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Spontaneous adrenal hemorrhages (AH) are a rare condition with no consensus about their management.Patients were identified using the Medicalization of the Information System Program database, imaging software and a call for observations to internists, intensivists and obsetricians working at our institution. Adult patients whose medical records were complete and whose diagnosis was confirmed by medical imaging were included.From 2000 to 2007, 20 patients were identified, including 15 were women. The clinical onset of AH was non-specific. In five cases, AH occurred during pregnancy; four of them were unilateral and right sided. The etiology of the other fifteen (bilateral adrenal hemorrhage in 11) were as follows: antiphospholipid syndrome (n=8), heparin-induced thrombocytopenia (n=4), essential thrombocythemia (n=3), spontaneous AH due to oral anticoagulants (n=1), complication of a surgical act (n=3), and sepsis (n=3). In seven cases, two causes were concomitant. The diagnosis of AH was often confirmed by abdominal CT. An anticoagulant treatment was initiated in 16 cases. Ten of the eleven patients presenting with bilateral adrenal hematomas were treated using a long-term substitute opotherapy. One patient died because of a catastrophic antiphospholipid syndrome.The clinical onset of HS is heterogeneous and non-specific. The confirmatory diagnosis is often based on abdominal CT. The search for an underlying acquired thrombophilia is essential and we found in this study etiological data comparable to the main series in the literature. Adrenal insufficiency is most of the time definitive in cases of bilateral involvement.

The aim of the study is to compare placental monochorionic angioarchitecture complicated with twin-oligohydramnios-polyhydramnios sequence (TOPS), twin anemia polycythemia sequence (TAPS), twin reversed arterial perfusion (TRAP) and selective intra uterine growth restriction (sIUGR) to normal uneventful monochorionic placenta.Between December 2012 and December 2015, monochorionic placenta has been studied at the multiple pregnancy care center of the Femme-Mère-Enfant Hospital in Lyon. Umbilical chords were catheterized and dye injected for macroscopic analysis of angioarchitecture at the anatomopathology department. Placentas treated with laser foetoscopic surgery were excluded.A total of 126 placentas were injected in the post-partum period. In total, 95% (119/126) of the placentas presented arteriovenous anastomoses (AVA). Median number of AVA was 7. The prevalence of at least one velamentous cord insertion was higher in TOPS and selective intrauterine growth restrictions P0.01 and P0.01 respectively, compared to uneventful pregnancies. Arterio-arterial anastomoses (AAA) were present in 82.7% (77/93) of uneventful placentas versus 33.3% of TOPS (P0.01) and 28.5% of TAPS (P0.01). The prevalence of veno-venous anastomoses was significantly higher in TOPS (P0.01). All TAPS placentas showed marginal arteriovenous anastomoses. In TRAP placenta, the acardiac twin had no specific vascular territory.The study confirms literature findings on prevalence of vascular anastomoses in monochorial placentas, suggesting the protective role of AAA in TOPS and TAPS. The role of VVA is yet hard to determinate. Macroscopic observations of monochorionic placentas are valuable and essential keys for understanding, managing and treating anastomotic syndromes.

The recent discovery of the earliest hominin cancer, a 1.7-million-year-old osteosarcoma from South Africa has raised the question of the origin of cancer and its determinants. We aimed to determine whether malignant and benign tumors exist in the past societies.A review of literature using Medline database and Google about benign and malignant tumors in prehistory and antiquity. Only cases with morphological and paraclinical analysis were included. The following keywords were used: cancer; paleopathology; malignant neoplasia; benign tumor; leiomyoma; myoma; breast cancer; mummies; soft tissue tumor; Antiquity.Thirty-five articles were found in wich there were 34 malignant tumors, 10 benign tumors and 11 gynecological benign tumors.The fact that there were some malignant tumors, even few tumors and probably underdiagnosed, in the past may be evidence that cancer is not only a disease of the modern world. Cancer may be indeed a moving target: we have likely predisposing genes to cancer inherited from our ancestors. The malignant disease could therefore appear because of our modern lifestyle (carcinogens and risk factors related to the modern industrial society).

The aim of the study was to evaluate feasibility and reproducibility of fetal transcerebellar diameter measurement during second and third trimester ultrasound mass screening by junior and senior physicians.A monocentric prospective study was conducted at the tertiary care teaching hospital in Lyon, including patients undergoing their second or third trimester planned ultrasound exam. For each patient, a resident and a senior practitioner measured each fetal transcerebellar diameter, during a blinded experiment, according to the transcerebellar plane described by the International Society of Ultrasound in Obstetrics and Gynecology. Images have been scored on 4 criteria. The inter-observer variability for transcerebellar diameter and image quality was assessed using an intra-class correlation coefficient. Image quality has been analyzed according to pregnancy term and to fetal presentation.Sixty-six patients were included, 44 patients before and 22 patients after 30 weeks. Inter-observer variability of transcerebellar diameter measurement was 0.4%. Inter-observer variability of image quality was 13.5%. Image quality was not significantly different between seniors and residents (P=0.06). Gestational age and fetal presentation did not affect significantly image quality (P=0.42) and (P=0.64) respectively.Transcerebellar diameter measurement during mass screening is simple and reliable. Posterior fossa abnormalities can be explored through its measurement.

To generate a national biobank made up of samples of the highest quality for the purpose of inciting basic research on gestational trophoblastic diseases (GTD).Three priority axes of research were defined to optimize the nature, method of collection, and storage of the samples. These are: to enhance our understanding of GTD, develop new diagnostic tests, and identify new therapeutic targets. The protocol for patient inclusion and sample processing was determined after extensive literature review and collaboration with international experts in the field of GTD.For each patient with a GTD and for control patients (legally induced abortions), chorionic villi, decidua and tumor samples (fresh, immersed in RNA-protective solution and fixed in formaldehyde), blood (serum, plasma, RNA, and peripheral blood mononuclear cells), urine (supernatant), and cell cultures of villous cytotrophoblasts are prospectively collected. Associations are then made between the collected samples and numerous clinical and biological data, such as human chorionic gonadotropic plasma levels following curettage in the case of a hydatidiform mole.Such a collection of high quality samples and their associated data open up new perspectives for both national and international collaborative research projects.

Echogenic bowel (EB) represents 1 % of pregnancy and is a risk factor of fetal pathology (infection, cystic fibrosis, aneuploidy). The aim of our study was to determine the fetuses' outcomes with isolated EB.This is a retrospective study of all patients who presented singleton gestations with a fetal isolated echogenic bowel between 2004 and 2011 in two prenatal diagnosis centers. Search of aneuploidy, infection and cystic fibrosis was systematically proposed as well as an ultrasound monitoring.On 109 fetus addressed for isolate echogenic bowel five had other signs associated and 74 had a real isolated echogenic bowel (without dilatation, calcification, intrauterine growth restriction). In 30 cases, the EB was not found. Eighty-five percent of the patients had in the first trimester a screening for trisomy 21. None fetus with isolated EB had trisomy, infection or cystic fibrosis. One fetus died in utero and one newborn died of a metabolic disease without digestive repercussions.The risk of trisomy 21 and the risk to have a serious disease appear low for the fetus with EB. It does not seem necessary to propose a systematic amniocentesis in case of isolated echogenic bowel.

To compare gestational age at birth and incidence of preterm birth inferior to 37 weeks of gestation (WG) in single pregnancies with either prolonged hospitalization, or early home discharge after arrested preterm labour.Management of preterm labour was changed in our public academic hospital because no evidence of benefits for prolonged hospitalization was found and because adverse effects related to long-term hospitalization were described. In this retrospective before-after study, we compare the attitude A (December 2006 to April 2008), a prolonged hospitalization until 32 or 34WG, with new attitude B (May 2008 to February 2010), an early discharge home if the cervical exam was unchanged since admission.A total of 140 patients were included: 70 in each group. Initial hospitalization stay was significantly shorter in Group B (respectively, 5.4±5.4 days and 11.4±12.1 days; P0.05). Preterm spontaneous delivery is 14 (20%) in group A and 21 (28.6%) in Group B (P0.05). Gestational ages at birth were 33(5/7) and 33(0/7) WG in groups A and B, respectively (P0.05). If we focus on patients who were discharged home in the two groups (women who did not deliver no matter the hospitalization length), the gestational age at birth (38(4/7) and 38WG; ns) and the prematurity rate inferior to 37WG (17.2% and 22.4%; ns) were statistically similar.This study suggests that shorter hospitalization does not decrease the delivery term, nor does it increase the premature delivery incidence.

The purpose of this study is to describe the diagnosis, the care and the prognosis of the fetuses with an antenataly diagnosed megacystis.Six year retrospective study about 46 cases of megacystis (26 diagnosed during 1st trimester; 14 during 2nd trimester; 9 during 3rd trimester) referred in the prenatal fetal medicine unit of the Femme-Mère-Enfant hospital in Lyon (France).The main aetiology is urethral occlusion, particularly for megacystis discovered during the 1st and the 2nd trimesters. Twenty-two terminations of pregnancy were performed (47.8%) and 6 pregnancies arrested spontaneously (13%). Eighteen children were born alive, but 2 died in neonatal period. Finally, 16 children survived (34.8%). Chromosomal abnormalities are frequent (22%).Antenatal discovery of a megacystis is a complex situation, and often of poor fetal prognosis. It requires a multidisciplinary approach to allow the concerned couple to be determined on the best care of this pregnancy.

"Colour code" was implemented in our labour and delivery room to facilitate communication between the different actors of emergency c-sections and, more specifically, to reduce the decision to delivery interval in crash c-sections called "red code". This study aims at evaluating "red colour" c-sections rate, emergency level and decision to delivery interval.Over a six-months-period, all "red code" c-sections have been independently reviewed by four experimented obstetricians, including two external from the department. For each c-section, they had to confirm or reject the indication for "red code" c-section. Decision to delivery interval was also collected.Thirty-eight "red code" c-sections were performed representing 2.3 % of all deliveries and 9.1 % of all c-sections. "Red code" c-section indications have been confirmed in 12 cases and rejected in 13 cases. Opinions were discordant in the 13 others cases. Mean decision to delivery interval was 10.8 minutes.In our department, defining emergency level by "colour code" is associated with a short decision to delivery interval in crash c-sections but also with a trivialization of this high-risk procedure. Indications should be restricted to avoid unjustified maternal and foetal complications.

Observational and retrospective study, from February 1, 2007 until February 29, 2008. All fetal versions cases in the Edouard-Herriot hospital's maternity have been studied.Seventy-eight cases were recorded: 19 were successful (24.4%) and 59 unsuccessful. Eighty-four per cent of fetus with success were born by vaginal delivery, and 16% by cesarean section. After unsuccessfully version, 11 women (19%) have vaginal delivery (nine breech presentations). There were no differences in the version's result in front of parity, gestational age, operator, placental location and amniotic fluid index.Low success rate seems to be related to inadapted tocolytic. A follow-up study concerning the type of tocolyse would be interesting to bring to light a possible improvement. The small number of cases not having allowed to obtain significant results, study with large scale would be also necessary before envisaging a modification of the service protocol.

Fetal monitoring during labour aims to identify fetal acidosis responsible for brain lesions or perpartum death. In France, continuous recording of fetal heart rate (FHR) is largely used during labour. However, FHR interpretation remains difficult, as no specific sign for fetal hypoxia or acidosis have been described. Fetal heart rate is regulated by the autonomous nervous system including the chemoreflex, the baroreflex and the central nervous system. Appropriate regulation is conditioned by tissue oxygenation. Therefore, basal FHR physiologic instability is reduced when fetal hypoxia or acidosis occur, leading to reduce variability. FHR decelerations are frequent during labour due to either fetal response to physiologic modification of oxygenation during labour or fetal hypoxia, which should be differentiated in order to avoid inappropriate intervention. Knowledge of physiologic mechanisms involved in FHR regulation and fetal haemodynamic adaptation to hypoxia could help in learning FHR interpretation. This review is exposing the factors regulating FHR and the mechanisms involved in fetal circulatory responses to hypoxia and acidosis.

In 2006, the Ministry of Health issued a legal text relating to organization of maternal transports: "By the end of the year 2008, transfers of women and new-born babies will have to be treated in a centralized way", have to provide a 24 hours service and can take several forms such as a regional transfer center, working for several perinatal network or a simple hotline within the level 3 maternity hospital of the perinatal network and would be managed by efficiently trained professionals. In order to help professionals to choose between various types of organizations, we considered to evaluate their degree of satisfaction with the Rhône-Alpes regional hotline center.A postal survey was carried out 15 months after the creation of the regional hotline center to the 146 obstetricians and neonatologists of the perinatal network. Eight questions dealt with the following points: organization of in utero transfers and retransfers for obstetricians on the one hand, and the organization of neonatal transfers and retransfers for pediatricians on the other hand.Moreover, several questions relating to the communication quality and the global transport organization were asked to all of these professionals. Finally, practitioners were asked whether the regional hotline center should carry on its activity or not.The response rate was 51%. Seventy-two percent of practitioners considered the regional hotline center improved the communication between professionals. 66,7% thought that it improved the organization of transport. Obstetricians get benefits in 91,7% of in utero transfers and in 63,8% of retransfers. Neonatologists get benefits in 92,3% of new born babies' transfers and in 53,8% of retransfers. Finally, 85,3% of the doctors felt that the regional hotline center was time saving and 96% of them felt that this structure should carry on its activity.In the French Rhône-Alpes region, most obstetricians and pediatricians are satisfied by a regional hotline center dedicated to in utero as well as neonate transfer.

Ogilvie's syndrome is a rare postsurgical complication. The high mortality rate (normally 15 to 31% and up to 45% after caecal perforation) explains the seriousness of this clinical situation. The early diagnosis is made by plain abdominal X-ray. Conservative treatment is usually effective and surgery should be reserved for complicated cases or refractory to conservative treatment. We report a case of Ogilvie's syndrome after cesarean section, which has been treated by conservative methods.

Preterm labour diagnosis rely on clinical arguments exhibiting low positive predictive values. Discrimination between uterine contractions leading to preterm delivery and physiologic uterine activity increase throughout pregnancy and remains difficult. Uterine electrical activity can be recorded non-invasively from the abdominal wall and could help in the diagnosis of preterm labour. Electrical signal characteristics are reflecting myometrial cells electrical properties which are varying throughout pregnancy and labour. During pregnancy, uterine electrical activity is very low. During term and preterm labour, uterine electrical activity increases as well as mechanical activity. Bursts become regular with high amplitude. Spectral analysis demonstrates an increase in the frequency content, as represented by the shift of the burst power density spectrum peak frequency from low to high frequencies. Consequently, the electromyogram signal reflects myometrial excitability and allows differentiating powerful uterine contractions leading to delivery from uterine physiologic activity. Moreover, electromyogram signal modifications occur before any increase in mechanical activity in the pregnant rats, allowing identification of preterm labour earlier than uterine mechanical activity measured by intrauterine pressure. Two studies performed in women present with preterm contractions are supporting the potential interest of the uterine electromyogram recording to help in the diagnosis of preterm labour; but further investigations are necessary.

This study aims to describe the organization that was implemented at the Rhône-Alpes perinatal hotline, as well as to describe in utero transfer and neonate transport from an epidemiological point of view.A cohort study was performed between January 2003 and December 2004. Every in utero transfer and neonate transport was included. Transfers performed in 2003 were compared to transfers performed in 2004. Three endpoints were defined: the rate of in utero transfer (number of in utero transfers/number of in utero transfers + number of neonatal transfers), the rate of transfer toward level II units (number of transfers from level I to level II/number of transfers from level I to level II + number of transfers from level I to level III) as well as the rate of intra network transfer (number of intra network transfers/number of intra network transfers + number of extra network transfers).In 2003, 865 in utero transfers (IUT) and 1297 neonate transports (NT) were performed, in 2004 848 IUT and 1069 NT were performed. The rate of in utero transfer significantly increased from 40 to 44.2% in 2004 (865/2162 versus 848/1917, p = 0.007). The rate of transfer toward level II units increased for the mothers from 31.8% to 36.9% (177/557 versus 174/471, p = 0.09) and significantly increased for the neonates from 43.2 to 51.6% in 2004 (335/775 versus 327/633, p = 0.002). Finally the rate of intra network transfer has not significantly changed: for the IUT it decreased from 87 to 86% (755/865 versus 732/848, p = 0.59) and for the NT from 91% to 90% (1179/1297 versus 963/1069, p = 0.45).The organization that was implemented allows not only a safe 24 hour on call management of maternal transfers as well as neonate transport, but also a precise knowledge of epidemiologic indications relative to perinatal transfer.

The Marfan's syndrome is an autosomal dominant genetic disorder resulting in a diminished strength of connective tissue. The ocular, skeletal and cardiovascular systems are mostly at risk. Principal complications of the disease are aortic dilatation and the risk of acute dissection. Pregnancy increases this risk. Based on the experience of our obstetrics department and after reviewing medical literature, we have tried to establish guidelines for obstetric care adapted to pregnant patients affected by Marfan's syndrome. Women with aortic root40 mm should avoid pregnancy. In all cases B-adrenergic receptor blockers must be used as soon as possible. Because there is a 50% risk that offspring will inherit the syndrome, prenatal diagnosis should be suggested. In addition to usual pregnancy monitoring, echocardiography should be performed every 3 months as well as 2 months after delivery. No increase of obstetrical complications has been shown in these patients. Route of delivery also depends on the diameter of the aortic root: vaginal delivery is warranted if the aortic root is40; cesarean section should be performed in the other cases. Thus, with appropriate supervision, women with Marfan's syndrome will tolerate pregnancy without any adverse effect.

Laparoscopic adjustable gastric banding and pregnancy.We intend to understand the interactions between pregnancy and laparoscopic adjustable gastric banding in order to ensure better care for patients.We undertake an observation retrospective study, from January 2004 to December 2005, at Edouard Herriot hospital, of births from women with laparoscopic adjustable gastric banding with a study of gastric banding interaction with pregnancy, neonatal outcomes and postpartum; we read through literature.We studied 35 pregnancies from women with a gastric banding out of 5773 pregnancies (0.6%); we noted lower obstetrical complications with loss of weight that we attributed to the gastric banding comparing with the pregnancies before the gastric banding: three hypertensive diseases and one gestational diabetes had been avoided; we observed a complication due to the gastric banding: occlusive syndrome, which implied gastric banding calibration during immediate postpartum.Our record folders are in accordance with literature and confirm improvement in obstetrical prognostic. Waiting for stabilization of weight is recommended before starting a pregnancy after gastric banding surgery; the adjustment of the gastric banding during pregnancy must be undertaken individually according to symptoms (vomiting, gain of weight...).

We report here the first published case of twin pregnancy in a woman with cystic fibrosis. This situation will become more and more common because the increased life expectancy of patients with cystic fibrosis and the development of medically assisted procreation. Conception of this twin pregnancy was medically assisted in a cystic fibrosis woman with moderate pulmonary disease. This observation is in accordance with several recent reports dealing with single pregnancies: morbidity, mortality and degradation of lung function have not been found to increase. The only effect of cystic fibrosis on pregnancy is an increased risk of preterm delivery. There is thus no systematic contraindication to pregnancy among women with cystic fibrosis provided that they are given attentive care by a multidisciplinary team. Genetic counselling and prenatal diagnosis also have an important role to play.

Prenatal diagnosis of a limb reduction defect poses difficult medical and ethical problems. Prenatal diagnosis can be at the origin of two opposing medical attitudes, either a medical termination of pregnancy, or the specific management of the child at birth. The objective is to carry out an enquiry of practices and to determine whether there is a threshold in the gravity of the malformation from which the medical termination of pregnancy is accepted.The study was carried out by a questionnaire addressed to the members of the French-speaking Club of Fetal Medicine.Outcome of 103 fetuses with limb reduction defect was described. Prenatal diagnosis and management of observed malformations were explained.Decisions concerning the outcome of the pregnancy are very variable from one couple to another and from one medical team to another. Parents making a request must be given complete information and accompanying psychological support. Collegial with a multidisciplinary team is necessary. For the parents, it is the physician's duty to avoid judgement errors related to anxiety and ignorance of the medical consequences. The physician should guide the parents towards the continuation of the pregnancy or its interruption. The proper decision proceeds from the reunion of the confidence of the couple and the conscience of the physician.

Preterm labor is one of the major causes of concern for level I and II obstetricians. The purpose of this study was to determine the incidence of in utero transfer performed for preterm labor. We also aimed to evaluate the algorithm we used in case of call for preterm labor. This algorithm allowed us to study the rate of endovaginal sonography use prior to in utero transfer, to calculate its predictive value and to evaluate the risk of delivery during transfer.We conducted an 8-months prospective study of all calls for preterm labor received at a regional call center in France (EU). All obstetrical data were entered in a computerized anonymous database. Three months after the first call midwives collected data from the receiving hospital.Calls for preterm labor account for 40% of calls for in utero transfer. Two hundred and sixty-five calls have been received for preterm labor; among them 50 cases were associated with a preterm rupture of membrane, a maternal or fetal pathology and 14 cases were lost for follow-up. Those 64 cases were excluded leaving 201 cases for analysis. Twenty-eight had a cervix dilated 4 cm, or more, while 173 had a cervix dilated less than 4 cm. Fifty percent of woman that had a cervical dilatation of 4 cm or more delivered more than 4 h after the call. Among the 173 patients that had a cervix dilated less than 4 cm, 71% had not delivered 7 days after the hotline call and 26% had an endovaginal ultrasonography performed before the transfer. None of the women that had a cervical length longer than 27 mm delivered in the 7 following days. None of the 176 women that were transferred delivered during the transfer.In utero transfer for preterm labor is the leading cause of in utero transfer. Endovaginal ultrasonography prior to transfer should be performed in order to avoid unnecessary transfer. Women who have a preterm labor with a cervical dilatation of 4 cm or more are not an absolute contra-indication to in utero transfer. In those cases the transfer indication should be discussed on a case-to-case basis including the actual term and the distance between hospitals.

To assess the consequences for the fetus of maternal toxoplasma infection acquired during the first 8 weeks of gestation and to set guidelines on how to manage these maternal infections.Data were prospectively analyzed on 360 pregnancies followed-up in our department due to a toxoplasma infection during the 8 first weeks of pregnancy. Estimates of the risk of fetal infection were based on all cases, including those which could not be followed up until infection was ruled out or confirmed. Severity of infection was estimated based on ultrasound findings during pregnancy, neonatal and long-term postnatal clinical, neurological and ophthalmologic work up.Out of the 360 included women, 336 gave birth to a live born child: 7 (2%) were infected, 302 (90%) were free of infection and follow-up was insufficient to conclude about the 27 (8%) remaining infants. The estimated risk of fetal infection ranged between 2 and 10% based on live born children and between 3 and 14% when the 24 interrupted pregnancies were included. At their last clinical evaluation at 70 months of age, all 7 children, including the 2 who had inactive peripheral eye lesions and the one who had a unique intracranial calcification were free of any ophthalmologic or neurological impairment.Our study confirms that in the event of a maternal infection during the first 8 weeks of pregnancy the risk of fetal infection is low and results mainly in a spontaneous termination of pregnancy. Future parents should be assured that conversely to a common opinion, the prognosis of congenital toxoplasmosis in live-born children is good. For these early maternal infections as for those acquired later, we recommend immediate treatment with spiramycin, monthly ultrasound surveillance, amniocentesis and treatment with pyrimethamine and sulphamides if the PCR is positive. Abortion should be restricted to cases with ultrasound lesions

Obstetrical management of women known to have a cerebral vascular malformation is controversial. The risk of cerebral hemorrhage during pregnancy is difficult to assess. We report thirteen cases of pregnancy in women with known cerebral vascular malformations who had or had not undergone surgical treatment. The effect of pregnancy on these malformations and corresponding obstetrical care described in the literature were studied. Our conclusion is that the risk of bleeding from cerebral arteriovenous malformations is not significantly increased during pregnancy whereas the risk of cerebral hemorrhage is slightly increased at the end of pregnancy, but unchanged during labor and delivery, in women with arterial aneurysms. There is no reason to advise against pregnancy in most cases and vaginal delivery is often possible unless there is a risk of dystocia.

In the past few years, many international publications have reported important improvements in the cesarean section procedure. Considering these improvements, M STARK suggests a new technique for the cesarean section which is calledMigav-Ladach method(=ML). To assess feasibility and efficiency of this technique the authors conducted a prospective randomised study for 4 months including all cesarean sections and compared the ML technique with the classical Pfannenstiel are. The following criteria were noted for each woman. Results showed the superiority of the M.L. technique especially with regard to the length of duration of the post-operative fever and the parietal blood collection, where difference is significant. Regarding the blood loss rate, the post-operation pain, the delay before gas and the duration of the hospitalisation period the M.L. technique seems to be better although the difference is not very significant statistically. Following this study and the international literature survey, authors conclude that the M. L technique is so much better than the pfannenstiel technique that it must be used throughout daily obstetrical practice.

To evaluate the prognostic value of colour pulsed Doppler in a prospective study of pelvic masses comparing resistance index, serum CA 125 and echographic findings with histology results.A prospective study included 91 patients examined at the Gynaecology-Obstetrics unit at the Croix-Rousse Hospital. Pelvic masses were classified as benign or malignant tumours on the basis of echography findings. Serum CA 125 was assayed before surgery; malignancy was suspected for levels above 35 IU/ml. A colour pulsed Doppler examination was performed at the same time as the echography. Tumours were classed as vascular or non-vascular. A resistance indexor = 0.5 was considered pathological. The sensitivity and specificity of each examination were determined. The ROC method was used to determine best threshold level for the resistance index. Finally, the performance of the 3 tests was analyzed with the Metha algorithm. All patients underwent exeresis of the pelvic mass. The pathology report was taken as the definitive diagnosis.A total of 80 benign masses were analyzed. Thirty percent of them had a vascularization detectable with colour pulsed Doppler. One case of dermoid cyst has a resistance index below 0.5. Echography gave doubtful results in 6 cases and CA 125 was higher than 35 in 9. There were 10 cancers of the ovary and 1 borderline tumour. Four had a resistance index above 0.5, but the operator reported a hypervascular tumour in all cases. Three of these tumours had been classified as benign after echography and CA 125 was35 IU in 4. The mean resistance index for benign tumours was 0.71 compared with 0.41 for malignant tumours. The sensitivity of colour pulsed Doppler was 0.66 with a specificity of 0.99 when the resistance index was below 0.5. For an index considered to be pathological; below 0.76, the sensitivity was 100% and the specificity 85%.Colour pulsed Doppler gives valuable pre-operative information on ovarian masses. Its performance is as least as good as CA 125 assay or echography.

Evaluate the reliability, safety and performance of hysterosonographic assessment of the uterine cavity.Hysterosonography was performed in 220 patients with injection of sterile saline into the uterine with a novel catheter. Among these patients, 132 patients then underwent a hysteroscopy or hysterectomy with a histology examination.There were 8 failures: 2 synechiae, 3 atresias of the cervix, and massive reflux in 3 cases. No other complication occurring. Hysterosonography appeared to give more information on the uterine cavity than standard vaginal sonography. In cases with metrorrhage before menopause, the diagnosis was correct in 75.4% of the cases. Errors were related to confusion between polyp and hyperplasia. In post-menopausal metrorrhagia, there was 92% agreement between sonography and histological results. Agreement was 86.3% in cases of infertility.Hysterosonography using saline solution injected with a novel catheter can be an excellent means of evaluating the uterine cavity and can completely replace classical hysterography, thus avoiding many exploratory hysterocopies.

Pulsed colour-Doppler imaging in the latest development in transvaginal sonography. Our objective is to study the uterine and ovarian perfusion during the menstrual cycle in normal fertile conditions. We studied 11 healthy volunteer women free of hormonal treatment. All studies were performed by the same operator, with the same sonograph. Measurements are made in the uterine arteries and their branches (arcuate, radial, spiral arteries) and in the ovarian vessels. The resistance index of Pourcelot (RI = [sequence: see text]) is used as reference. The statistic test is the non-parametric test of Kruskall-Wallis. The uterine and ovarian vascularization varied greatly during the menstrual cycle. Blood flow increased significantly in the luteal phase in the uterine arteries and their branches even in the active ovarian arteries. So, in the uterine artery, the RI was 0.43 in the follicular phase, 0.50 during the ovulatory peak, and 0.41 in the luteal phase. These variations were significant (p = 0.04). These results were the same all along the uterine artery. In the acurate arteries, the RI was respectively 0.75, 0.93, 0.72 at the same time of the menstrual cycle (p = 0.04). In an anovulatory cycle, blood flow remained unchanged and the arterial compliance remained stable. Quick and reproductible blood flow measurements are possible with transvaginal colour-Doppler. Millimetric vessels such as arcuate, radial and spiral arteries can be studied. This non-invasive technology can be used as a part of routine work in the management of infertility.

In order to try to understand and treat efficiently pathology in the human pregnant woman the authors have carried out experimental work on animals. Twenty four pregnant ewes with a single fetus were operated on in the last trimester of pregnancy. Fetal distress was provoked by injecting microspheres into the aorta beneath the renal arteries via the femoral route. The first results in terms of survival, by chemical and Doppler measurements were very encouraging. The operation itself was not a significantly disturbing factor, but the injection of microspheres did cause fetal distress. This experiment should be continued.

Endocavity ultrasound during the first three months of pregnancy provides greater detail in a number of obstetrical fields. In most cases, endocavitary ultrasound is not simply a way of "gaining time" in comparison with conventional transabdominal ultrasound (time saved estimated to be one week). In some cases it is also offers a definite "extra". Two areas of interest are focussed on particularly by the authors: 1) the fetal appendages (vitelline sac, membranes, extra-embryonic coelom, trophoblast) which may be detected or revealed in greater detail by endovaginal ultrasound, make it possible to get a picture of the embryology of the fetus and of the prognosis of the pregnancy. The combination of color coded Doppler corroborates this new approach to the fetus; 2) the developments of this "sono-embryology" makes it possible to identify certain fetal malformations at a very early stage (neuro-medullary, parietal malformations...). However, interpreting the morphology of the fetus examined during the first three months must remain prudent and is no substitute for the morphological ultrasound scan carried out at about four and one half months of pregnancy.

The diagnostic and prognostic value of Doppler velocimetry in delayed intrauterine growth was investigated in a series of 105 abnormal pregnancies. The diagnostic value of the umbilical Doppler velocimetry, whether alone or combined with simultaneous exploration of the umbilical and cerebral vessels was very limited. In contrast, the simultaneous exploration of the umbilical and cerebral vessels was of considerable prognostic value, since with regard to the risk of fetal distress, the sensitivity was 86.6%, the specificity 80% and the positive predictive value 63%. The negative predictive value was 95% and the prevalence 28.5%. The authors' experience also confirms the prognostic seriousness of the absence of diastolic flow or of reverse flow (2 perinatal deaths out of 6 cases). The interval between the changes in Doppler velocimetry and fetal distress is variable, however, ranging from two days to three weeks or more in these cases.

Eighty non-menopausal patients who had troubles of menorrhagia or metrorrhagia who were neither pregnant nor had cervical pathology, were investigated first by vaginal ultrasound and then by hysteroscopy. In 43 of the cases a hysterosalpingogram had been carried out before hand. All patients had histological examination of tissues. The main pathological ultrasound features were clearly made out. Vaginal ultrasound, and the conditions under which the study was undertaken, gives much more information than hysterosalpingography and will be able in future to a greater extent, to replace conventional radiography. Vaginal ultrasound manages to achieve information about the endometrium and the uterine cavity almost equal to that obtained by hysteroscopy and furthermore it gives more precise information about the state of the myometrium. Vaginal ultrasound therefore seems to be an excellent first stage examination to investigate menstrual disturbances in reproductive life, and so long as it is carried out under good conditions will limit the indications for hysteroscopy and will be able to indicate when it is necessary to carry out simple exploratory hysteroscopy or operative hysteroscopy.

The synthesis pathways for prostaglandins (PG) are derived from membrane phospholipids via arachidonic acid. The prostaglandins are the most active substances in inducing maturation of the cervix. They include PGF2 alpha which induces contractions of the uterine muscle and PGE2, which is active on the cervical connecting tissue with no effect on the body. The authors recall the role of the prostaglandins in triggering the spontaneous onset of labour, and suggest the use of PGE2 in the artificial induction of labour. PGE2 can be administered by local or systemic route. The authors report their personal experience with cervical maturation in a retrospective study covering a wide range of clinical circumstances. A prospective study in cases of premature rupture of the membranes, already reported, concludes that labour is induced earlier in a population receiving PGE2 than in a control population. The authors then discuss the literature data and stress the possible use of PGF2 alpha. To conclude, if prostaglandin-induced maturation appears to be more effective, it is nonetheless not the ideal method in view of the side effects and concomitant effects on uterine labour and the cervix. This method has the advantage of being usable in difficult cases.

The authors carried out a combined study using Doppler Flow Studies of the umbilical and fetal anterior cerebral arteries in 26 pregnancies which were complicated by maternal hypertension. Using the ratio between the cerebral and the umbilical blood flow it may be possible to diagnose intra-uterine growth retardation more accurately than using classical measurements. An inversion of the ratio between the cerebral and the umbilical flows has a great prognostic value with a sensibility of 91.6%, a specificity of 87.5% and a positive predictive value of 84.6% with a negative predictive value of 93.13%. There may however quite often be a lengthy interval of time between the appearance of change in the ratio and the appearance of fetal distress, so that this sign can only be one indication for delivery of the fetus.

First the authors recall the synthesis cycles of prostaglandins and the main physiological effects of the latter. Taking into account these effects, antiprostaglandins can be used in two obstetrical pathologies: the threat of premature labour, the delayed intra-uterine development with or without toxaemia. In the particular case of the threat of premature labour, the authors report a certain number of clinical observations concerning non-steroidal anti-inflammatory drugs and namely indometacin, showing the efficacy of the treatment. They also evoke the complications of this therapy where the stenosis of the arterial canal and its repercussion on the renal function predominate. They conclude with some practical advice. In the particular case of delayed intra-uterine development with or without toxaemia, the authors put forward some physiopathological arguments leading to the use of the combination Aspirin/Dipyridamole. They report the results of their personal experience. Out of 52 cases taking platelet aggregation inhibitors, 43 are linked with an obstetrical pathology and amongst them, 86 p. cent have a pathological past record (severe toxaemia, isolated DIUD, DIUD + toxaemia, IUFD). In the great majority of cases, treatment was administered before 20 WA. The pregnancy progressed normally in 76 p. cent of the cases and all the pathologies observed were minor. No serious complications have been reported. The average term of pregnancy is of 38 WA with an average growth weight of 2,920 g. The efficacy seems better if the past record is a DIUD rather than a toxaemia. The authors then compare their results with the literature data.(ABSTRACT TRUNCATED AT 250 WORDS)

Ultrasound diagnosis of a fetal visceral malformation raises many questions concerning both medical and ethical aspects. Are there associated malformations or chromosomal anomalies? Is the malformation compatible with life. What will be the quality of survival after birth? Is there efficient surgical treatment? Is it possible to maintain the pregnancy until term or must we consider a premature delivery or an interruption of pregnancy? The decisions are difficult and they necessitate co-operation between the different specialists involved with the antenatal and immediate postnatal care of the fetus. In this paper the authors analyse the various situations that may be encountered depending upon the type of digestive, pulmonary or urinary tract fetal abnormality (cardiac or cerebral malformations have been excluded).

The authors report a case of pregnancy in a patient suffering from moderately severe cystic fibrosis (the syndrome consisted of diffused obstruction in respiratory function with a vital capacity of 79% and the lowered blood oxygen level with arterial blood gas estimations; oxygen saturation was 94%). The condition was marked by temporary worsening during the pregnancy in which infective bronchitis supervened). She also threatened to go into early labour and did in fact deliver at 36 1/2 weeks of an infant which was normal for the duration of the maturity. The authors review previous known facts about cystic fibrosis. A study of the literature has made it possible to be more accurate in describing methods of ante natal diagnosis of the condition and ways of following the pregnancy and the illness as well as the woman's fertility and her ability to breast feed.

Severe chronic respiratory distress accompanied by pregnancy is not rare. It means that the fetus is at risk of being born prematurely and with intra-uterine growth retardation and the mother, apart from the obstetric complications that she is likely to suffer, has the chance of becoming decompensated as far as her cardiac and respiratory systems are concerned. There is therefore a very real need for assisted respiration. The authors report a case of chronic severe restrictive respiratory function and pregnancy in which the outcome was successful for the mother and for the fetus but where the mother had to be ventilated by a new procedure. This consisted of intermittent positive pressure ventilation using a nasal mask at home. The efficiency of this method has been proven and it is a method that must be preferable to tracheotomy.

Protein C is a protein found in the serum, dependent on vitamin K. It is a strong protection against venous thrombosis. Deficiency in protein C, whether constitutional or acquired, can give rise to thrombo-embolic accidents in young patients without any obvious triggering factor. The authors start by describing the physiological features of protein C. Deficiencies of this protein are transferred through a dominant autosome. Two cases are described where protein C deficiency occurred in pregnancy. This association has not been previously described. They then discuss the kinetics of protein C in pregnancy, at delivery and in the newborn. They then point out how important it is to treat with anticoagulants in prophylactic doses during the pregnancy. They use repeated doses of Heparin as an anticoagulant and for its antivitamin K action following the delivery. They give a list of precautions that have to be observed in this relay system which should be slow and carefully worked out later. Obstetrical observation has to look for the onset of pre-eclampsia and intra-uterine growth retardation due to placental microthrombi. The authors conclude, after pointing out the frequency and the seriousness of this condition, by proposing that it should systematically be looked for in families where there have been cases of thrombo-embolic accidents.

Doppler pulses or continuous flow in the umbilical artery is a technique recently used in practical obstetrics and of value particularly in screening at risk pregnancies. The authors wish to study its value as a diagnostic and prognostic tool in the special cases where ultrasound has given rise to a suggestion that there may be intra-uterine growth retardation (I.U.G.R.). In a preliminary publication they report their experience in 100 normal pregnancies so that they have obtained a control diagram. Then, working on a population of 117 pregnancies with ultrasonically diagnosed I.U.G.R. they studied the birth-weight, the early neonatal morbidity and the neonatal mortality as a function of the Pourcelot S - D/S index. They were able to separate out 63 cases of I.U.G.R. without any hypertension and 54 cases associated with hypertension. They analyse the same parameters. They then discuss first the value of the diagram they have made in comparison with other known curves, also the diagnostic and prognostic performance of the method. They conclude that there is a moderate diagnostic value in Doppler velocimetry. The prognostic value is much better because the Doppler can differentiate those case of slow growth that are going to do well against those that are going to do badly.

A thread which is absorbed slowly and which has a polyglycolic acid base has been used since 1975 in the Sainte-Foy-les-Lyon Maternity Unit to sew up episiotomies and perineal tears. The authors had 98.70 p. 100 of excellent results out of 1082 cases from the anatomic, aesthetic and functional angle. This technique appears to be a useful one in early mobilisation in obstetrics.

Doppler assessment has become the fashion in obstetric screening at present and this is absolutely justified in view of the quality of the information that is obtained. The authors have tried to assess the two methods of analysing the blood flow through the umbilical artery by using pulsed Doppler and continuous Doppler techniques. They have used a fairly new statistical method (differential). The authors have found that the methods are interchangeable. They did this on 32 patients who on the same day had pulsed and continuous Doppler tests and they used Pourcelot's placental resistance technique. These observations show that consistent diagrams which are equivalent to one another are obtained by the two methods and they can be used economically.

The authors start with an anatomical description which makes it possible to distinguish from one another septate, bicornuate unicornuate and pseudo-cornuate uteri. The diagnosis is often suggested by the clinical features and is made by using complementary examinations such as ultrasound, hysterography, hysteroscopy and laparoscopy. Although it is difficult to be sure of the incidence of the condition it is thought to be around 1%. In the 10 years from 1978 to 1987 the authors have studied 296 pregnancies occurring in 109 patients who were not operated on and 34 pregnancies occurring in 21 patients who had plastic operations on their uteri. They show that the condition has an effect at all stages of pregnancy and delivery and in the first category of patients (abortion in 38%, extra-uterine pregnancy in 8%, prematurity, pre-eclampsia and malpresentation in 28%, with a high rate for caesarean section in 37%). The prognosis was quite different in patients who had been operated on. The published literature confirms these findings. The authors discuss the different ways of carrying out surgical treatment (simple section or excision of the septum, or Bret-Palmer's plastic operation on the uterus with treatment of the associated vaginal abnormalities), plus the medical treatment (with rest and the use of vasodilatators and drugs for anti-platelet aggregation) to be used during the pregnancy. They conclude that it is necessary to make a diagnosis of what type of malformation is present, to decide which surgical procedures to carry out as this does improve the prognosis greatly.

There are few cases of chronic renal deficiency associated with pregnancy for the following reasons: lowered fertility, a high level of spontaneous early abortions and unwillingness of doctors to allow such pregnancies to continue. The authors report their personal experience of three cases with different outcomes: one, delivery nearly at term, one premature delivery without complications and one premature delivery with neonatal death. The authors, having studied the literature, point out that there are different problems, on the one hand because od kidney conditions requiring more frequent dialysis and on the other hand the obstetrical conditions and in particular high blood pressure with its risk of premature delivery, and finally of intrauterine growth retardation. Finally, the authors point out how important it is to have effective contraception and, if pregnancy does occur, how important it is for the nephrologist, the obstetrician and the paediatrician to cooperate in the care of the patients.