Predictive value of hemoperitoneum for outcome of methotrexate treatment in ectopic pregnancy: an observational comparative study

OBJECTIVE

To assess the predictive value of hemoperitoneum for the outcome of methotrexate (MTX) treatment of ectopic pregnancy (EP).

METHODS

This observational prospective single-center study included women presenting with EP treated with MTX from November 2007 to November 2009. The percentage of women with hemoperitoneum at the beginning of MTX treatment was compared between two groups: those whose treatment was successful and those whose treatment failed. The rate of hemoperitoneum in each group and its value in predicting the outcome of MTX treatment of EP were assessed.

RESULTS

MTX treatment was successful in 69 of 93 (74%) cases. The percentage of women with hemoperitoneum at the beginning of treatment was significantly higher in women in whom MTX treatment failed as compared to those in whom it was successful (15/24 (62.5%) vs 17/69 (24.6%); P = 0.001). The likelihood of requiring surgery following treatment with MTX was higher in women with hemoperitoneum (odds ratio, 5.1; 95% CI, 1.74-15.14). Study of the diagnostic performance of hemoperitoneum in predicting the need for surgical treatment after MTX treatment revealed a sensitivity of 0.63, a specificity of 0.76, a positive predictive value of 0.47 and a negative predictive value of 0.85.

CONCLUSIONS

The presence of hemoperitoneum appears to be a risk factor for MTX treatment failure. It is important to inform women as fully as possible about the risk of such failure. Nonetheless, the predictive value of this sign is insufficient for either routinely excluding women with hemoperitoneum from MTX treatment or omitting post-treatment monitoring.

[Comparative study of patients with placenta accreta with or without a history of cesarean section]

OBJECTIVE

To evaluate characteristics of placenta accreta (PA) in patients without previous cesarean section.

MATERIAL AND METHODS

Retrospective cohort study from December 1993 to April 2010 in two departments of obstetrics in university hospitals, Marseille, France. Comparison of clinical characteristics, circumstances of diagnosis, maternal morbidity and treatment was performed between PA diagnosed in patients with (n=63) and without prior cesarean section (n=35).

RESULTS

In group of patients without previous caesarean section, rate of placenta praevia, and antenatal diagnosis were lower (16/35 [46 %] vs. 44/63 [70 %], [P: 0.02]) and (4/35 [11 %] vs. 28/63 [44 %], [P<0.001]) and rate of pregnancies obtained by IVF was higher (5/35 [15 %] vs. 2/63 [3 %], [P=0.05]). In this group, no hysterectomy was performed but risk of uterus necrosis following embolization was increased (3/35 [8.6 %] patients vs. 0/63 patients [P: 0.02]).

CONCLUSIONS

Patients without previous caesarean section have specific characteristics in terms of risk factor and of management.

Fetal heart disease and interruption of pregnancy: factors influencing the parental decision-making process

OBJECTIVE

To identify factors influencing parental decision when a fetal cardiac disease is diagnosed.

METHOD

All pregnancies with fetal cardiac abnormalities diagnosed at three academic hospitals of Marseille, France, between 2004 and 2008, were retrospectively studied. The association between maternal and fetal variables (maternal age, parity, ethnicity, gestational age at diagnosis, nuchal translucency, fetal gender, chromosomal and extra cardiac abnormalities, and severity of the cardiopathy) and parental decision was tested using univariate and multivariate statistical methods

RESULTS

One hundred eighty-eight cases of fetal cardiac disease were analysed, of which 63 were interrupted pregnancies (IP) and 125 continued pregnancies (CP). Four factors were important in the parental decision-making process: the severity of cardiac malformation, the ethnic origin of the parents, the gestational age at diagnosis and the chromosomal abnormalities.

CONCLUSION

Counselling of parents following the diagnosis of a congenital heart disease should take into account that, in addition of the severity of the congenital heart disease (CHD), ethnicity, gestational age at diagnosis and chromosomal abnormalities influence parental decision regarding pregnancy continuation or interruption.

[Port-site metastasis after retroperitoneal lymphadenectomy for endometrial adenocarcinoma]

Port-site metastasis is a rare but serious complication of laparoscopic surgery. The etiologies are poorly identified and multiple. We report the case of port-site metastasis after laparoscopic retroperitoneal lymphadenectomy for endometrial adenocarcinoma. In the literature, three cases of port-site metastasis after laparoscopic retroperitoneal lymphadenectomy are reported: two cases concerning cervical cancer and one case concerning a kidney cancer. To our knowledge, this is the only case about port site metastasis after laparoscopic retroperitoneal lymphadenectomy for endometrial adenocarcinoma.

[Clinical and ultrasonographic factors affecting successful medical treatment of early pregnancy failure]

OBJECTIVES

To assess clinical and echocardiographic factors impacting the effectiveness of misoprostol in early pregnancy failure.

PATIENTS AND METHODS

An observational study was carried out within the gynaecological emergency service from 01/06/2000 to 15/05/2010. Patients had pregnancy failure in the first 12 weeks at ultrasonic examination. The patient received 4 misoprostol tablets (800 μg) intravaginally with clinical and ultrasound examination 24 hours later. The treatment was considered effective if the endometrial thickness was lower than 15 mm by ultrasound examination and absence of secondary endo-uterine aspiration. If the treatment was considered as a failure, an endo-uterine aspiration was carried out. Variables studied were clinical (patient age, date of the last menstrual period, gravidity, parity, history of miscarriage, endouterine aspiration, ectopic pregnancy, vaginal delivery, caesarean section) and ultrasound-based (presence or absence of an embryo, CRL, gestational sac diameter).

RESULTS

Five hundred and one patients were included. The success rate was 336/501 (67.1%). After univariate analysis, the averages of parity (P=0.048) and caesarean section (P=0.002) were significantly higher in failure cases. The history of one or more caesarean section was a significant risk factor for failure (P=0.001). There was no significant difference for the other criteria. In multivariate analysis, the average number of caesarean sections (P=0.003) and the history of one or more caesarean section remained significant (P=0.002).

DISCUSSION AND CONCLUSION

The ultrasound criteria and gestational age do not impact the effectiveness of misoprostol in the treatment of early pregnancy failure. The history of one or more caesarean section (s) significantly decreased the success rate. It has to be confirmed by other studies. This new data can be an aid to decision-making for the patient and the physician in case of early pregnancy failure.

[Acute vulvar ulcer of Lipschütz: a misdiagnosis entity]

Acute vulvar ulcer or Lipschütz ulcer has been described in 1917 [1]. Clinical pattern is characterized by a prodromic period, with hyperthermia, malaise, headache, odynophagia, myalgia and cough before the apparition of vulvar localization. Vulvar ulcer is classically deep, painful, necrotic, with edema and adenopathy in an adolescent or young woman without any previous sexual contact. Epstein-Barr Virus is the first etiology, but some authors have suggested other infections. Differential diagnosis has to be made with other sexually transmitted pathology, Behçet disease and Crohn disease. Gynecologist and dermatologist should be aware of this diagnosis to avoid unconscionable treatment and reassure patient and family about sexual transmission.

[Initial results of a novel technique for sperm retrieval in male infertility due to refractory retrograde ejaculation]

AIMS

To describe and evaluate a novel technique of spermatozoa retrieval from patients suffering from infertility secondary to refractory retrograde ejaculation.

METHOD

Prospective study to compare mobility and vitality of spermatozoa obtained from urine (U) after oral modification of chemical parameter (PH, Osmolarity) versus from endovesical instillation of sterile spermatozoa culture medium before ejaculation (F). Patients were their own controls. Twelve month prospective follow-up was achieved to document the results of assisted procreation.

RESULTS

Eight patients were included and mobility and vitality were improved in all patients after F technique was compared to U technique. With U technique, eight patients on eight had negative defrost test; after F technique, seven patients on eight had a positive defrost test and could therefore have access to assisted reproduction techniques. Four couples had five ICSI and obtained three pregnancies leading to five births.

CONCLUSION

Endovesical instillation of sterile spermatozoa culture medium before ejaculation was a safe and effective technique to improve spermatozoa quality in male infertility related to refractory retrograde ejaculation.

Ultrasound monitoring in patients undergoing in-vitro fertilization after methotrexate treatment for ectopic pregnancy

OBJECTIVES

To compare sonographic characteristics of the endometrium and follicles during in-vitro fertilization (IVF) before and after methotrexate (MTX) treatment for ectopic pregnancy.

METHODS

This retrospective study, conducted at Conception Hospital from January 2000 to July 2007, included all patients diagnosed with an ectopic pregnancy resulting from IVF treatment that was treated with MTX and who then underwent another IVF cycle. We compared the number and size of follicles and the endometrial thickness and quality on the day of human chorionic gonadotropin injection in the cycles before and after the MTX treatment to determine whether MTX had any effect.

RESULTS

Eleven patients were included in the study. The median interval between the IVF cycle resulting in ectopic pregnancy and the first IVF cycle after MTX therapy was 180 (range, 150-900) days. There was no statistically significant difference between the before and after MTX treatment groups with respect to number of follicles (14 (3-20) vs. 9 (4-16), P = 0.12), follicle size (16.5 (14.7-21.7) mm vs. 17.8 (14.9-19.8) mm, P = 0.37), endometrial thickness (10.0 (9.5-12.0) mm vs. 10.0 (7.5-14.0) mm, P = 0.31) or endometrial quality (P = 0.32). Four women became pregnant during the IVF cycle following MTX treatment.

CONCLUSIONS

Ultrasound monitoring showed no modification of the characteristics of the endometrium or follicles during IVF after MTX treatment for ectopic pregnancy.

[Medical abortion at home and at hospital: a trial of efficacy and acceptability]

OBJECTIVES

To evaluate the efficacy and the acceptability of medical abortion at home and at hospital.

PATIENTS AND METHODS

From 11 February 2008 to 16 July 2008, 399 patients were included in the study: 173 at home and 226 at hospital.

RESULTS

Efficacy was evaluated for 305 patients because 94 were lost of follow-up (23.6%). Efficacy of medical abortion was 86.7% (124/143) at home and 95.8% (155/162) at hospital. There were one ongoing pregnancy and 25 surgical aspirations (8.6%). The family planning nurse received a phone call from five patients after mifepristone at home (2.9%) and seven patients after mifepristone at hospital (3.1%). Only one patient "at home" had an emergency consultation (0.6%) and nine patients "at hospital" (4%). Ten patients went back to their gynecologist before their appointment for follow-up (2.5%): five "at home" (2.9%) and five "at hospital" (2.2%). Thirteen patients were referred by the private provider to the hospital medical specialist. Acceptability is known for 70.2% of patients: 98% thought that medical abortion at home was acceptable and 92.9% at hospital.

DISCUSSION AND CONCLUSION

The failure rate of medical abortion is higher at home and is due to aspirations for incomplete abortion. The procedure at home seems to be more acceptable than at hospital. It will be interesting to realize a prospective randomized study to compare the procedures at home and at hospital.

A hierarchical analysis of transcriptome alterations in intrauterine growth restriction (IUGR) reveals common pathophysiological pathways in mammals

Intra-uterine growth restriction (IUGR) is a frequent disease, affecting up to 10% of human pregnancies and responsible for increased perinatal morbidity and mortality. Moreover, low birth weight is an important cause of the metabolic syndrome in the adult. Protein depletion during the gestation of rat females has been widely used as a model for human IUGR. By transcriptome analysis of control and protein-deprived rat placentas, we were able to identify 2543 transcripts modified more than 2.5 fold (1347 induced and 1196 repressed). Automatic functional classification enabled us to identify clusters of induced genes affecting chromosome structure, transcription, intracellular transport, protein modifications and apoptosis. In particular, we suggest the existence of a complex balance regulating apoptosis. Among repressed genes, we noted several groups of genes involved in immunity, signalling and degradation of noxious chemicals. These observations suggest that IUGR placentas have a decreased resistance to external aggression. The promoters of the most induced and most repressed genes were contrasted for their composition in putative transcription factor binding sites. There was an over-representation of Zn finger (ZNF) proteins and Pdx1 (pancreatic and duodenal homeobox protein 1) putative binding sites. Consistently, Pdx1 and a high proportion of ZNF genes were induced at the transcriptional level. A similar analysis of ZNF promoters showed an increased presence of putative binding sites for the Tata box binding protein (Tbp). Consistently again, we showed that the Tbp and TBP-associated factors (Tafs) were up-regulated in IUGR placentas. Also, samples of human IUGR and control placentas showed that human orthologous ZNFs and PDX1 were transcriptionally induced, especially in non-vascular IUGR. Immunohistochemistry revealed increased expression of PDX1 in IUGR human placentas. In conclusion, our approach permitted the proposition of hypotheses on a hierarchy of gene inductions/repressions leading to massive transcriptional alterations in the IUGR placenta, in humans and in rodents.

Antigenic profile, prevalence, and clinical significance of antiphospholipid antibodies in women referred for in vitro fertilization

The aim of this prospective study was to assess the prevalence of antiphospholipid antibodies (aPL) in women who had undergone in vitro fertilization (IVF) and the relationship between aPL and IVF outcome. A total of 101 infertile women with at least three unsuccessful IVF attempts were consecutively included in this study. Samples were collected in the follicular phase of a spontaneous ovarian cycle 2 months after the last ovulation induction treatment. Age-matched healthy fertile women (n = 160) were included as controls. All were evaluated for the presence of lupus anticoagulant (LA), antibodies (IgG, IgA, IgM) to cardiolipin (aCL), beta2-glycoprotein I (abeta2GPI), and phosphatidylethanolamine (aPE). Out of the 101 infertile women, 40 were persistently positive for aPL, showing a prevalence significantly higher than in controls (39.6% versus 5%, P < 0.0001). Among aPL, aPE were found with a significantly higher prevalence compared with LA, aCL, and aP2GPI (67.5% versus 0%, 15%, and 40%, respectively). Interestingly, aPE were found in 70% of the cases in the absence of the other aPL. The predominant isotype of aPL was IgA, in particular for abeta2GPI. Finally, no significant association was found between the presence of aPL and IVF outcome. This prospective study shows aPE as the most prevalent aPL in infertile women and IgA as more common than IgG and IgM. However, our results do not support an association between aPL and IVF outcome.

[What are at present the real hopes of pregnancy after ovarian cryopreservation?]

Survival rates for cancers that occur in childhood and adolescence have improved over the last decades, and preservation of future fertility in these patients has become a relevant issue. Premature ovarian failure is a consequence of exposing women to chemotherapeutic drugs and ionizing radiation. Ovarian cryopreservation is an alternative to cryopreservation of embryos or oocytes for theses patients. Ovarian cryopreservation aims to reimplant ovarian tissue after complete remission into the pelvic cavity (orthotopique site) or a heterotopic site like the abdominal wall or the forearm. In vitro folliculogenesis, that aims at the maturation of ovarian cortex primordial follicles cryopreserved for a FIV, is still in an experimental research stage. In this review, the objective was to evaluate the real hopes of pregnancy after ovarian cryopreservation. Indeed, many teams offer ovarian cryopreservation at present time, although only two pregnancies have been achieved to date. In both cases, it can be discussed whether the fertilized oocyte originated from the transplant or from the native ovary. Furthermore, the potential for reintroduction of cancerous cells may limit this technique in cancers that are known to have a risk of ovarian dissemination. The hopes engendered by ovarian cryopreservation, but also its limits, must be explained to the patients before an ovarian surgery for cryopreservation.

Development and internal validation of a nomogram to predict macrosomia

OBJECTIVE

To develop a nomogram to predict macrosomia with a combination of clinical and ultrasound variables.

METHODS

Data from 194 women who underwent sonographic fetal weight estimation were used to develop and calibrate a nomogram to predict fetal macrosomia. The nomogram was subjected to 200 bootstrap resamples for internal validation and to reduce overfit bias. An Internet-based tool was developed to facilitate use of the nomogram.

RESULTS

The macrosomia prediction nomogram, based on parity, ethnicity, body mass index and fetal weight estimated macrosomia, had good discrimination and calibration before and after bootstrapping (area under curve (AUC), 0.860 and 0.850, respectively). The predictive accuracy of our nomogram was significantly better than was sonographically estimated fetal weight using Hadlock's formula (AUC, 0.740; P<0.001). We have provided a web-based interface to predict the individual probability of macrosomia.

CONCLUSION

We have developed a nomogram to predict the individual probability of macrosomia based on clinical and ultrasound findings. Our web-based interface should help to guide patients and physicians in decision-making.

[Comparative evaluation of the Joel-Cohen cesarean section versus the transrectal incision]

OBJECTIVE

The aim of this study was to compare the Joel-Cohen method for cesarean section to the traditional transrectal incision.

METHOD

Fifty-two patients requiring a caesarean section were enrolled in this prospective study. Overall morbidity and post-operative pain was assessed. Four surgeons participated to this study, each included 13 patients. The main judgement criterion was post-operative pain on the first day.

RESULTS

Post-operative pain on the first day was less important (50 vs 23% p=0.04) in Joel-Cohen's. This method was shorter compared to the transrectal incision (33.6+6.4 min vs 51.2+8 min p<0.0001). There was no difference in overall morbidity between the two groups.

CONCLUSION

Joel-Cohen's method decrease post-operative pain and is a shorter procedure compared to the transrectal incision.

[Delivery of a macrosomic infant: factors predictive of failed labor]

OBJECTIVE

To determine risk factors of failed labor in case of fetal macrosomia.

MATERIALS AND METHODS

Medical charts of two hundred and forty six women who delivered macrosomic infants (>4,000g) between January 2004 and May 2005 were reviewed. Maternal and obstetrical data were analyzed by mode of delivery. Univariate and multivariate (logistic regression analysis) were performed to identify risk factors of failed labor.

RESULTS

Rate of cesarean delivery was 18.3%. Indications for cesarean were: failure to progress in 55.6%, arrest in fetal descent in 22.2%, fetal distress in 6.7%, and other in 8.9%. There was a higher risk of failed labor in nulliparous women (p<0.001), in case of a symphysio-fundal measurements>34cm (p=0.004), in nulliparity associated with symphysio-fundal measurements>34cm (p<0.001), in case of previous cesarean delivery (p=0.004), in cases of maternal height<1.65m (p=0.02), and with ocytocin use (p=0.05). In multivariate analysis, nulliparity associated with symphysio-fundal measurements>34cm (OR=5.2; CI 1.5-18.4), previous cesarean section (OR=3.7; CI 1.1-12.4) and maternal height<1.65m (OR=2.6; CI 1.2-5.5) were independent factors of failed labor.

CONCLUSION

Failure of labor in case of macrosomia can be predicted in the event of previous cesarean section, shorter maternal height, and association of nulliparity and symphysio-fundal measurements>34cm.

[Ovarian cryopreservation: clinical and ethical problems arisen further to study on cases of ovarian cryopreservation]

OBJECTIVE

An early ovarian failure and sterility, on patients often still young, may result from some of the anticancerous treatments. Ovarian cryopreservation is a research way for fertility restoration on patients who will have gonadotoxic treatment. The aim of our work was to study the cases of ovarian tissue preserved in our Department, enabling us to assess the clinical and ethical problems of this technique.

PATIENTS AND METHODS

A retrospective study was conducted from January 2001 onwards up to October 2005, on 14 patients, whose ovarian cortex was frozen our the University Fertility Center (Hôpital de la Conception, Marseille, France).

RESULTS

In our study, the patients' average age was 17+/-5.5 and the median was 14 years [13-24]. Eight patients were under 18 (11+/-3-years-old). The cryopreservation indications were especially haematological (N = 9). More than half of the patients (N = 8) had undergone a gonadotoxic treatment before ovarian cryopreservation.

DISCUSSION AND CONCLUSION

Ovarian cryopreservation is still a recent technology in reproductive medicine. The future of ovarian tissue after thawing, with its different techniques of autograft, is still not consensual. Experimental research remains essential to improve the freezing protocols and ovarian transplant in human medicine.

[Evaluation of controlled-release dinoprostone Propess for labor induction]

OBJECTIVE

To evaluate the efficacy of cervix ripening with vaginal controlled-release Propess.

PATIENTS AND METHODS

A retrospective study of all women who underwent cervical ripening with Propess during the study period from 1(st) January 2002 to 31(st) December 2004 was carried out. A total of 130 patients who experienced Propess was compared with the next following patient who delivered spontaneously matched on gestational age. Modes of delivery, failure of labor, maternal morbidity were recorded.

RESULTS

Indications for induction of labor were: post-term pregnancies in 18.5%, pre-eclampsia in 20.8%, oligohydroamnios in 18.5%, post-term pregnancy and oligohydramnios in 10.8%, intra-uterine fetal growth in 6.9%, premature rupture of membranes in 6.9%, diminution of fetal mobility in 6.1% and miscellaneous in 11.5%. Failure of cervical ripening was 21.2%. Patients in the Propess group had a 3.5 fold higher risk of Cesarean section [95% CI: 1.5-8.3; P < 0.04]. There was no case of maternal or fetal death. There was no difference in incidence of maternal complications, and post-partum haemorrhage.

DISCUSSION AND CONCLUSION

Use of vaginal pessary Propess does not induce adverse maternal or fetal morbidity. However, it was associated with a higher incidence of Cesarean delivery.

Diagnosis and management of adenocarcinoma of the ampulla of Vater during pregnancy

BACKGROUND

Cancer of the biliary tract has a poor prognosis and its association with pregnancy is uncommon. Early diagnosis allowing curative surgical resection offers the only hope of long-term survival.

CASE

This report describes the case of a young 26-week-pregnant woman admitted for cholestatis documented by clinical and laboratory examination. Ultrasonography (US) and magnetic resonance cholangiopancreatography (MRCP) were indicative of common bile tract obstruction. Caesarian section was performed at 32 weeks of pregnancy and the tumor was promptly biopsied. Histology demonstrated carcinoma of the ampulla of Vater. The patient underwent a Whipple procedure. Both mother and baby survived.

CONCLUSION

Pregnant patients with digestive cancer require careful management. Acute non-invasive assessment and radical surgery improve outcome for both the mother and fetus.

Diagnostic de torsion d'annexe : existe-t-il des signes prédictifs de nécrose ?

OBJECTIVE

To determine the most relevant findings for diagnosis of adnexal torsion and predictive factors of adnexal necrosis.

PATIENTS AND METHODS

Clinical, biological, ultrasound, pathologic and surgical findings in surgically confirmed cases of adnexal torsion treated over a five-year period in a gynaecologic emergency department were retrospectively reviewed.

RESULTS

A total of 52 cases of adnexal torsion were studied. Abdominal pain was present in 80.8%, vomiting in 13.5% and fever only in 9.6%. Leukocytosis was noted in 19 (36.5%). The most frequent ultrasound findings were ovarian enlargement in 22 patients (42.3%), ovarian cysts in 26 (50%), and hyperechogenic parenchyma with follicles along the periphery of the ovary in 13 (25%). Age over 40 years and a delay to surgery longer than 10 hours were significantly associated with diagnosis of adnexal necrosis.

DISCUSSION AND CONCLUSION

Prompt diagnosis of adnexal torsion requires a combination of clinical, biological and radiological evidence. No predictive factors of necrosis are found. Risk of adnexal torsion is potentially increased by waiting period for surgery and patient's age.

[Conservative treatment of placenta accreta]

OBJECTIVE

Examination of modalities and results of conservative treatment of placenta accreta.

MATERIAL AND METHOD

Ten-year hospital records were reviewed, with analysis of patients who had diagnosis of placenta accreta associated with conservative treatment.

RESULTS

During the study period, 21259 deliveries were registered, with an incidence of placenta accreta of 1 per 1 000 deliveries (n=23). Conservative treatment was applied in 13 patients. All of them had factors commonly associated with placenta accreta: prior cesarean sections (7/13), prior curettage or endouterine surgery (11/13), placenta praevia (11/13). Antenatal diagnosis was performed in only 64% of the cases (n=7). In our conservative strategy, placenta accreta was always left in situ, with an associated treatment in most of cases (n=10): Bilateral hypogastric artery ligation (n=7), medical treatment with methotrexate (n=5), uterine artery embolization (n=2). There was no case of maternal mortality. Conservative treatment was successful in 11 patients. It failed in 2 cases: hysterectomy was performed in one case for life-threatening hemorrhage, and in the other case for post-embolization uterine necrosis. The morbidity described was blood transfusion (n=7), endometritis (n=1), and one late hemorrhage with expelling necrotic tissue. Afterwards, 2 women became pregnant: one miscarriage and one normal term delivery.

CONCLUSION

Conservative treatment of placenta accreta appears to be a efficient way to preserve fertility. Antepartum diagnosis should be improved among patients with a high risk of placenta accreta in order to optimize conservative strategy.

[Beta-thalassemia and pregnancy. Apropos of 2 cases]

Homozygous beta-thalassemia is a severe, transfusion dependent anaemia that also causes infertility. Preimplantation genetic diagnosis is possible. Very few pregnancies are reported among such patients. They have a very high obstetrical risk and a pluridisciplinary follow is necessary.

Combined brachytherapy and surgery for early carcinoma of the uterine cervix: analysis of extent of surgery on outcome

PURPOSE

The aim of this retrospective study was to evaluate the survival data and rates and patterns of complications and recurrences for patients who had early uterine cervix carcinoma and underwent brachytherapy and subsequent surgery.

METHODS AND MATERIALS

Between January 1990 and December 1997, 192 women with cervical carcinoma (Stages IA2 with vascular invasion [n = 28], IB1 [n = 144], and IIA [n = 20]) underwent brachytherapy, delivering 60 Gy and then hysterectomy with external iliac lymphadenectomy. Piver class I, II, and III hysterectomies were performed on 136, 38, and 18 patients, respectively. Adjuvant chemoradiotherapy was delivered to patients with positive lymph nodes.

RESULTS

The median follow-up time was 61 months. After brachytherapy, a pathologically complete response (CR) was observed in 137 (71.3%) of 192 women. The distribution of CRs according to tumor stage was as follows: Stage IA2, 24 (85.7%) of 28; Stage IB1, 105 (72.9%) of 144; and Stage IIA, 8 (40%) of 20. Patients with Stage IB1 cancer had 13 lymph node metastases (9%), as did 6 with Stage IIA disease (30%). Pelvic recurrences occurred in 9 (4.6%) of the 192 patients; in 3, local relapses were associated with relapses at distant sites. Ten patients had systemic relapses (5.2%). Recurrences at distant sites were more frequent (p < 0.02) in partial responders, and other recurrences were more frequent in patients with lymph node metastases (p < 0.04). The overall 5-year disease-free survival rate was 91.2% (96.2% for Stage IA2, 91% for Stage IB1, and 84.4% for Stage IIA cancers). The class of hysterectomy did not influence the outcome. Late complications occurred in 28 patients (Grade 1, 24 [12.5%]; Grade 2, 4 [2%]; and Grade 3, 1 [0.5%] of 192 patients).

CONCLUSIONS

Combined treatments resulted in high local control and low morbidity rates in patients with early-stage cervical carcinoma. Limited surgery seemed to be adequate after intracavitary therapy.

[Pregnancy outcome and the status of the newborn infant after ICSI at La Conception Hospital in Marseille]

OBJECTIVE

To evaluate obstetric outcome of pregnancies and pediatric follow-up of children born after ICSI procedure.

MATERIAL AND METHOD

Prospective study from october 1994 to September 1998 in medical assisted procreations center in La Conception hospital in Marseilles. Three hundred forty-two couples undergoing ICSI procedures.

INTERVENTIONS

analysis of pregnancy rates, prematurity rates, obstetric outcome and frequency of congenital malformations.

RESULTS

One hundred seventy-eight pregnancies have been obtained with 111 children. Multiple pregnancy rate arise 29.7%. The average term at birth in the singleton pregnancies (38.7 weeks) is higher than in the twins (35.7 weeks). The prematurity rate of delivery before 35 weeks of gestation is about 9.6%. Seven of 111 neonates was born with a congenital malformation, no cardiovascular one. One of boys presents a bilateral cryptorchidism with severe bilateral hypotrophy.

CONCLUSIONS

Our results are similar with those of others teams. Congenital malformation rates is near rates reported in others studies. However, no bilateral cryptorchidism with bilateral severe hypotrophy has been yet reported in literature.

Excretion of lidocaine and bupivacaine in breast milk following epidural anesthesia for cesarean delivery

BACKGROUND

There is a lack of information and knowledge about the practical importance of even low concentrations of the excretion of local anesthetics into breast milk, particularly concerning bupivacaine. The present work aims to confirm, under practical clinical conditions of admission of parturients, the passage of local anesthetics (lidocaine and bupivacaine) into breast milk after an epidural anesthesia.

METHODS

Twenty-seven pregnant women admitted for cesarean delivery received epidural anesthesia with 0.5% bupivacaine and 2% lidocaine. Blood and milk samples were simultaneously collected at 2, 6 and 12 h after the beginning of the epidural infusion. Lidocaine, bupivacaine and its main metabolite, pipecolylxylidide (PPX), were determined in serum and milk by a gas-liquid chromatographic technique. APGAR scores were systematically performed at delivery and a clinical examination was done 24 h after delivery.

RESULTS

Our data indicate that lidocaine and bupivacaine as well as PPX are excreted into breast milk. The milk/serum ratio based upon area under the curve values were 1.07 +/- 0.82, 0.34 +/- 0.24 and 1.37 +/- 0.61 mean +/- SD for lidocaine, bupivacaine and PPX, respectively. Most of the newborns had a maximal APGAR score. Our study does not reveal any adverse reactions related to the excretion of local anesthetics into breast milk.

CONCLUSION

This study documents the magnitude of excreted lidocaine, bupivacaine and PPX in breast milk, and indicates that the use of both lidocaine and bupivacaine for epidural anaesthesia is safe with regard to breast-feeding.

[Intrauterine insemination with the husband's sperm: conclusions of five years experience]

We analyzed retrospectively 936 intrauterine insemination (IUI) cycles with husband's sperm (384 couples). Superovulation and induction monitoring occurred in the majority of cases; IUI was timed 36-40 h after ovulatory hCG. The overall pregnancy rate per cycle (PR/C) was 11.4% (107/936). Data analysis demonstrated that PR/C decreased with infertility duration, woman's age (especially after 38 years old) and number of attempts (significantly after the 4 th cycle). Superovulation (in particular by antiestrogens) and induction monitoring seemed to provide an increase in cycle pregnancy rate. Highest PR/C were observed in dysovulation and male infertility groups. In cases of sperm defects, our data showed that 2 parameters had a significant influence on pregnancy outcome: the number of motile progressive inseminated spermatozoa (> 300,000) and the spermatozoa survival rate after 24 h (> 50%). As a conclusion, intrauterine insemination can be proposed as a satisfying treatment of infertility, if precise protocol is followed and its indications well-defined.

Plasma fibronectin: predictive factor in gestational hypertension?

Our purpose was to evaluate fibronectin as a marker of endothelial cell injury, and as a test for predicting preeclampsia. A retrospective study was performed from November 1993 to March 1995. Results from 142 women were examined: 108 normal pregnant women and 34 pregnant women with evidence of preeclampsia. The plasma fibronectin concentration was significantly higher in pre-eclamptic gravidas (620 +/- 210 mg/l) than in normotensive gravidae women (390 +/- 130 mg/l). A fibronectin concentration lower than 400 mg/l predicted the non-development of a hypertension with a negative predictive value of 96%. The present findings suggest that fibronectin is rather an exclusion parameter than predictive test for hypertension disorders of pregnancy.

Pelvic inflammatory pseudotumor with predominant macrophagic reaction

We describe the clinical and pathological features of a case of inflammatory pseudotumor of the pelvis, exceptionally reported in the female genital tract. Macroscopically the lesion consisted in several yellowish nodules, one on the uterus fundus, others along the ureteral serosa and the urinary bladder suggesting a multifocal pelvic malignancy during the surgical intervention. The histological examination of the nodules showed a total lack of malignant cell proliferation and a macrophagic reaction, enclosing numerous non birefringent heterogeneous crystal structures. In the patient file no colonic diverticulosis or previous pelvic surgical excision was recorded. The differential diagnosis in particular malignant tumors is discussed.

Congenital diaphragmatic hernia: can prenatal ultrasonography predict outcome?

OBJECTIVE

We wanted to establish whether prenatal ultrasonography predicts postnatal outcome in congenital diaphragmatic hernia.

STUDY DESIGN

We designed a retrospective multicenter cohort study of 135 patients with congenital diaphragmatic hernia (122 left, 10 right, 2 bilateral, 1 anterior). In isolated left congenital diaphragmatic hernia five potential prenatal prognostic factors were studied: diagnosis at < or = 25 weeks' gestation, polyhydramnios, intrathoracic stomach, small abdomen, and major mediastinal shift.

RESULTS

None of the 44 fetuses or infants who had multiple malformations survived. Of the 91 cases of isolated congenital diaphragmatic hernia, there were 82 live births; 76 of these infants had a left congenital diaphragmatic hernia. Of these, 51 (67%) died postnatally. A statistically significant relation was found between mortality and polyhydramnios, intrathoracic stomach, and major mediastinal shift. Mortality increased as a function of the number of these prognostic factors from 20% when none was present to 94% when all three were present.

CONCLUSION

In the majority of cases of isolated left congenital diaphragmatic hernia the prognostic value of fetal ultrasonography is too low to alter perinatal management.

[Home delivery]

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.

Concomitant chemoradiation prior to surgery in the treatment of advanced cervical carcinoma

In patients with locally advanced cervical cancer, most of the treatment failures occur within the pelvis. In an attempt to improve local control, 40 patients with bulky tumors (stage IB > 5 cm, stage IIB with distal parametrial invasion, and stage III-IVA) were treated between 1988 and 1992 with concurrent chemoradiation (CCR). The whole pelvis received a midplane dose of 45 Gy over 33 days. Daily radiation dose was 1.8 Gy, with twice-daily fractionation in the last 20 patients. Chemotherapy was administered on the 1st and 21st days of radiation therapy (RT) consisting of cisplatin (60 mg/m2), followed by 5-fluorouracil (600 mg/m2/day continuous i.v. infusion) over 96 hr (and decreased to 40 and 400 mg/m2, respectively, in the last 23 patients). CCR was first followed by a single intracavitary application and then by a parametrial boost in stage IIB-III patients and in stage IVA patients with disease reaching the pelvis side wall. Then surgery (colpohysterectomy with lymphadenectomy or pelvic exenteration) was performed in 35 patients. Median follow-up time was 2.6 years (0.6-5.6 years). Acute toxicity (WHO grade 3-4 diarrhea) in 13 patients led to 6 RT interruptions and 4 incomplete RTs. One patient died of a septic episode without leukopenia after completion of CCR. Five postexenteration complications required a second surgical procedure, of which one patient died with tumor and small bowel fistula. One patient developed small bowel late complication and another patient developed urinary late complications. No postoperative or late complications were observed in patients treated with twice-daily fractionation. Pelvic control was achieved in 32 of 40 patients (81 and 74% in stage IB-IIB and stage III-IVA, respectively). Sites of failure were the pelvis (6 cases), metastases (7 cases), and both (2 cases). Two-year survival and DFS rates were 61 and 66%, respectively, in stage IB-IIB and 77 and 65% in stage III-IVA. High SCC-TA4 values significantly worsened DFS rates. In patients with stage III-IVA tumors, additional surgery could be an important component of this treatment strategy and may be compatible with CCR using twice-daily fractionation radiotherapy. However, these results must be confirmed by a large-scale prospective study.