to each step of the pregnancy. Consequently, both the feto-placental metabolism and the hormonal regulation of fetal growth will be successively considered. Data from clinical and animal models and from selective genic invalidation experiments will be reported. Genomic imprinting and the fetal origin of adult disease will be further discussed.

Office hysteroscopy is an important examination to be performed for infertility assessment. It is carried out to evaluate the uterine cavity, seeking for the abnormality that might explain the fertility disorder. Office hysteroscopy is the most effective investigation for such assessment, despite improvements in sonohysterography or ultrasonography. Hysteroscopy should be systematically performed before IVF initiation, to prevent transfer or implant failure.

Urinary incontinence is a distressing condition in women; it may occur at any age and impairs their quality of life. It affects about 20% of the female population. Genuine stress incontinence (GSI) and detrusor instability (DI) are by far the most frequent causes of urine leakage. They can be recognized by physical examination and confirmed essentially by urodynamics. GSI requires pelvic floor retraining and/or surgery while DI usually requires anticholinergic treatment.

The effective incidence of uterine malformations is not clearly defined in the literature. If minor uterine abnormalities are considered, this incidence is about 6-7 % among the normal fertile population and >25 % in women with recurrent miscarriages. Nevertheless, major malformations are observed in only 0.5% to 5% of the general population, in 0.1% to 3% of fertile women, in 3% of infertile women and in 5-10 % of women with recurrent miscarriage. The most frequently encountered uterine malformations are bicornuate and septate uteri. The diagnosis is confirmed by both hysterosalpingography and endoscopy (hysteroscopy and laparoscopy). Hysteroscopic metroplasty is commonly used to repair uterine septa and enlarge T-shaped uterus in women exposed in utero to deithylstilbestrol.

Conization is the gold standard in the treatment of intra epithelial dysplasias induced by a Papillomavirus. Following cervical treatment, infertility can be due to post-surgical stenosis or inappropriate mucus. The risk of cervical stenosis after conization decreases with the height of the cone (below 20 mm) and the electrosurgical excision procedure.

Achievement of aortic lymph node dissection is a prerequisite for the practice of surgical gynaecologic oncology. Aortic node dissection may be required, routinely or indicated on the basis of macroscopic enlargement of aortic, scheduled or decided preoperatively in any malignancy of the upper genital tract. It can be performed by midline laparotomy, or using laparoscopic techniques, transperitoneally or extraperitoneally. Surgical standards must be respected, including complete dissection and a defined template, extending between the lumbar ureters up to the level of the left renal vein. Adequate exposure and the use of vascular dissection technique are required. External drainage is not required. Adding an aortic lymph node dissection to a radical procedure does not add significantly to perioperative morbidity.

This article describes the current techniques used for foetal sampling. All of them are actually ultrasound guided, and therefore generally very safe. Nevertheless, rigorous learning process remains necessary, together with particular attention to the quality of the physician-patient communication. The choice of a technique depends on the indication and on the term of the pregnancy. The most frequently used technique is the amniocentesis which presents a low risk of foetal loss, estimated between 0.2 and 0.5%. The interest of chorionic villus sampling is the possibility to obtain results at an earlier stage of pregnancy, with a lower risk when compared to early amniocentesis. We prefer transabdominal chorionic villus sampling to the transvaginal technique. Foetal blood sampling is still required in some cases, but the risk of complications is higher, around 1%.

Donation of gametes, be they oocytes or spermatozoa, or embryos, represents three palliative methods for the management of a couple’s infertility. They are combined with medically assisted procreation techniques. Once their indications have been confirmed, practicing these interventions has been legalized by the French Bioethics Law of 29 July 1994. The fundamental general principles are: donation is voluntary, non-remunerated, anonymous and confidential; these programs are conducted within mandated organizations and under the responsibility of practitioners authorized to collect and handle the gametes provided as a donation or by the biologist who is responsible for frozen embryos. In terms of management, the analysis of indications, compilation of legal documents, serological testing of donor and recipient couples, pairing of donor and recipient, and data collection are essential in the functioning of the system. The federation of French Centers for the Study and Conservation of Sperm (CECOS) reported a pregnancy rate of 10-15 % per cycle obtained by intracervical insemination with donated sperm, with better success rates being achieved after intrauterine or in vitro fertilization. The French Group for the Study of Oocyte Donation (GEDO) published clinical pregnancy annual rates ranging from 17 to 22 %, after transfer of frozen-thawed embryos derived from donated oocytes. Transferring “fresh” embryos is now authorized by the French decree of 24 June 2004 and should improve these results. The rare studies on the follow-up of gamete donation indicate good outcomes in terms of child development and family relationships. The more recent technique of embryo donation is currently implemented in some authorized centers; the evaluation of their results necessitates some more years of observation.

In both cervical and endometrial cancers, the lymph node status is an important prognostic factor and a major criterion in decision making concerning an indication for neoadjuvant chemotherapy, which makes the lymph node dissection mandatory. The sentinel lymph node detection has been developed in the aim of reducing surgical morbidity. It appears to constitute a major advance in the management of patients with various malignancies. Its clinical utility became rapidly obvious in malignant melanoma, vulvar cancer and, more recently, breast cancer. In uterine cancers, this procedure is still at the feasibility phase. The present article presents the technical aspects, and the first published results on the potential role of sentinel lymph node detection in cervical or endometrial cancers.