Impact du 1er confinement pour COVID-19 sur les consultations aux urgences gynécologiques d’un CHU

Objectifs

Évaluer l’impact du 1^er confinement pour COVID-19 sur le nombre de consultations d’urgence gynécologiques (CUG), leurs motifs et devenirs.

Méthode

Étude de cohorte qui comparait les CUG réalisées dans un CHU entre le 17/3/20 et le 11/5/20 à celles réalisées dans ce même service entre le 17/3/19 et le 11/5/19. Principales variables recueillies : antécédents médicaux, motifs des CUG, horaires et devenir. Les CUG incluaient les grossesses <24 SA.

Résultats

Mille neuf cent soixante-dix-sept dossiers ont été analysés (la totalité), 776 en 2020, 1201 en 2019 soit une diminution de 35,4 %, avec en 2020 plus de CUG avec des grossesses <24 SA (55,5 % vs 41,3 %) que pour motifs gynécologiques (41,3 % vs 52,7 % p < 0,001).

Entre 2020 et 2019, pour tout type de CU il n’y avait pas de différence selon l’âge des femmes (25–34 ans 48,5 % vs 44,9 % p = 0,12), l’heure de CU (en journée 78,1 % vs 78,8 % p = 0,71), le terme des grossesses (<12SA 62,2 % vs 63,8 % p = 0,65) et la parité (nullipares 42,7 % vs 42,3 %, p = 0,88). Les CU étaient plus souvent réalisées les jeudis-vendredis (41,3 % vs 29,6 % p < 0,0001) que du samedi au mardi avec plus d’hospitalisation/transfert (8,1 % vs 4,9 % p = 0,003).

Avaient augmenté les motifs de CUG pour altération de l’état général et contrôles échographiques avec dosage de ßHCG (respectivement 13,1 % vs 10,1 % p = 0,04 ; 11,9 % vs 8,7 % p = 0,02). Avaient diminué les CUG pour douleurs abdomino-pelviennes, suspicion d’infection génitale et urinaire (respectivement 44,1 % vs 52,5 % p = 0,0002 ; 4,3 % vs 8,2 % p = 0,0006 ; 2,3 % vs 4,5 % p = 0,01). Les CUG pour métrorragies et pathologies mammaires restaient inchangées (respectivement 39,2 % vs 38,2 % p= 0,75 ; 2,6 % vs 2,1 % p = 0,53).

Les diagnostics à l’issue des CUG révélaient une augmentation des fausses couches/grossesses arrêtées/molaires (15,5 % vs 11,4 % p = 0,05) et des grossesses extra-utérines (5,3 % vs 1,2 % p < 0,001) et une diminution des diagnostics de grossesses d’évolution incertaine et d’infections génitales (respectivement 1,9 % vs 22,9 % p < 0,0001 ; 6,7 % vs 13,1 % p < 0,0001). Ceux pour endométriose/dysménorrhée/anomalies de règles, douleurs ligamentaires et métrorragies/décollements placentaires restaient inchangés (respectivement (10,1 % vs 8,9 % p = 0,50 ; 6,5 % vs 6,5 % p > 0,99 ; 1,6 % vs 0,9 % p = 0,29).

Conclusion

Si l’offre de soin en consultation d’urgence gynécologique a été maintenue au CHU* lors du 1e confinement, ce sont les motifs de CUG et leurs diagnostics qui ont évolué. Même si les urgences chirurgicales étaient majorées en période de mobilité restreinte, la majorité des CUG étaient évitable, ce qui pourrait conduire à envisager une réorganisation de la gestion de ces CUG.

[Guidelines for Clinical Practice of the French College of Obstetricians and Gynecologists 2021: Prophylactic procedures associated with gynecologic surgery]

OBJECTIVE

To draw up recommendations on the use of prophylactic gynecologic procedures during surgery for other indications.

DESIGN

A consensus panel of 19 experts was convened. A formal conflict of interest policy was established at the onset of the process and applied throughout. The entire study was performed independently without funding from pharmaceutical companies or medical device manufacturers. The panel applied the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system to evaluate the quality of evidence on which the recommendations were based. The authors were advised against making strong recommendations in the presence of low-quality evidence. Some recommendations were ungraded.

METHODS

The panel studied 22 key questions on seven prophylactic procedures: 1) salpingectomy, 2) fimbriectomy, 3) salpingo-oophorectomy, 4) ablation of peritoneal endometriosis, 5) adhesiolysis, 6) endometrial excision or ablation, and 7) cervical ablation.

RESULTS

The literature search and application of the GRADE system resulted in 34 recommendations. Six were supported by high-quality evidence (GRADE 1+/-) and 28 by low-quality evidence (GRADE 2+/-). Recommendations on two questions were left ungraded due to a lack of evidence in the literature.

CONCLUSIONS

A high level of consensus was achieved among the experts regarding the use of prophylactic gynecologic procedures. The ensuing recommendations should result in improved current practice.

[Impact of luteal phase support by human chorionic gonadotropin (hCG) in intrauterine inseminations]

OBJECTIVES

The objective of our study is to evaluate the impact of luteal phase support by hCG in intrauterine inseminations preceded by ovarian gonadotropin stimulation.

METHODS

A retrospective study was conducted at the CHU of Nice between March 1, 2016 and October 31, 2017. During this period, 300 intrauterine inseminations were included in data analysis. Ovarian stimulation was performed by gonadotropins and a GnRH antagonist was added, if needed. Following a modification of standard operative procedure in the department, patients who performed an intrauterine insemination from December 1, 2016 received luteal phase support with two injections of hCG 1500 IU, performed at three days of interval. Pregnancy and ovarian hyperstimulation syndrome were the primary and secondary study endpoints, respectively.

RESULTS

Out of 300 inseminations included in the analysis, 144 were performed with luteal phase support and 156 without support. No statistically significant difference in pregnancy rate was observed between these two groups (19.4% of pregnancy in the luteal phase support group and 15.38% in the group without luteal phase support, P=0.353). No ovarian hyperstimulation syndrome occurred over the course of the study.

CONCLUSION

Our study shows a slight improvement of pregnancy rate in the group subjected to luteal phase support by hCG after intrauterine insemination, but the benefit was not significant. A randomised prospective study based on a large cohort could help to assess the effect of luteal phase support during intrauterine inseminations.

[Barriers to the use of emergency contraception in a population consulting for an abortion]

OBJECTIVES

In France, one pregnancy out of three is unplanned. Half of those pregnancies lead to abortion. However, the use of emergency contraception is far from systematic. It is therefore relevant to question the reasons and factors linked to the low rate of use of emergency contraception.

METHODS

A retrospective observational study was conducted in the orthogenic service of the University hospital Center of Nice, over a six weeks period. Patients were consulting in the context of voluntary termination of pregnancy and were subjected to a questionnaire during a semi-structured interview. The collected data were: age, degree of education, profession, size of their home town municipality, legal status, obstetrical history, contraception used at the time of unplanned pregnancy, emergency contraception background and justification for not using an emergency contraception.

RESULTS

A total of one hundred and five questionnaires were studied. The absence of emergency contraception was due to an underestimation of the risk of pregnancy in 81% of cases. Among characteristic variables of the studied population, none was related to the non-use of emergency contraception.

CONCLUSIONS

Independently of the patient profile, underestimation of the risk of pregnancy is the main cause of non-use of emergency contraception. It seems crucial to inform women with childbearing age and their families about their fertility and the basic mechanisms of fertility in order to reduce the number of unplanned pregnancies in France.

Which Foetal-Pelvic Variables Are Useful for Predicting Caesarean Section and Instrumental Assistance?

OBJECTIVE

To assess the variables useful to predict caesarean delivery (CD) and instrumental assistance, through the analysis of a large number of foetal-pelvic variables, using discriminant analysis.

MATERIALS AND METHODS

One hundred and fourteen pregnant women were included in this single-centre prospective study. For each mother-foetus pair, 43 pelvic and 18 foetal variables were measured. Partial least squares-discriminant analysis was performed to identify foetal-pelvic variables that could statistically separate the 3 delivery modality groups: spontaneous vaginal delivery (SVD), CD, and instrument-assisted delivery (IAD).

RESULTS

For the SVD versus CD model, voluminous foetuses and women with a narrow pelvic inlet had a greater risk for requiring CD. The most efficient variables for discrimination were the transverse diameter and foetal weight. The antero-posterior inlet and obstetric conjugate were considered in this model, with the former being a useful variable but not the latter. For the SVD versus IAD model, the most important variables were the foetal variables, particularly the bi-parietal diameter. Women with a reduced antero-posterior outlet diameter and a narrow pubic arch were more at risk of requiring an IAD.

CONCLUSION

The antero-posterior inlet was an efficient variable unlike the obstetric conjugate. The obstetric conjugate diameter should no longer be considered a useful variable in estimating the arrest of labour. Antero-posterior inlet diameter was a sagittal variable that should be taken into account. The comparison of sub-pubic angle and bi-parietal and antero-posterior outlet diameters was useful in identifying a risk of requiring instrumental assistance.

[Role of imaging in cases of bleeding after spontaneous or induced abortion]

Post-abortum hemorrhage is a common clinical situation and etiological diagnosis has to be made early to avoid further complications such as persistent bleeding, infection or adhesions that may compromise fertility. Retained products of conception are the most common cause of bleeding. The diagnosis is based on endovaginal color doppler ultrasound showing a thickened and hypervascular endometrial echo-complex extending partly to the myometrium. The main differential diagnosis is uterine arteriovenous malformation, mostly iatrogenic. Diagnosis is based on the presence of myometrial confluent cystic lesions filled with turbulent and high velocity arterial flow on endovaginal color doppler ultrasound. The distinction between these two etiologies of post-abortion bleeding is mandatory because of totally different treatment: typically medical and/or surgical in case of retained products of conception and by selective arterial embolization in case of vascular malformation.

[Distribution of human papillomavirus genotypes amongst HIV-negative and HIV-positive women diagnosed with ASC-US cytology. Preliminary data of a local retrospective study]

OBJECTIVES

Analysis of the distribution of human papillomavirus (HPV) genotypes amongst HIV-negative and HIV-positive women diagnosed with atypical squamous cells of undetermined significance (ASC-US).

PATIENTS AND METHODS

We performed a retrospective study of HPV genotype distribution in 313 ASC-US Pap smears from women who consulted at the University Hospital of Nice between 2008 and 2012. HPV genotyping results, conducted on PapilloCheck(®) HPV DNA Chip, and information on the status of HIV patients were retrospectively collected. The odds ratio were calculated by logistic regression.

RESULTS

In co-infected HIV/HPV women we observed a low prevalence of HPV16, a high prevalence of oncogenic HPV low risk and a high prevalence of HPV 68 compared to non-co-infected women. By grouping HPV HR based on their prevalence in cervical cancer of the uterus and their genetic proximity we observe that HPV 18, 45, 68 (the "alpha-7") are 7.4 times more represented (CI95 [2.48 to 22.35]) than HPV 16, 31, 33, 52, 58 (the "alpha-9") in the population of women co-infected with HIV.

DISCUSSION AND CONCLUSION

Given that HPV "alpha-7" are responsible for 46.3% of adenocarcinomas, the high prevalence of these HPV found in ASC-US Pap smears of co-infected women should be put in relation with the highest prevalence of glandular abnormalities found in this population. HPV genotyping could become an essential tool for gynecological care for HIV positive women.

Evaluation of single incision laparoscopic surgery "low-fidelity" simulation training

GOAL

Evaluate the learning curve of SILS (Single Incision Laparoscopic Surgery) on a simulator, based on two tests of the Fundamentals of Laparoscopic Surgery certification program (FLS(®)), in a population of novice medical students, and compare their performance to those of senior surgeons practicing both "conventional" laparoscopic surgery and SILS.

MATERIALS AND METHODS

Monocentric prospective study with four groups: two groups of novice medical students, and two groups of senior surgeons. The two FLS(®) tests used for evaluation were the peg transfer and the precision cutting tasks.

RESULTS

No statistically significant differences were found between the novice groups, whether they started their first session directly, or immediately after watching a video presentation of the exercises. For the novice medical students, the average completion time of both tests improved significantly between the first and the sixth sessions with a short learning curve. The group of experienced seniors performed fastest in both tests. For the peg transfer task, the skills of the novice medical students were comparable to those of non-experienced seniors after the 4th session and improved after 6 sessions (P=0.017). For the precision cutting task, the average timing of the novice group became better than that of the non-experienced seniors, starting from the third session.

CONCLUSIONS

FLS(®) "low fidelity" simulator training is effective for the training of novice medical students. To minimize the risk of technical errors, novice medical students should practice a minimum of six simulator-training sessions before starting their practical learning of SILS in the operating room.

[Vaginal metastasis revealing an adenocarcinoma of the transverse colon]

Secondary localization to vagina had a severe prognosis, suggesting a disseminated metatastic disease. We report the case of prevalent vaginal metastasis of adenocarcinoma of the transverse colon. A 65 years old patient has consulted for vaginal mass. After delayed diagnosis, she presented with disseminated metastatic disease with peritoneal carcinomatosis. After neoadjuvant chemotherapy, the following treatment consisted of complete cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy and vaginal adjuvant radiotherapy. No recurrence occurred after one year. Vaginal metastasis of colon cancer are rare. The dark prognosis might justify a systematic gynecological examination of women presenting colorectal neoplasy.

[Conservative treatment of a compressive adenomyosis: report of a case]

Adenomyosis is frequent, mostly asymptomatic. A hypertrophy of the smooth muscular cells around ectopic endometrial glands might induce a compressive syndrome. We report the case of an embolization of a voluminous adenomyosic uterus which has triggered venous iliac's compression in patient refusing surgery. This treatment was efficient in reduction of uterin volume, without recurrence after three years. MR imaging is the exam of choice particularly when diagnosis is still uncertain and allows a non-invasive and good evaluation, and follow-up. Embolization is not actually recommended. But, it appears to be efficient, relatively safe and contributes to the conservation of fertility.

[Fertility preservation among patients with cancer: report of a French regional practical experience]

OBJECTIVE

Improvement in cancer treatments has led to reconsider the importance of quality of life after cancer, especially concerning maintening the potential of fertility since it is often altered after healing. Our objective was to estimate the knowledge and practices of the physicians in the field of Oncology in a French Region (Provence Alpes- Côte d'Azur).

PATIENTS AND METHOD

Prospective survey, conducted between January and April 2012, amongst oncologists working in Provence Alpes Côte d'Azur region, through questionnaires distributed during multidisciplinary meetings in oncology.

RESULTS

Among 225 replies, 54% of the physicians had sent no patient to any oncofertility consultation during the previous six months (n=120). Besides, 33% of the oncologists (n=68) declared they had difficulties in addressing their patients to oncofertility consultation, and 58% of them (n=39) considered they lacked information on techniques and indications of fertility preservation.

CONCLUSION

This study provides an estimation of the current practices in PACA region concerning oncofertility and underlines the physicians' need of information. In this context, the regional oncology network has set up a regional network « cancer and fertility » in order to facilitate the access to fertility preservation prior to any potentially sterilizing treatment for all patients.

[Prolactinoma: from quest of pregnancy to delivery]

Prolactinoma is the most frequent hormone-secreting pituitary tumor (100 for million patients) and a major cause of both female and male reproductive function disorders. Physician, gynecologist, urologist and sexologist can face this situation during their career. As part of the fertility restoration, treatment gives very satisfactory results. With adequate management, most women are expected to achieve successful pregnancies. The natural history of these tumors during pregnancy depends on their size with a risk of a clinically relevant estimate between 5 to 30 %. Their management is complex, requiring finding balance between effects of pregnancy on tumor growth and potential risks of overtreatment on fetal development. The aim of this study is to discuss the management of prolactinoma on woman before, during and after pregnancy, and to evaluate the medical and surgical alternatives regarding the actual literature.

[A recurrent cutaneous fistula secondary to the migration of a clip: report of a complication of tubal sterilization]

The tubal sterilization is a safe and recognized sterilization method. The complications of this intervention are rare and mainly concern failure of surgical procedure or clip migrations. We report the first case of spontaneous migration of a clip behind the psoas followed by a chronic osteitis.

[Post-menopausal ovarian hyperthecosis]

Ovarian hyperthecosis is infrequent but it represents the first cause of post-menopausal hyperandrogenia. Pathophysiology of ovarian hyperthecosis remains poorly understood but the metabolic syndrome observed in most patients suggests that insulin resistance associated with high, postmenopausal LH levels, might play a role as in polycystic ovarian syndrome. We report here four patients who presented post-menopausal hyperandrogenia. Although high, tumoral, plasma testosterone levels, lack of focused radiological lesions except enlarged ovaries, associated to the metabolic syndrome, suggested ovarian hyperthecosis. Bilateral annexectomy allowed histological confirmation of hyperthecosis showing specific luteinized stromal cells and led to the complete suppression of the inappropriate androgen secretion.

The place of simulation in the surgical resident curriculum. The pedagogic program of the Nice Medical School Simulation Center

INTRODUCTION

Surgical training relies on medical school lectures, practical training in patient care and in the operating room including instruction in anatomy and experimental surgery. Training with different techniques of simulators can complete this. Simulator-based training, widely used in North America, can be applied to several aspects of surgical training without any risk for patients: technical skills in both open and laparoscopic surgery, the notion of teamwork and the multidisciplinary management of acute medicosurgical situations.

METHOD

We present the curriculum developed in the Simulation Center of the Medical School of Nice Sophia-Antipolis. All residents in training at the Medical School participate in this curriculum.

RESULTS

Each medical student is required to pursue theoretical training (familiarization with the operating room check-list), training in patient management using a high fidelity mannequin for various medical and surgical scenarios and training in technical gestures in open and laparoscopic surgery over a 2-year period, followed by an examination to validate all technical aptitudes. This curriculum has been approved and accredited by the prestigious American College of Surgeons, making this the first of its kind in France.

CONCLUSION

As such, it should be considered as a model and, in accordance to the wishes of the French Surgical Academy, the first step toward the creation of true schools of surgery.

Normal serum concentrations of anti-Mullerian hormone in a population of fertile women in their first trimester of pregnancy

BACKGROUND

Anti-Müllerian hormone (AMH) levels are used to evaluate the ovarian reserve. AMH serum concentrations have recently been studied among women attending fertility centers, and among women with regular menstrual cycles but normative values have not been established among fertile women: the objective of this study was to establish those values.

METHODS

This prospective cross-sectional study included 340 healthy fertile women attending a single centre, aged between 15 and 50 years. The women were all in the first trimester of pregnancy, had no serious medical history and attended the abortion service of the University Hospital of Nice, France. Serum AMH was measured using a second-generation AMH enzyme-linked immunosorbent assay.

RESULTS

Median AMH concentration was 2.42 ng/ml (25-75 percentiles 1.19-4.12). The relationship between AMH concentration and age was best fitted by a polynomial function. Serum AMH values rose until age 29 years and then showed a significant decline (R(2)= 0.289, P < 0.001). Normative values for serum AMH were established in different age groups between 15 and 50 years.

CONCLUSIONS

We established the normative values for serum AMH in a population of French fertile women in their first trimester of pregnancy.

[Who limit vaginal birth for breech presentation: medical practice or Law? Discussion between a medical doctor, a lawyer and the head chief of an university hospital]

The mode of delivery of breech presentation still remains a debate in France. Despite the medical arguments, themselves in debate, exists a legal pressure felt by medical practitioners. Our study highlights the different opinions of medical practitioners, lawyers and medical teachers faced with breech presentation.

[Contribution of new MRI sequences in the exploration of the pelvic gynaecological disease]

MRI has emerged for several years as the imaging examination of second-line indications in the majority of female pelvic imaging, after ultrasonography. Recent technical advances have allowed the widespread use of new MRI sequences, allowing a morphological and functional analysis of the pelvic organs. Diffusion weighted-imaging has a definite interest for the detection, characterization and staging of uterine and adnexal lesions. Dynamic contrast-enhanced imaging is an essential tool for characterizing adnexal lesions and to optimize the staging of uterine cancers. The 3D morphological imaging allows multiplanar reconstructions and is particularly useful in mapping fibroids, uterine malformations and in endometriosis.

[Is there a real place for robotics in proximal tubal surgery?]

Tubal surgery requires a fine gesture. Its complexity, the difficulty of learning, the low recognition at the time of T2A and the success of Assisted Reproductive Technology (ART) could have announced the obituary of this surgery. However, in well-trained hands, tubal surgery avoids unnecessary ARTs and even allows pregnancies when medical technology fails. In this context, it is legitimate to ask whether the contribution of new technologies in the operating theatre, such as robotic surgery, can lead to an easy realization of microsurgery on a particularly complex portion of Fallopian tubes: the proximal segment.

[Comparison between two analgesic protocols on IVF success rates]

OBJECTIVES

Analgesic protocols administered before a follicular puncture under local anesthesia are well tolerated when using NSAIDs, but we still do not know their possible impacts on in vitro fertilization (IVF) outcomes.

MATERIAL AND METHODS

A retrospective monocentric study using two consecutive temporal cohorts of patients was conducted to compare two analgesic protocols: paracetamol/alprazolam (P/A), then nefopam/ketoprofen (N/K).

RESULTS

We demonstrated that biochemical pregnancy rate and the others outcomes of IVF are not significantly influenced by the type of analgesic protocol used.

CONCLUSION

The protocol N/K enhances patient comfort without jeopardizing the IVF success rates.

[The gynecologist and the melanoma: breast and endometrial metastases]

Melanoma has an important metastatic potential and its incidence is greatly increasing. Even after many years of negative follow-up, gynecologists should be aware that a gynecological tumor might be a secondary location for a woman with a medical history of melanoma. Because of a poor prognosis and a reduced life expectancy, it is necessary to make a disease staging in order to offer a prompt diagnosis and a personalized strategy of treatment. Considering the increasing incidence of melanoma, gynecologists will face more frequently with this situation.

[A role of robotic-assisted surgery to preserve female fertility? Comments about the first paratubal cystectomy performed with the "Da Vinci S" robotic system in a young girl]

In the field of adnexal surgeries in children, robotic surgery seems to make easier the realization of minimal invasive surgery. It could lead to a decrease of post-surgical adherences and therefore preserve the fertility of young patients. We report the first paratubal cystectomy performed using robotic assistance on a child in order to preserve her future fertility and discuss advantages and disadvantages of this technology.

[Experimental research on mechanical behavior of human placenta]

OBJECTIVES

Determination of mechanical properties of human placenta.

PATIENTS AND METHODS

Realisation of an experimental study using 80 human placentas and modelisation of this study using a finite element numerical model. Using the inverse analysis method, research of the parameters of placenta's behavior.

RESULTS

Hyper-Visco-Elastic law written by Ogden, optimized for placenta with parameters: mu(1)=0.0001881Mpa, mu(2)=-0.000240Mpa, mu(3)=mu(4)=0Mpa and alpha(1)=2, alpha(2)=-8, alpha(3)=alpha(4)=0 in static condition.

DISCUSSION AND CONCLUSION

The parameters enable an approach of the mechanical behavior of the placenta. They could be used in numerical modelisation.

[Learning use of spatulas: risks of perineal injuries and newborns morbidity]

OBJECTIVES

To examine the acute neonatal and maternal perineal morbidity due to resident training on spatulas assisted deliveries.

MATERIAL AND METHODS

We conducted a retrospective observational study of succesful spatulas-assisted deliveries at Nice University Hospital between January2003 and December2006. We performed univariate analysis and logistic regression to assess risk of severe perineal injuries, vaginal laceration and newborn hospitalization according to operator status, controlling for confounders.

RESULTS

Among 1004 deliveries, 86.4% were performed by residents. No significant difference was found on incidence of severe perineal tears between the 872 extractions performed by residents and the 132 performed by an attending physician (6.9% versus 7.9% p=0.706; OR=0.86 IC95% [0.41-1.81]), but extraction performed by young residents were associated to more severe perineal tears than those performed by senior residents (8.0% versus 4.5% p=0.035; OR=2.10 IC95% [1.16-3.77]). There was no difference between groups concerning newborn morbidity and hospitalisation in special care units (6.4% versus 9.8% p=0.149; OR=1.49 IC95% [0.73-304]).

CONCLUSION

According to our data, training of resident do not increase the incidence of severe perineal injuries, neonatal complications and hospitalisation linked to spatulas assisted delivery.

[Surprising vaginal polyps]

We present herein a particular case of surprising vaginal polyps, associated with nodular lesions (epidermal cysts). Fibroepithelial polyps are rare and benign but pathological aspect may be similar to malignant lesions. Vaginal polyps usually appear after genito-urinary surgery, during pregnancy, or with hormonal treatment. These lesions are effectively treated by local resection, with rare recurrence.

[Anorexia nervosa during pregnancy: an unusual association]

We report the case of a pregnancy associated with severe restricting anorexia nervosa in a 33-year-old patient who weighed 41kg for 1.61m at conception. She continued to lose weight during pregnancy and she gave birth to an eutrophic child by cesarean section at 34 weeks of amenorrhea. Because of complications induced by the chronic food restriction, anorectic pregnant women should be viewed as being at high risk and also monitored closely both during and after pregnancy to optimize maternal and fetal outcomes.