Revue francaise de gynecologie et d'obstetrique最新文献

The authors report a case of rupture of the uterus 22 weeks after the LMP, due to placenta praevia percreta and requiring emergency hysterectomy to arrest bleeding, followed by urinary complications. With the predisposing factors of the scars of 4 previous cesarean sections and the low anterior insertion of the placenta, this exceptional case--in terms of its rarity and gravity--led the authors to undertake a review of the literature seeking other cases of this greatly feared obstetric complication. They review the clinical, ultrasonographic (notably the use of color Doppler) and paraclinical (MRI, cystoscopy) diagnostic approach necessary to make an accurate diagnosis of placenta percreta (if possible before any hemorrhagic complications). This situation virtually invariably requires hysterectomy to arrest bleeding, under very difficult conditions because of the massive hemorrhage involved. Mortality remains high and morbidity principally concerns the urinary complications frequently encountered.

Vaginal leiomyosarcoma is a very rare tumor. The authors report a case of primary presentation in a 51-year-old multipara who complained of the development, since about 12 months previously, of a vaginal swelling accompanied by bloody discharge and pain. The outcome was fatal twenty two months later following treatment combining chemotherapy, radiotherapy, and surgery. The case is discussed in the light of data from the literature.

Sixty cases of severe eclampsia were treated in an intensive care unit between January 1989 and September 1993. Mean age was 26, and 70% of patients were primipara. The pregnancy has been unsupervised in almost all cases. All had visceral lesions and/or hematologic problems and there was impaired conscious level in 9 cases out of 10. Medical treatment involved the control of seizures and of hypertension. Cesarean section was performed in 34 cases. The maternal death rate was 23.3%. Our experience indicates that mortality depends upon visceral lesions (cerebral, disseminated intravascular coagulation, acute pulmonary edema, Hellp syndrome). Better awareness of severity factors in preeclampsia improves both maternal and fetal prognosis by precisely indicating the best time for fetal extraction.

Stress incontinence of urine without cervicocystoptosis secondary to difficult labor and delivery is essentially due to rupture of the smooth muscle sphincter of the bladder. Other changes affecting the anterior vaginal wall (thinning of fibrous tissue, partial splitting of the striated urethral sphincter, etc.) are found before difficult labor without stress incontinence of urine. Only operative microscopy enables anatomical analysis. Lateral cystography confirms the clinical diagnosis. There is no correlation between the extent of lesions and functional study results. Surgery is limited to the dissection and apposition of the residual zone of the smooth muscle sphincter retracted laterally. There were neither postoperative dysuria nor dyspareunia. There were 11 recurrences. No marked symptomatic change 5 years later.

The authors report their critical analysis of perinatal mortality concerning 265 twin pregnancies collected between 1982 and 1993 in the Maternity Unit of the Yaoundé (Cameroon) Teaching Hospital Group. There were a total of 14,277 deliveries during this period. The twin pregnancy rate was 1.8 per cent. Delivery was spontaneous in 89.6 per cent of cases and by cesarean section in 10 per cent of cases. In 3 cases the second twin was delivered by section after spontaneous delivery of the first twin. Perinatal mortality evaluated at 6.9 per cent (37 cases) was analysed according to fetal risk factors such as gestational age, type of delivery, fetal presentation, birth weight, birth rank and the time interval between birth of the first and second twin. Perinatal mortality of premature twins with 25 fetal deaths accounted for approximately 2/3 of the fetal deaths in this series. Twenty-two cases of fetal deaths seen in the group of second twins accounted for more than half of all fetal mortality. The time interval between the two births was an important factor in the fetal prognosis of the second twin. There were 14 cases of death of the second twin for a time interval longer than 20 minutes as compared with 8 fetal deaths for an interval of 20 minutes or less. Breech presentation was associated with abnormally high fetal mortality (16 cases). Our conclusion is that improved perinatal mortality in twin pregnancies must be sought by preventing prematurity. Breech presentation is a factor of poor prognosis, in which it is important to widen indications for prophylactic cesarean section aimed at improving fetal prognosis.(ABSTRACT TRUNCATED AT 250 WORDS)

There were 5503 deliveries between 1989 and 1991 in the Guy de Lorier Maternity Unit (Pr Salat-Baroux) of Tenon Hospital, Paris. These included 81 women testing HIV+ in the department with 33 asymptomatic black African women among 781 deliveries. Africans account for 14% of women delivered in the department but for 40% of seropositives in the unit, with a predilection for women from Zaïre (central Africa), accounting for 17 seropositives. They only represent 50% of all cases of African HIV+ and 20% of the unit, while they account for only 6% of the black African community and 0.8% of the maternity unit. Women from west Africa accounted for 45.5% of African seropositive cases, with Ivory Coast in first place with 24.3% while only 9% of women from Mali, accounting for 40% of African patients and 5% the units, tested positive (3 cases out of 309 patients). The mean age of seropositive patients was 23 +/- 4, pregnancies proceeded normally and there were 4 therapeutic abortions. There were 9 births by cesarean section, with no evidence of neonatal contamination, the same applying in the other 20 vaginal deliveries. Routine testing (informed consent) for HIV in these high-risk (endemic zone, drug addiction) or unrecognised seropositive patients is important whenever the opportunity presents itself (prenuptial examinations, prenatal visits, family planning, preoperative assessment) in order to attempt to lower infection rates and ensure the best possible care for mother and child when there is a wish to continue the pregnancy, but also to protect hospital staff from the risks to which they may be exposed.

The authors analyse, in the context of a developing country, a number of factors which can determine the choice of site of delivery in a population with access to several possibilities. The role of peripheral (or local) maternity units is considered in particular, in view of the utilisation problems which they raise. This leads to the conclusion of a degree of irrationality in the choice of health care services and the characteristics of women interacting with those of professionals when explaining the choice of site of delivery. Better management of available services is desirable in order to render peripheral maternity units more useful, and improve the medical performance at the time of delivery. Sensitization of the public and above all of health professionals nevertheless remains essential.

Forty one patients with 51 pregnancies form the basis of this study of etiological factors and reciprocal effects of pregnancy and thyrotoxicosis. Pregnancy influences the course of thyrotoxicosis and may modify its diagnostic aspects, clinical course, variations in laboratory parameters and treatment. The effect of thyrotoxicosis on pregnancy may lead to abortions, premature labour and/or toxemia. It may sometimes influence the products of conception. The essential point appears to be to seek the minimal dose of antithyroid drug capable of controlling thyroid disease without impairing fetal thyroid function.

Our intentions were to determine the incidence of the association of anemia and pregnancy, to evaluate maternal and fetal prognosis and to offer some recommendations regarding national health care policies. This prospective study lasting 30 months included all cases of anemia and pregnancy detected by clinical and laboratory examinations. Thus 13,191 women were enrolled in the study but only 1408 cases of anemia and pregnancy (10.67%). Primipara and grand multipara were particularly at risk. Severe forms of anemia and pregnancy were encountered often (51.71%). Maternal and fetal prognoses were very poor. Maternal mortality was 852/100,000, accounting for 65% of the maternal mortality of the department. The stillborn rate was 50 per thousand. This is a serious health problem which needs to be dealt with by a national health education programme.

The epidemiological characteristics of iron deficiency anemia after radioimmunoassay of serum and erythrocyte ferritin were evaluated in 209 Malian women at the time of delivery in a maternity unit in Bamako, Mali. The incidence of iron deficiency anemia was high (36.8%). This incidence did not reflect socio-economic status, nor even any particular obstetric history, but was significantly higher in younger mothers (aged under 26). The severity of anemia was such that 2.4% of women would require a blood transfusion post-partum. It looks therefore desirable, in Mali, to screen routinely and to ensure the prevention of iron deficiency in adolescent girls and to include, in the prevention of anemia of pregnant women, routine iron supplements from the beginning of pregnancy.