EMC - Gynécologie-Obstétrique最新文献

The indication and extent of lymph node dissection in the surgical management of endometrial cancers remain highly controversial. Randomized studies are necessary to verify its efficacy but there are no studies available, and probably they will lack for a long time considering the very large sample size required to show a small difference in survival. The trend towards a reduction in the routine use of external radiation therapy weakens the argument that radiation therapy makes adequate lymph node dissection useless. The balance stays between the risk for node involvement and the expected complications rate of the procedure. Lymph node dissection is advised whenever there is a non-negligible risk of node metastasis in a patient at low surgical risk.

In the first trimester of pregnancy, ultrasound is crucial to screen for aneuploidies based on nuchal translucency, to diagnose major birth defects, and to establish chorionicity. Indeed prenatal diagnosis strategies as well as obstetrical management options are largely based on placental type. In the second trimester, maternal serum screening is not as effective, and ultrasound screening is more difficult in twins than in singletons. When a severe abnormality in found in one twin, selective termination of pregnancy may be considered. This technique is safe in dichorionic twins, but hazardous in monochorionic pregnancies. Selective termination in dichorionic twins is safer in the first trimester, underscoring the need for early prenatal diagnosis in twins. Monochorionic twin pregnancies carry specific risks, such as the twin to twin transfusion syndrome, which can be treated by endoscopic photocoagulation of intertwin anastomoses in the severe early onset cases, or by amnioreduction in milder cases.

The Caesarean section is one of the most frequently undertaken surgeries. Although the technique has been standardised by several generations of surgeons, gynaecologists and obstetricians, many improvements have been observed during the last two decades. These modifications aim to decrease the incidence of both mortality and morbidity.

Numerous recommendations have been addressed this past decade in relation with the frequency and severity of bacterial infections of the newborn induced by maternal-fœtal contamination. They are principally aimed at promoting the Streptococcus agalactiae screening and its eradication by a per partum antibiotherapy. In this literature review we attempt to present a synthesis of the successive published French and American recommendations, with a focus on the related drawbacks: difficulty of application, maternal risk in relation with the antibiotherapy, i.e., the emergence of resistant Gram–bacteria, the neonatal risk, since the results of these strategies suggest their likeliness to be inefficacious (outbreak of bacteria-resistant neonatal infections, sepsis onset, use of antibiotherapies with wider spectrum, and increased rate of bacteria-resistant nosocomial infections). Finally we will consider the factors involved in the risk of infection, and propose some types of management.

This review is an update on the various methods of management of the intractable postpartum haemorrhage. PubMed and MEDLINE^® were the electronic sources for data retrieval, in english and french languages. Uterine atony and abnormal placental insertions (placenta praevia or accreta) are the major causes of primary postpartum haemorrhages. To preserve fertility, the available techniques are angiographic selective embolization or surgical vascular ligations. Embolization is a non-invasive method that consists in a simple catheterization under local anaesthesia. Vascular ligation of the uterine vessels or internal iliac arteries requires most of the time a laparotomy. New and easier surgical methods, such as uterine compression or haemostatic suturing techniques have been described, for which we lack experience. For uterine atony, the success rate of arterial embolization and uterine artery ligations is close to 100%. Ligation of internal iliac arteries is a little less effective and technically more difficult to carry out. It remains interesting in case of obstetrical traumatic hurts that do not concern the uterus. If bleeding from the lower segment occurs during caesarean section, low uterine artery ligatures are necessary. These methods are all the more effective than they are prematurely implemented before the rise of major coagulopathy. In such case, uterine devascularization has also to be applied to ovarian vessels. With placenta accreta, accreta portion of the placenta can be left in place and arterial embolization or vascular ligations can be done. Nevertheless the main cause of failure with conservative treatments is placenta accreta. The simplest and the least morbid methods must be retained. After vaginal birth, arterial embolization can be undertaken, if there is no maternal haemodynamic disorder, and if the interventional vascular radiology unit is nearby. During caesarean section, progressive uterine artery ligation can be carried out, taking into account the bleeding cause. In case of conservative treatment failure, it would be dangerous to multiply techniques. In such cases, emergency peripartum should remain the choice procedure.

Polycystic ovary syndrome (PCOS) is a common cause of hyperandrogenism in adolescent girls. In its complete post menarchal expression, the syndrome is characterized by the association of typical clinical, biological, and ultrasonographic findings. Many factors have contributed to our knowledge of different clinical forms of PCOS in adolescent girls. They are helpful for clarifying misleading situations in a period of life when diagnosis of PCOS implies a treatment for many years and may interfere with gynecological outcome. During the last 3 years, we had the opportunity to follow-up in our unit 45 adolescent girls with ovarian hyperandrogenism: 32 of them had PCOS and the other 13 functional ovarian hyperandrogenism defined by clinical and biological hyperandrogenism without ultrasonographic abnormality. In this review, we report, from our personal experience as well as from recent literature data, the various clinical expressions of PCOS in the pubertal period: the classical post menarchal form, the exceptional pre menarchal form, the post precocious pubarche and the post precocious puberty forms, the familial expression as well as the dominant metabolic expression.

Listeriosis is a rare food-born disease which affects primarily pregnant women and subjects with major medical conditions. Listeria monocytogenes is found in about 10% of food samples, particularly in sausages, raw meat, soft cheese and smoked fishes. The incidence of listeriosis have been dramatically reduced over the past decade, following prevention measures in food industry. Currently, the annual incidence is about 4 cases per million, including 20 to 25% of cases associated with pregnancy. About two thirds of perinatal cases are diagnosed in the third trimester. The most frequent maternal symptoms are fever, flu-like syndrome and preterm labor. Meningoencephalitis is rare during pregnancy. In contrast, the overall fetal and neonatal mortality rate is of 25% in recent studies. Therefore, listeriosis should be evoked in any case of unexplained fever during pregnancy. This requires blood cultures and immediate antibiotic therapy with amoxicillin for 10 days. The treatment of choice in case of documented listeriosis is high dose amoxicillin for 3 weeks plus gentamicin for 2 weeks.

Embryo implantation is a multifactorial event. Biochemical factors are implicated in the quality of the endometrium and in its vascularization. The non invasive vaginal scan analyses the endometrial morphology whereas color and power Doppler analyses its vascularity. In this literature review, we point out the interest of such technics in ART.

About 100000 births/ year follow a pregnancy resulting from medically assisted procreation (MAP). The management of MAP children, and the follow-up of their development begins at birth and goes on for several years. It consist of the analysis of perinatal data, malformations and chromosomal abnormalities, assessment of the psychomotor, height and weight, and intellectual development, and medical surveillance until adulthood.