Revue francaise de gynecologie et d'obstetrique最新文献

Awareness of the physiological changes associated with pregnancy is essential for the management of patients during pregnancy. Cardiovascular status is characterised by hypervolemia and cardiac hyper-output with low resistance. Increased oxygen consumption and respiratory work result in an increased risk of hypoxia. Fetal well-being must also be taken into account. During cardiorespiratory arrest, aortocaval compression by the pregnant uterus may impair the efficacy of CPR and uterine displacement is a routine measure starting from 20 weeks after the LMP. The same factors are involved in hemorrhagic shock, justifying uterine displacement and the ensuring of optimal oxygen transport and utilisation.

The pattern of ectopic pregnancy, defined by an ectopic site of the fertilised ovum, has changed in recent years in developed countries. It is only rarely responsible for maternal death in industrialised countries though the possibility remains (1/4000). However, it plays an increasing role in the pathophysiology of female infertility. In terms of epidemiology, the increase in its rate is linked to that of salpingitis and sexually transmitted diseases, and the sequelae of tubal surgery. Regarding symptomatology and prognosis, dramatic, life-threatening forms are in clear decline, because of the possibility of the early detection of pregnancy by sensitive and rapid assay of beta sub-unit human chorionic gonadotrophin (beta-hCG) and transvaginal ultrasonography. This enables conservative management regarding the tube, but is associated with the risk of recurrence. In terms of treatment, laparoscopic surgery is gradually taking the place of laparotomy. Such laparoscopic surgery must now be considered "theoretically" to be the reference treatment. Medical treatment methods using methotrexate are currently being evaluated and it is even possible in certain cases to suggest that no treatment is required.

Ovarian hyperstimulation syndrome (OHS) is the most serious complication of ovulation induction, particularly in in vitro fertilization. It is a potentially life-threatening situation. Its pathophysiology is poorly understood. This syndrome is explained by a sudden increase in capillary permeability which results in a rapid fluid shift from the intravascular space into a third space leading to haemodynamic changes. In its most severe forms. OHS is characterized by multicystic ovarian enlargement, hemoconcentration, hypovolemia, oliguria, third space accumulation of fluid in the form of ascites and pleural effusion, renal failure, thrombotic disorders. Mild and the most of moderate forms of OHS usually do not require any active form of therapy. Severe OHS requires hospitalization, correction of fluid and electrolyte imbalance, prevention of thromboembolism, aspiration of the ascites and pleural effusion causing respiratory discomfort and dyspnea. Surgical interventions are exceptionally indicated and reserved for ovarian or rupture of ovarian cyst. Although severe OHS may not be completely avoided, early recognition of high-risk factors, judicious monitoring of ovulation induction (plasma estradiol levels and ultrasonography), and, perhaps in future, substitution of hCG for triggering ovulation should reduce the incidence of this iatrogenic syndrome.

Home delivery, although unconventional, has not totally disappeared. It sometimes results from the desire to "demedicalise" an event deemed natural and is sometimes the consequence of government policy and hence approved by medical authorities. This is the unique situation of Holland, where a highly efficient home delivery system has been created, with the possibility of transfer of the mother at any time to rapidly available emergency medical teams. In fact the large majority of home deliveries are accidental, unprepared and take place in the absence of any medical or paramedical assistance. All available studies show that perinatal and maternal morbidity associated with these accidental deliveries is greater than that of hospital deliveries, and this despite the setting up of emergency services responding as soon as a distress call is received. Home delivery should remain the exception at present since it is unable to guarantee a birth as undangerous as possible.

Premature delivery menace is still a major issue in obstetrics. It concerns 4 to 5% of the pregnancies. Being responsible of an important fetal morbidity, it implies the use of a rapid and efficient treatment. This treatment uses progestins, prostaglandins inhibitors and beta-mimetics. The more efficient these medicines are, the more dangerous is their use so that their prescription must be weighted thoroughly, after setting apart the absolute counter-indications. Since they may cause severe accidents, especially cardio-vascular ones as for the beta-mimetics, this implies an indespinsable medical follow up during their use. This article, using a review of the literature, enumerates the various pharmacological families prescribed for the treatment of the premature delivery menace. For each, the pharmacological effects, the tolerance, the side effects and the accidents are detailed. The modalities of their prescription as well as the necessary medical follow up are given. Taking into considerations these elementary rules of prescription enhances the chances of lowering down at most the risks related to the use of these treatments.

Pregnancy related hypertension is the primary cause of perinatal mortality and morbidity. Its incidence is of the order of 10%. Serious forms, which account for 10% of all cases of pre-eclamptic toxemia, remain a potential cause of maternal mortality and morbidity. Retroplacental hematoma, neurological problems dominated by eclampsia, coagulation disorders, Hellp syndrome, and hepatic, pulmonary, cardiac and renal problems are the essential complications of this pathology. They are described separately here, but are often associated. These potential complications require the careful evaluation of the severity of materno-fetal status. The management of these patients requires cooperation between the anesthetist/intensive care specialist, obstetrician and pediatrician. Such teamwork results in appropriate management for each individual patient. The various types of treatment are reviewed. Maternal and fetal mortality and morbidity could nevertheless be reduced by the early and careful management of high-risk patients, in particular by the prescription of low doses of aspirin and by careful clinical, ultrasound and velocimetric monitoring.

Complications of delivery are dominated by the problem of obstetric hemorrhages. Minor complications are common, concerning about 20% of all labors, while serious complications are rare: of the order of 0.1%. Their peculiarity lies in their association with blood coagulation disturbances of multifactorial origin. Treatment requires close cooperation between the anesthesiologist/intensive care specialist and the obstetrician when management decisions are made. Trials of medical and obstetric measures should not lead to any delay when deciding that laparatomy is required to ensure hemostasis. Hesitation most often compromises the chances of success of conservative surgical treatment by selective ligations and forces hysterectomy.