[The Hellp syndrome: a frequent (?) obstetric emergency]

Preeclampsia is a multisystem disorder of pregnancy whose clinical presentation is related to the importance and the extent of maternal microvasculature damage. 16 patients with preeclampsia, thrombocytopenia (< 100,000/mm3), elevated liver enzymes and hemolysis are described. Weinstein in 1982 assigned the acronym of Hellp syndrome for this clinical presentation of preeclampsia. This syndrome was seldom recognized during the first years of the study but was diagnosed later on, in 1 pregnancy out of 600 parturitions and in 5% of preeclampsia in 1991. Two out of the patients developed eclamptic seizures. The mode of delivery was as follows: 9 out of 16 had an emergency Caesarean section; the 7 other patients had vaginal delivery after induction of labor. Delivery occurred before 32 weeks of gestation for 6 out of 17 newborns. Outcome was good for 14 of the 17 newborns (one twin pregnancy). Two fetuses died: one in utero and one during interruption of the pregnancy at 24 weeks of gestation. A small for gestational age preterm of 32 weeks died on his second day of life. Early diagnosis of Hellp Syndrome, especially when abdominal pains are present, allows a prompt management of these patients, including delivery, which appeared in our experience, the only way to avoid fetomaternal complications. The thrombotic microangiopathics and acute fatty liver of pregnancy are potential imitations of Hellp syndrome and they must be considered for differential diagnosis. The frequency of Hellp Syndrome varies from one study to another. It can be increased up to 6 fold if referred to the number of pregnancies and up to 3 fold if referred to the number of preeclampsias. These differences can be real but may be due to bias related to differences in practice between centers and also differences in definitions of Hellp Syndrome and preeclampsia.

Medications exposure during pregnancy. A study in a university hospital

To collect informations about drugs prescribed during pregnancy in France we carried out a retrospective survey from august to december 1989. This study was based on a questionnaire at delivery for 225 women. Socio-economic status, obstetrical past history and patterns of prescribing medications were studied. 99.5% of the women were found to have used drugs during pregnancy with a mean of 6.84 medications per woman. There was no influence of age, geographic origins, number of previous pregnancies on drug consumption; socio-professional status was also found to have a poor correlation with drug intake. Patterns of prescribing were compared to those of a previous French study made in 1976: changing pattern of prescribing were found for progestatives, corticoids, neurotropes, aspirin and beta adrenergic agents. We also pointed out that self-administered drugs decreased from 25.9 to 17.9%. This evaluation supports the need of further epidemiological studies in our country.

[Indications and results of autotransfusion. Normovolemic hemodilution in gynecology-obstetrics]

Considering the importance of haemorrhagic complications in gynaecology-obstetrics and the increasing fear of accidents during blood transfusion, the authors propose, from the literature and the study of 13 cases, a reflection on the indications of deferred autotransfusion (DAT) and of normovolemic haemodilution (NVH). In obstetrics, even if DAT has undoubtedly certain advantages (besides viral contaminations, appearance of allo-antibodies...), it can be indicated at present only for pregnant women exposed to a predictable risk of haemorrhage or for women with a rare blood group. In gynaecology, the authors have not found any significant advantages in our study as regards NVH associated with DAT. However, as in obstetrics, the technique is harmless, and no thrombo-embolic complications have been observed, even in women at high thrombotic risk. These methods are expensive and require qualified personnel. Their exact modalities and indications, as well as their medico-legal aspects, are yet to be defined.

[Invasive cervix cancer stage I and II in women less than 35 years old]

The results of a retrospective study of 74 women under the age of 35, treated invasive cervical cancer, stage I and stage II, between 1973 and 1985, were compared with those obtained in 547 women over 35, treated during the same period of time for a similar cervical cancer. The treatment consisted of: association radium therapy-surgery for stages IB less than 25 mm and II A moderately extended and an association radiotherapy-radium therapy for stages IB greater than 25 mm and II A extended, II B and II C. A better distribution per stage is found in women under 35, identical regarding the histological type with 5-year survival identical in both groups at the same stage. Relapses or recurrences occur much earlier in younger women. In the literature, the age as a prognosis factor is very much controverted. On the contrary, other factors should be taken into consideration: clinical stage, node invasion, size and volume of the tumor, depth of infiltration of the cervix.

[Fetal risk in viral hepatitis. Reflections and management of a case of death in utero in a patient with viral hepatitis A]

Fetal death in-utero during viral hepatitis is not the infection itself. It seems that the alteration of the liver functions is the determinant, as it is exactly the case during cholestasis in pregnant women. On the occasion of a death in utero during a viral hepatitis A, the authors review the literature.

[Place of automatic oxytocin perfusion devices in the artificial induction of labor]

Automatic and self-regulated ocytocin perfusion sets, currently available, are able to precisely analyze the uterine activity in 15 minutes and automatically reduce the ocytocin output when a stable and effective uterine activity is obtained. The authors report the results of 41 inducements with the Autosoma pump and compare them with 358 inducements with manually controlled pumps. The duration and the amount of ocytocin perfused with Autosoma are comparable to the results obtained with manually controlled pumps. The frequent release of Autosoma alarms at the beginning of the experiment partially explains the lack of advantages of the automatic perfusion set.

[Should we still explore placental sulfatase deficiencies? Reflections apropos of a case report]

The finding of low or very low levels of oestrogen during pregnancy should suggest the diagnosis of placental sulfatase deficiency, which is confirmed by performing dynamic biochemical tests. These biochemical tests also enable sulfatase deficiency to be differentiated from other conditions which may be accompanied by an abnormal decrease in oestrogens. The authors report one case and stress the harmlessness of sulfatase deficiency and the associated ichthyosis in boys and they question the value of the dehydroepiandrosterone sulfate test which only confirms an abnormality which is now well known and benign.

[Primary surgery in the treatment of invasive cancer of the cervix uteri]

The statistical data reported in this study show that the results obtained with surgery in invasive carcinoma of the cervix uteri are equivalent to those obtained with radiotherapy alone or associated with surgery. The overall proportion of operable patients in this series was 94% (stage I: 98%, stage II: 89%, stage III: 72% and stage IV: 23%). The overall survival rates at 5 years were 90.7% for stage I patients (stage I A 98.0%, stage I B 84.9%), 54.6% for stage II patients (stage II A 68.9%, stage II B proximal 67.1%, stage II B distal 25%). 20.2% for stage III patients and 7.6% for stage IV patients. The drawbacks (mortality, morbidity) of surgery and its advantages (lower psychological and financial cost) are examined. The possibility to adjust the surgical operation to the local and regional extension of the cancerous lesions and the indications for supplementary radiotherapy are discussed.

Correlation of plasma hormone levels and peripheral circulating lymphocyte subpopulations during human pregnancy

Using monoclonal antibodies (OKT3, OKT4, OKT8) peripheral blood lymphocyte subsets were determined in 40 normal primiparous pregnant women and compared with those of 31 nonpregnant controls. In pregnant women plasma concentrations of estradiol, progesterone, human placental lactogen (HPL), beta subunit of human chorionic gonadotropin (beta HCG), and alpha-fetoprotein were measured by means of radioimmunoassay. We studied if correlations between peripheral lymphocyte subsets and plasma hormone levels might exist. We observed in pregnant women from 10 to 40 wk of amenorrhea a decrease in the percentage of OKT3 and OKT8 cells, and during the course of pregnancy an increase in the percentage of OKT4 cells. This increase inversely correlated with plasma beta HCG levels and directly correlated with plasma HPL levels.

[Evaluation of pelvic irradiation during x-ray computed tomography]

Accidental irradiation of an early and unknown pregnancy during abdomino-pelvic computed tomography has not yet been reported, but this situation will certainly occur as the indications for this type of investigation are extended. Assessment of foetal risk depends essentially, as in ordinary radiology, upon the X-ray dose received by the foetus. Only a few studies have been devoted to determination of the "gonad dose" received during an abdomino-pelvic scan. In ten patients undergoing abdomino-pelvic scan with a mean of 22.1 +/- 4.7 exposures per patient, the authors used a small thermoluminescent dose-meter placed in the uterus or endocervix to measure the gonad dose received. The dose delivered to the uterus was 1.67 cGy +/- 1.14 per patient, i.e. approximately the same as for hysterography (1.27 cGy). Thus any abdomino-pelvic scan before twelve weeks should be viewed as an indication for therapeutic abortion, whilst after twelve weeks the amount of radiation received does not in itself represent an indication for abortion.