[Lymphocytic mastitis]

Lymphocytic mastitis is a non infectious inflammatory disease of the breast with lobulocentric lymphocytic infiltrate of variable intensity, collagenous fibrosis and progressive lobular atrophy. The pathogenesis of lymphocytic mastitis is still unknown but some recent reports have suggested an autoimmune origin. We investigated a series of 10 cases by immunohistochemistry and we collected patients' biologic data. The most striking histologic feature was a prominent lobulocentric stromal or intraepithelial lymphocytic infiltrate. Occasionally, the infiltrate was perivascular and nodular along the lobule border. B and T lymphocytes, both demonstrated by immunophenotypic analysis, were shown with a particular pattern of distribution. Pathologists must be aware of this disease in order to recommend immunological investigation.

[Richter's spinofixation in vaginal prolapse]

The transvaginal sacrospinous fixation, called Richter operation was initially aimed to cure vaginal vault prolapse after hysterectomy. The results are as good as those of the abdominal promontory fixation with the well known advantages of the vaginal route. Indications way be extended to V3 U3 R3 prolapse and cure of elytrocele with good results in our practice. In few cases remnant cystocele may be a trouble some problem.

[Hysteroscopy infection risk]

OBJECTIVES

The aim of this study is to evaluate the infectious risk of the hysteroscopy.

METHODS

A prospective study was carried for nine months in the Belle-de-Mai maternity, in Marseille. We performed 81 operative or diagnostic hysteroscopies. A vaginal sample was achieved before the intervention and an endo-uterine sample after the procedure. The statistical analysis used the Chi 2 test.

RESULTS

Fifty per cent of the patients of whom vaginal sample was contaminated present an endo-uterine sample infected at the end of an operative hysteroscopy. In 25% of cases, whereas the vaginal sample was normal, the endo-uterine prelevment was infected. The relative risk of the endo-uterine bacterial contamination, in case of vaginal contamination was 8.75 during this procedure. Within diagnostic hysteroscopy, no patient with a normal vaginal sample, was contaminated. No patent infection was observed.

CONCLUSION

There is a risk of endo-uterine contamination during hysteroscopy. This risk is higher when the vaginal sample is contaminated before the intervention. This risk is smaller than the infectious risk of hysterectomy.

Hepatic endometriosis: a case report

OBJECTIVE

To describe a case of hepatic endometriosis.

DESIGN

Case report.

SETTING

University hospital.

PATIENT

A 34-year-old woman with a 2-year history of cyclic right subcostal pain.

INTERVENTIONS

Gonadotropin-releasing hormone agonist (GnRH-a) therapy followed by surgical resection.

RESULTS

Ultrasonography, computed tomography scan, and magnetic resonance imaging of the liver disclosed a 6-cm diameter mass. The GnRH-a therapy for 4 months led to clinical and radiologic improvement. Surgery performed to allow pregnancy confirmed the diagnosis of hepatic endometriosis.

CONCLUSIONS

Hepatic endometriosis is uncommon. It may result from metaplasia of the peritoneum or from hematogenic or lymphatic spread.

Attitudes towards cancer predictive testing and transmission of information to the family

Before the organisation of breast cancer predictive testing in France, consultands' attitudes towards this kind of testing and towards passing on information about the family cancer risk to their relatives were investigated. This survey was carried out from January 1994 to January 1995 at six specialised cancer genetic clinics located in different parts of France Female consultands who were first degree relatives of cancer patients and who had at least one case of breast cancer in their family, affecting either themselves or a first degree relative or both, participated in this study. Among the 248 eligible consultands attending the clinics during the study period, 84.3% answered a post-consultation questionnaire. Among the 209 respondents, 40.7% (n = 85) were cancer patients and 59.3% (n = 124) were healthy consultands. A high consensus in favour of genetic testing was noted, since 87.7% of the sample stated that they would ask for breast cancer gene testing if this test became available. The underlying assumption of 96.6% of the women was that their health surveillance would be improved after a positive test. A high awareness of the anxiety that would be generated in a family after a positive result was observed and found to be associated (p < 0.05) with the anxiety and depressive profiles of the patients. Half of the healthy respondents said they would not change their attitude towards screening if the results of predictive testing turned out to be negative. Only 13.7% of the 161 patients who stated that the oncogeneticists asked them to contact their relatives firmly refused to do so, mainly because of difficult family relationships.

Large chorioangioma associated with hydrops fetalis: prenatal diagnosis and management

A large chorioangioma located at the insertion area of the umbilical cord was diagnosed at 19 weeks of gestation by ultrasound and color Doppler ultrasound. This chorioangioma led to a progressively appearing hydrops fetalis and to fetal distress. The infant presented at birth with edemas and ascites associated with severe hemolytic anemia and thrombocytopenia.

Hysteroscopic management of menstrual disorders: a review of 395 patients

OBJECTIVE

To evaluate the long-term effectiveness of transcervical resections in menstrual disorders.

DESIGN

Retrospective consecutive patient follow-up.

PATIENTS

From 1987 to 1993, 395 patients with menstrual disorders (menorrhagia and/or metrorrhagia) were treated with operative hysteroscopy in our department. Resection of endometrial polyps was performed in 65 cases, resection of submucous fibroids in 196, and endometrial ablation in 134. Fourty-one patients had a repeat procedure.

RESULTS

Our mean follow-up period was 2.7 years. Thirteen complications were noted (3%), two of which were serious (one hemoperitoneum after uterine perforation, one severe symptomatic hyponatremia). Twenty-eight patients did not remain in contact after hospitalization (7.1%). Menstrual disorders were controlled in 297 patients (75.2%). Failure was noted in 70 patients (17.7%), including hysterectomy in 50 patients and persistent bleeding in 20.

CONCLUSION

Hysteroscopic surgery is a satisfying technique for women with abnormal uterine bleeding who want a conservation of the uterus. Better results are noted with resections of polyps and fibroids than with endometrial ablations.

Hysteroscopic surgery in postmenopausal women

OBJECTIVE

To assess the efficacy of hysteroscopic surgery in postmenopausal women presenting with abnormal uterine bleeding.

DESIGN

A retrospective audit of 102 patients.

SETTING

The Department of Obstetrics and Gynecology B, La Conception Hospital, Marseilles, France.

PATIENTS

One hundred and two women between the ages of 47-67 years with postmenopausal bleeding or bleeding related to hormone replacement therapy were evaluated by pelvic ultrasound and diagnostic hysteroscopy. A benign organic cause was noted in 87 cases (polyps in 51 and fibroids in 36.) Fifteen patients had no significant disease.

INTERVENTIONS

Resection of polyps or fibroids, endometrial ablation.

RESULTS

One hundred and seven procedures were performed on 102 patients. Major operative complications were rare and included one perforation and one case of glycine toxicity. Eighty-eight patients were satisfied with the results. Six patients were subsequently treated by hysterectomy. Six patients complained of recurrent abnormal bleeding.

CONCLUSIONS

This modality of treatment appears to be effective over the long term. The operative criteria should take the causes of bleeding and not just the age of the patient into account.

Gasless laparoscopic gynecologic surgery

OBJECTIVE

Evaluate gasless laparoscopic gynecologic surgery as an alternative to conventional technique with carbon dioxide insufflation.

STUDY DESIGN

Retrospective study of 49 cases.

RESULTS

Gasless laparoscopic gynecologic surgery was successful in 90% of cases. The gasless technique permits the surgical team to use the laparoscopic and vaginal approach simultaneously.

CONCLUSIONS

Gasless laparoscopic gynecologic surgery seems to be a reliable alternative to conventional laparoscopy for selected indications.

A new cell surface proteinase: sequencing and analysis of the prtB gene from Lactobacillus delbruekii subsp. bulgaricus

Investigation of the chromosomal region downstream of the lacZ gene from Lactobacillus delbrueckii subsp. bulgaricus revealed the presence of a gene (prtB) encoding a proteinase of 1,946 residues with a predicted molecular mass of 212 kDa. The deduced amino acid sequence showed that PrtB proteinase displays significant homology with the N termini and catalytic domains of lactococcal PrtP cell surface proteinases and is probably synthesized as a preproprotein. However, the presence of a cysteine near the histidine of the PrtB active site suggests that PrtB belongs to the subfamily of cysteine subtilisins. The C-terminal region strongly differs from those of PrtP proteinases by having a high lysine content, an imperfect duplication of 41 residues, and a degenerated sequence compared with the consensus sequence for proteins anchoring in the cell walls of gram-positive bacteria. Finally, the product of the truncated prtM-like gene located immediately upstream of the prtB gene seems too short to be involved in the maturation of PrtB.

Hysteroscopic management of uterine synechiae: a series of 102 observations

This retrospective study concerns 102 cases of intra-uterine adhesions treated by exclusive hysteroscopic approach. Fifty-two patients (51%) presented with reproductive problems, 44 patients (43%) with menstrual problems and 6 were asymptomatic. Seventy-eight patients (76.5%) had an antecedent endometrial trauma on a gravid uterus. One hundred and forty-eight operative hysteroscopies were performed to treat 102 patients; 70 patients were treated in one endoscopic session (68.6%), 23 in two sessions (22.6%), 4 in three sessions (3.9%) and 5 in four sessions (4.9%). We report no infectious, hemorragic or metabolic complication but 6 perforations (5.8%). The mean follow-up is 24.4 months (from 6 to 46 months). Ten patients did not keep contact during follow-up. A good anatomical result was obtained in 88 patients (86.2%) after one or two hysteroscopic sessions. A good result on menstrual problems was obtained in 75% of the cases, especially in amenorrhea (90.5% success rate). The reproductive outcome is more disappointing. We obtained 34 pregnancies in 28 patients (10 abortions, 24 live born children). Twenty-two patients achieved no pregnancy (44%), but 13 of these patients presented with additional infertility factors.

[Transmission of human immunodeficiency virus to the fetus during pregnancy]

Estimates of the rate of human immunodeficiency virus vertical transmission range from 15% to 40%, and the rate is lower in European and American studies than in African studies. There appears to be a relationship between maternal factors, mode of delivery and mother-to-child transmission. The risk factors or markers associated with increased vertical transmission are analyzed in this review. The use of zidovudine, administered to HIV-infected women during pregnancy and labour, and to the offspring for 6 weeks reduce the mother-to-infant transmission rate from 25% to 8%. Other strategies to alter transmission of HIV, including the use of combinaison of anti-retroviral drugs, immunoprophylaxis against HIV or obstetric interventions needs to be evaluated.

[Human immunodeficiency virus infection in pregnancy. General aspects]

Seroprevalence of HIV infection in pregnancy is on the increase worldwide. Approximately 10 million infants will have been infected by the year 2000 and the majority of these children will have acquired infection by vertical transmission of HIV from infected mothers. Recent reports suggested that pregnancy does not accelerate the course of HIV infection. Prospective studies from industrialized countries where most women have asymptomatic HIV infection, have not shown an association with increased risk of adverse pregnancy outcome. Estimates of the rate of vertical transmission range from 15% to 40%.

[Hysteroscopic treatment of uterine synechias. A report of 102 cases]

This retrospective study of 102 patients with uterine synechias treated exclusively hysteroscopically included 52 (51%) low fertility patients, 44 (43%) with menstrual disorders and 6 (6%) with no other symptoms. More than three-fourth of the patients (76.5%) had a past history of trauma on a gravid uterus. Operative hysteroscopy was performed 148 times, including sections with scissors in 63 cases (42.4%), section with laser in 4 (3%), uterine collapse in 19 (13%) and electrosection in 62 (41.6%). A single endoscopic procedure was sufficient in 70 patients (68.6%) and 2, 3, 4 procedures were required in 22.6%, 3.9% and 4.9% of the patients respectively. No complications due to infection, bleeding or metabolic disorders occurred, but perforations were seen in 6 patients (5.8%) including 4 cases with complexe synechias. Mean follow-up was 24.4 months (range: 6-49 months); 10 patients were lost to follow-up. Good anatomic results were achieved in 88 patients after 1 or 2 hysteroscopic procedures (86.2%). Clinical results were less satisfactory, particularly in cases with low fertility in which another pathology was often associated (59%). We obtained good results in 75% of the patients with dysmenorrhoea. However, one or more pregnancies was achieved in 28 of the 50 patients contacted later (a total of 34 pregnancies including 10 abortions and 24 normal deliveries). A hysteroscopic procedure should be proposed as first intention treatment in all cases with synechia. In addition to diagnosis, hysteroscopy allows selective, reproducible treatment with little morbidity and conservation of the surrounding endometrium. After several unsuccessful procedures, surgery using Musset's technique can be proposed.

Recurrent congenital toxoplasmosis in a woman with lupus erythematosus

We describe the case of a patient with systemic lupus erythematosus, treated by corticosteroids, who presented during two successive pregnancies with serological reactivation of toxoplasmosis associated with fetal lesions. The first infected fetus died in utero with signs of hydrops. The second fetus was treated in utero with a combination of sulfadoxine and pyrimethamine, administered to the mother, and is now well. The increasing number of immunocompromised pregnant patients with immunity to Toxoplasma gondii may lead to a higher risk of reactivation of maternal toxoplasmosis and congenital infection.

[Borderline tumors and cancers of the ovary. Laparoscopic-surgical evaluation]

OBJECTIVES

Benign cysts of the ovary can now be correctly treated with laparoscopic surgery, but it is difficult to confirm the benign nature of the suspected formation. Thus, the major risk of the laparoscopic surgery is the dramatic consequences in case of malignancy as reported in several cases in the literature. We conducted a survey to evaluate this risk.

METHODS

A retrospective multicentric survey of laparoscopic procedures performed for a diagnosis of lesions of the annexes or cyst of the ovary was conducted. Forty-four centres reported a total of 7,122 laparoscopic procedures, including 5,307 in which laparoscopic surgery was performed. Laparoscopic treatment included puncture (21.3%), partial exeresis (51.3%) and complete exeresis (25.6%). Conversion to laparotomy was required in 20 cases (25.6%). A complementary surgical procedure was needed after the laparoscopic procedure within a delay of 78 days in 49 cases (58%). Laparoscopy was the only procedure used in 16% of the cases.

RESULTS

Pathology reports of the surgical specimen indicated malignant lesions of the ovary in 78/5, 307 cases (1.47%) including 60 borderline tumours and 18 cancers. Among these 78 cases, preoperative work-up and laparoscopy had led to a diagnosis of a benign lesion in 17 (21.8%). Among the 49 cases with secondary surgery, a more advanced FIGO (International Federation of Gynaecology-Obstetrics) stage was observed in 11 (i.e. 8.3% of the 78 malignant cases) compared with the initial assessment.

CONCLUSION

These findings demonstrate that it is not rare to discover the malignant nature of an ovarian tumour after initial laparoscopic treatment of a formation initially diagnosed as benign. Such accidents are the result of insufficient security in risk evaluation before laparoscopy. Whenever there is even a minimal risk of malignancy, laparotomy must be performed as the procedure of choice.

Laparoscopic management of malignant ovarian cysts: a 78-case national survey. Part 2: Follow-up and final treatment

This paper reports a retrospective multi-institutional French survey carried out in 1992 to determine the incidence of laparoscopic management of malignant ovarian cysts. Of 5307 ovarian lesions treated endoscopically, 78 were malignant (1.47%) including 60 borderline tumours (77%) and 18 ovarian cancers (23%). Laparoscopic treatment was puncture in 23% of cases, partial exeresis in 51% and total removal in 26%. Laparotomy was immediately performed in 25% of the cases and as a second stage procedure in 58% (mean delay: 78 days). Laparotomy was not performed in 16% of the cases. Our findings suggest that laparoscopic management of ovarian lesions that subsequently prove to be malignant is not uncommon. To prevent the risk of metastasis, thorough pre-operative and per-operative evaluation is mandatory. In 22.4% of the patients presenting lesions in this study, laparoscopic tampering resulted in an upgrading of FIGO stage.

[Complications of hysteroscopic resections]

The complications in a series of 699 hysteroscopic resections are presented. These include 10 perforations, 8 métabolic syndromes, 1 endometritis et 2 haemorrhages. The incidents are rare, but can have serious consequences.

[Painful pelvic adhesion syndrome]

Pelvic adhesions may be responsible for pelvic pain, at least partially, in the following conditions: sequelae of past infection, chronic active inflammatory state, endometriosis, post-operative adhesions. The problem in the presence of adhesions is to determine whether pain is mechanical, inflammatory and/or linked to associated ovarian dystrophy, and what is the psychological component. The postulate "adhesion = pain" is far from constant and there is no systematic relationship between clinical picture and anatomical findings. After careful clinical and laboratory evaluation, celioscopy is the key diagnostic procedure. It should include thorough examination of all pelvic organs, of the abdomen in general and the peri-hepatic region in particular. A diagnosis of psychosomatic pain can be made only in the absence of any macroscopic, histological and bacteriological lesion, though bearing in mind that this term certainly covers failure to recognise other causes.

Fetomaternal hemorrhage: diagnostic problems. Three case reports

This report describes 3 successive cases in which fetomaternal hemorrhage was suspected but confirmed in only 2. The manifestations of fetomaternal hemorrhage are often nonspecific and diagnosis can be difficult. We discuss diagnostic methods, especially the value of the Kleihauer-Betke test and maternal serum alpha-fetoprotein measurement, and approach.

[Serious forms of arterial pregnancy-related hypertension]

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.

Laparoscopic management of malignant ovarian cysts: a 78-case national survey. Part 1: Pre-operative and laparoscopic evaluation

This paper reports a retrospective multi-institutional French survey carried out in 1992 to determine the incidence of laparoscopic management of malignant ovarian cysts. Of 5307 ovarian lesions treated endoscopically, 78 were malignant (1.47%) including 60 borderline tumors and 18 ovarian cancers. In 33% of cases preoperative diagnosis indicated that the tumor was benign. Preoperative findings were suspicious in 59%. Laparoscopic treatment was puncture in 23% of cases, partial exeresis in 51% and total removal in 26%.

Fetal chest wall hamartoma: a case report

A fetal chest wall hamartoma successfully treated by surgical resection after birth is described. Ultrasonography showing a heterogeneous partially calcified thoracic tumor allowed in utero diagnosis.

Proline iminopeptidase from Lactobacillus delbrueckii subsp. bulgaricus CNRZ 397: purification and characterization

Proline iminopeptidase (PepIP) is a major peptidase in Lactobacillus delbrueckii subsp. bularicus CNRZ397, encoded by the pepIP gene. Amplification and expression of this gene in Escherichia coli K12 resulted in a very high level of enzyme production. Moreover, export into the E. coli periplasm of 45% of PepIP activity allowed us to purify the enzyme easily by a single ion-exchange chromatography step. PepIP is a trimer of Mr 100000 , composed of three identical subunits. In the presence of 0.1% BSA, PepIP activity was optimal at pH 6-7 and stable at temperatures below 40 degrees C. The enzyme was strongly inhibited by 3,4-dichloroisocoumarin, a serine protease inhibitor, by bestatin and by heavy metal ions. It was also inactivated by p-chloromercuribenzoate, but was reactivated by adding dithiothreitol. PepIP is characterized by a high specificity towards di- or tripeptides with proline at the NH2-terminal position, but is not able to hydrolyse longer peptides, or peptides with hydroxyproline at the NH2-end. The NH2-terminal amino acid sequence of the purified PepIP corresponds to the amino acid sequence deduced from the nucleotide sequence of the pepIP gene.

Cloning, sequencing and characterization of the pepIP gene encoding a proline iminopeptidase from Lactobacillus delbrueckii subsp. bulgaricus CNRZ 397

The proline iminopeptidase (PepIP) of Lactobacillus delbrueckii subsp. bulgaricus is a major peptidase located in the cell envelope. Its structural gene (pepIP) has been cloned into pUC18 and expressed at a very high level in Escherichia coli to give a PepIP activity 15,000-fold higher than that found in L. delbrueckii subsp. bulgaricus. The nucleotide sequence of the pepIP gene revealed an open reading frame of 295 codons encoding a protein with a predicted M(r) of 33,006, which is consistent with the apparent size of the gene product. The amino acid sequence of PepIP shows significant homology with those of other hydrolases involved in the degradation of cyclic compounds. In particular, there is a region which includes an identified catalytic site containing a serine residue and a motif specific for the active sites of prolyloligopeptidases (Gly-X-Ser-X-Gly-Gly). The PepIP opens a new way for supplying cells with proline using the peptides resulting from the proteolytic degradation of caseins.

[Risk of systematic celioscopic treatment of ovarian diseases. 2 cases]

We report 2 cases of malignant ovarian tumours. These tumours had been missed at a first laparoscopic examination, and a second examination detected the presence of cancer cells disseminated in the peritoneum and the abdominal wall. The risk of propagation of an overlooked cancer makes it necessary to carry out a preoperative thorough evaluation based on clinical and ultrasonographic data before any attempt at laparoscopic surgery. If a laparoscopic treatment is decided, it must be performed under strict conditions and include meticulous exploration of the abdominal cavity, systematic peritoneal cytology, needle cytology of the cyst, emptying of the cyst in a water-tight manner, extemporaneous biopsy in case of doubt, peritoneal cleansing, and extraction of the cyst or the ovary in a bag. If malignancy is suspected, laparotomy must be performed immediately.

Prenatal diagnosis of fetal cerebral abnormalities by ultrasonography and magnetic resonance imaging

We found magnetic resonance imaging (MRI) of the fetal brain to be effective in confirming or denying diagnosis of fetal cerebral defects when ultrasonography was inconclusive or incomplete. In this paper we describe 31 cases in which ultrasonographic evidence of fetal brain defects was verified by MRI. MRI was performed after curarization of the fetus. In 21 cases, ultrasonographic evidence was confirmed by histological study of the fetus or postnatal radiological examination. In 10 cases, ultrasonographic diagnosis was denied by MRI and healthy infants were born. In one case of cerebral toxoplasmosis, ultrasonography detected periventricular calcifications but MRI was normal. In 20 cases MRI ascertained or further documented the ultrasonographic findings. However in 4 of these 20 cases autopsy of the fetus was required to determine the exact nature of the lesion.

Two cell-wall-associated aminopeptidases from Lactobacillus helveticus and the purification and characterization of APII from strain ITGL1

Lactobacillus helveticus ITGL1 is able to hydrolyse many amino-acyl and dipeptidyl-p-nitroanilides. Analysis of heat inactivation kinetics, metal ion and protease inhibitor effects, and the subcellular location of aminopeptidase activities in both the parental strain and mutants deficient in lysyl-p-nitroanilide hydrolysis, led to the characterization of two cell-wall-associated aminopeptidases, APII and APIV. APII, which catalysed L-lysine p-nitroanilide hydrolysis, was purified about 28-fold to homogeneity from cell-wall extracts of L. helveticus ITGL1 and characterized. The purified enzyme appeared to be monomeric, with a molecular mass of 97 kDa. Aminopeptidase activity was greatest at pH 6.5 and 50 degrees C. APII was completely inhibited by bestatin, chelating agents such as EDTA or 1,10-phenanthroline and the divalent cations Zn2+ and Cu2+. The activity of the EDTA-treated enzyme was restored by Co2+, Ca2+ or Mn2+. Although APII was able to degrade several dipeptides and tripeptides with hydrophobic N-terminal amino acid (Leu, Ala), it was inactive on peptides containing Pro or Gly, and may thus contribute to the development of cheese flavour by processing bitter peptides.

[Biological changes in intra-uterine resections under glycine irrigation]

This study was carried out to assess the relations between plasma glycine concentrations and the biochemical changes occurring during intra-uterine resections (IUR) under glycine irrigation. Sixty patients with benign uterine conditions were included. They were all ranked ASA 1 or 2. The biological parameters were assessed before surgery (T0), at the end of surgery (T1) and 60 min afterwards (T2). They included the blood count and blood concentrations of sodium, potassium, chloride, proteins, bicarbonates, glucose, urea nitrogen, creatinine and glycine. Plasma osmolarity was calculated. The irrigation of the uterine cavity resulted in an increase of glycine concentrations (28% of cases), and a decrease of sodium (22% of cases), proteins and haematocrit (32% of cases). Mean osmolarity remained unchanged. Blood glycine concentrations were directly correlated with the volume of irrigating solution, as well as with the duration of surgery. Protidaemia was inversely related to the blood glycine concentration. Multiparous patients had lower glycine concentrations than nulliparous patients. This was probably due to the uterine cavity being less compliant in the latter. On the other hand, there was no correlation with the uterine pathological condition. In this series, five cases of uterine perforation occurred with very large biological variations, especially a decrease in haematocrit and osmolarity. In these cases a clinical and biological water intoxication syndrome may occur as a result of large volumes of irrigating fluid passing into the peritoneal cavity.

[Neonatal consequences of premature rupture of membranes (more than five days) before the 34th week of gestation]

Twenty-six cases of premature braking of the membranes which occurred before week 34 of amenorrhea and lasted for more than 5 days are assessed retrospectively. The mean age when the membranes broke was 26.6 weeks of amenorrhea. Delivery occurred on average at 31.5 +/- 2 WA, with an interval of between 6 and 91 days (mean 35 +/- 23 days). In 4 cases, chorioamniotitis complicated the premature breaking of the membranes. The perinatal mortality rate was 5 out of 27, including 2 still births. Nine of the neonates showed respiratory distress which required artificial ventilation. Four cases of pulmonary hypoplasia were confirmed by pathological examination. In all cases, this was associated with a reduction in the volume of the amniotic fluid, reduced fetal mobility and delayed intrauterine growth. In contrast, when these three factors were absent the prognosis was always good, regardless of the date at which the membranes broke. In the long term, the surviving children showed no neurological sequelae.

[Current role of laparoscopy in the diagnosis and treatment of ovarian cysts]

Between October 1986 and March 1990, 220 patients underwent surgical treatment for ovarian cysts. 156 of these patients underwent an initial celioscopy and could potentially benefit from celiosciopic treatment. The group mean age was 33.3 years. The circumstances under which the cysts were discovered usually consisted of pelvic pain or diagnosis during a routine examination. Twenty-four patients underwent laparotomy immediately after coelioscopy either due to a suspect macroscopic diagnosis either due to technical difficulties. 84.6 percent of the patients in the group were able to undergo celioscopic treatment only, essentially consisting of intraperitoneal cystectomy. The main advantages were the reduction in adherent sequelae in these women of a sexually active age, but also some financial savings related to the reduced duration of hospitalization and of sick leave. The theoretical reservations consist of the risk of malignancy and macroscopic diagnosis following coelioscopic exploration must be very restricted, with laparotomy whenever there is any doubt. No malignant tumor was escaped detection in this group.

[Hysteroscopic endometrial reduction. Analysis of 85 cases]

The authors report the results of their experience of hysteroscopic endometrial reduction through a retrospective series of 85 patients who underwent surgery between October 1988 and February 1991. The indication consisted of hemorrhage (menorrhagia and metrorrhagia) of endometrial origin in women with a group mean age of 46 years who had no intention of becoming pregnant in the future. The pre-treatment assessment was based on diagnostic hysteroscopy and was intended to eliminate neoplasm of the endometrium or its precursors. The endometrial reduction procedure always preserved an isthmic ring of endometrial tissue. No peroperative complication was reported. The mean duration of surgery was about 39 minutes. With a follow-up period of more than one year, bleeding had disappeared in 78% of cases. The authors conclude that the technic of endometrial resection in the treatment of benign lesions of the endometrium, on condition that the possibility of any disorder calling for laparotomy is ruled out and that there is regular postoperative follow-up.

[Triplet pregnancies in France. Results of a retrospective, multicenter study of two years (1987-1988). Proposals for optimal management]

The explosion of procedures for medically assisted parenthood (MAP) has resulted in a previously little known type of pregnancy: triple pregnancies. In order to assess the current obstetrical and pediatric situation, the authors have carried out a major retrospective, multicenter survey in France concerning the triple pregnancies from 1987 to 1988: 156 case histories have been collected. The finds are compared with those reported in the French and international literature, showing that in France, three-quarters of such pregnancies result from MAP, mainly due to ovulation-inducing agents. Hospitalization is prolonged (averaging 27 days), early (24 WA) and imposed by complications (in 8 out of 10 cases), prophylactic hospitalization being rarely prescribed. The main complications encountered are late miscarriages (1.9%), in-utero death (6.41%), dysgravidia (16.6%), hydramnios (5.12%) and serious cardio-pulmonary complications related to the use of beta-mimetics. A Cesarian is performed in only 87 percent of cases. The mean birth weight was 1,776 g. Neonatal mortality is on the decline, but still equivalent to 80.3 per thousand. Hypotrophy is common (27%). Birth is nearly always premature (99.3%), but very early prematurity (28-32 WA) was reduced. The approach suggested for optimum management is based on the personal experience of the authors, the findings of their survey and of the international literature. It is based on the prevention of prematurity and a fundamentally multidisciplinary approach.

[Indications for operative hysteroscopy. A series of 418 interventions]

Over a period of 38 months, from October 1, 1987 to December 31, 1990, 418 surgical hysteroscopies were carried out following systematic pre-operative hysteroscopy. Two-hundred and eighty-two patients presenting with a benign intercavitary lesion were treated by transcervical endo-uterine resection (EUR). The efficacy of the surgical method was assessed from the control of hemorrhagic phenomena, the most frequent sign. 89.7 percent of the patients who presented with menometrorrhagia, had become asymptomatic from the first cycle after EUR and 83.5 percent remained asymptomatic after a mean follow-up period of 28 months, 71 endometrectomies were carried out by EUR during this period, after careful hysteroscopic and histological evaluation of the endometrium. The results after one year of cycles were satisfactory in 82 percent of patients. Twenty-two patients presenting with a uterine septum were treated by endoscopic hysteroplasty. In most cases, the authors used the tip of the Charriere 21 resector. The follow-up period exceeds 1 year in 15 patients, 11 of whom became pregnant, giving birth to 9 live infants, 43 cases of synechia were treated by hysteroscopy in the context of Ashermann's syndrome. The functional results were good in 90 percent of patients, with the restoration of normal cycles. Only limited results were obtained in fertility in cases of muscular or fibrous synechia. The risks linked to surgical hysteroscopy are analysed. They appear to be acceptable, on condition that rigorous methods are used. The quality of sequelae and the short hospitalization make operative hysteroscopy preferable in the selected indications.

[Conservative treatment of cancer of the ovary]

The authors assess the potential of conservative treatment in a series of cases of ovarian cancer. Surgical evaluation is essential, in order to confirm that the conditions required for conservative treatment are present. The tumor must be a stage IA tumor, with a low histoprognostic score and small in size. Conservative treatment must be proposed in cases of tumors of potential malignancy and tumors of the sexual cords. It is debateable in epithelial tumors. The question of the necessity of further surgery to remove the genital tract after the desired pregnancies may be debateable in cases of epithelial tumors.

[Treatment of urinary stress incontinence by a modified Pereyra procedure:Chrub's operation]

The authors report the utility of suspending the cervix by means of the pubo-urethrax ligaments anchored to Cooper's ligaments in treating exercise-related urinary incontinence. A prospective series of 40 female patients gave 97.5% of successful outcomes with regard to the incontinence. The use of the pubo-urethrax ligaments and the absence of subsphincterian dissection confers major urodynamic advantages, particularly with regard to closing pressure. These anatomical and physiological arguments appear to give the procedure an advantage over suspensions using the vagina wall, whether these make use of the upper or lower route. Anchoring to Cooper's ligaments should ensure long-term stability of the outcome.

Cell-wall-associated proteinase of Lactobacillus delbrueckii subsp. bulgaricus CNRZ 397: differential extraction, purification and properties of the enzyme

Whole cells of Lactobacillus delbrueckii subsp. bulgaricus CNRZ 397 were able to hydrolyse alpha- and beta-caseins. Irrespective of the growth medium used, milk or De Man-Rogosa-Sharpe (MRS) broth, identical patterns of alpha- and beta-casein hydrolytic products, respectively, were visualized by sodium dodecyl sulphate-polyacrylamide gel electrophoresis. A soluble proteinase present in cell-wall extracts was active on caseins and displayed the same hydrolytic patterns as whole cells. It was purified from cell-wall extract to homogeneity by ultrafiltration and ion exchange chromatography. The enzyme is a monomer with a molecular mass of 170 kDa, an optimum temperature of 42 degrees C and an optimum pH of 5.5. It was strongly activated by dithiothreitol and partially inhibited by E-64. These properties indicate that cysteine residues play an important role in the enzyme mechanism. The purified proteinase was not able to hydrolyse di- or tripeptides.

Monoclonal antibody 1BE12 immunoreactivity with human endometrium. Correlations with hormone receptors and proliferation cell markers

The monoclonal antibody (MAb) 1BE12 has recently been reported to react with several human normal and abnormal tissues. In human endometrium, it reacts more strongly with carcinomas than with normal tissue. To investigate the effectiveness of MAb 1BE12 in identifying cell proliferation in human endometrial cancers, 1BE12 immunocytochemical assays (ICAs) were performed on frozen (n = 47) and paraffin (n = 100) sections with subsequent computer-assisted microcytophotometric (SAMBA) evaluation of immunoprecipitate distribution. MAb 1BE12 immunoreactivity was not impaired by tissue fixation and paraffin embedding. It reacted with normal proliferative endometrium but not with normal secretory endometrium, and immunoreactivity increased with the degree of cell proliferation and malignancy, the amount of immunostaining being greater in invasive carcinomas than in normal proliferative endometrium and endometrial hyperplasia. ICAs showed no correlation between MAb 1BE12 immunoreactivity and estrogen and progesterone receptor antigenic sites. On the other hand, MAb 1BE12 staining in frozen sections increased with Ki67, EGFR, pHER-2/neu, and cathepsin immunostaining. These findings suggest that ICAs on frozen and paraffin-embedded biopsy specimens using MAb 1BE12 along with other markers can be useful for early detection and grading of endometrial carcinoma. The relevance of MAb 1BE12 to the selection of patients for laser ablation of the endometrium rather than hysterectomy is also discussed.

[Sites of endometriosis]

Endometrious may be located in many parts of the body which are not limited to the pelvic region. While the classical theory of menstrual reflux easily accounts for the genital locations, other theories, notably metaplasia, have been propounded to explain more remote locations. Among the sites of implantation of the disease, the most common is the ovary followed, in order of frequency, by the anterior and posterior parts of the vaginal fornix, the broad ligament of the uterus and the uterosacral ligaments. Endometriosis of the digestive or urinary tract may create problems of differential diagnosis with cancer. External locations are much less frequent.

[Management of HIV seropositive pregnant women and HIV seronegative women with seropositive partners]

The population of HIV seropositive women of child-bearing age is increasing regularly. Termination of pregnancy must be offered to pregnant women during the first trimester. When HIV is detected during the last trimester, vaginal delivery must be accepted. Pregnancy does not seen to worsen the prognosis in HIV positive women, but it does so in women with confirmed AIDS.