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We report two cases of maternal diaphragmatic hernia during pregnancy. Diaphragmatic hernia is an unusual and severe disease. Maternal and fetal prognosis are threatened. Diagnosis is uncertain when confronted to respiratory and digestive symptoms without any specificity. The chest X ray is the first exam to perform. The objective of this work is to discuss the management of such a pathology in terms of ways of delivery and surgical cure of hernia.

To investigate the frequency of main symptoms of Obstructive Sleep Apnea Syndrom (OSAS) and their relationship with Pregnancy Induced-Hypertension (PIH) as well as Intrauterine Growth Retardation (IGR) as suggested by recent studies.Four hundred (and) thirty-eight enquiry forms completed during post-partum period were analysed, after exclusion of multiple pregnancies. Collected data were demographic characteristics, obstetrical events, sleep disorders during last trimester, screening of snoring and vigilance troubles with an Epworth score.Forty-five percentages of the patients reported to have habitual snoring during pregnancy. Among these, 85% were non-snorers before pregnancy. Daytime somnolence concerned 84,5% of the population with an Epworth score significatively increased (P0,0001). The prevalence of PIH was found to be 4,5%, with two apparently independent risk factors: the body mass index (OR=1,1) and an association between snoring and increased vigilance trouble (OR=2,6). No statistical difference was found concerning IGR.SAS symptoms are frequent during pregnancy and snoring appears to be linked with PIH. However, polysomnographic data are not yet sufficient to explain pathophysiological mechanisms and find relevant diagnostic markers during pregnancy.

To show that intrapartum prophylactic amnioinfusion in case of oligohydramnios or particulate meconium-stained amniotic fluid could be beneficial.From March 1st, 1993 until December 31st, 1996, 6845 women were delivered at the University Hospital of Poitiers. Patients presenting with oligohydramnios (G1) (118 patients with an amniotic fluid index below 5 cm) or a particulate meconium-stained amniotic fluid (G2)(77 patients) were included. Each group was compared with a historical control group constituted retrospectively according to the following criteria: oligohydramnios (CG1), particulate meconium-stained amniotic fluid (CG2)), age, parity, gestational age, and duration of labor. Statistical analysis was performed using the Student's t test and the Fisher's exact test when appropriate with a level of significance of p0.05.The mean infused volume was 883 ml in G1 and 751 ml in G2. A significant difference was found in terms of cesarean section between G1 and CG1 (14% versus 25%, p0.05) and of assisted deliveries for fetal distress between G2 and CG2 (5% versus 18%, p0.02). No other significant difference was found between the study groups and their control for all other studied criteria. When considering more specifically the presence of meconium below the vocal cords we also find a difference between G2 and CG2 (5% versus 14%) which was not significant. No neonatal or maternal adverse effects happened in this short study.Amnioinfusion is easy to perform during labor in case of oligohydramnios or particulate meconium-stained amniotic fluid. In case of oligohydramnios, a decreased rate of cesarean sections has been observed in the infused group. Considering patients with particulate meconium-stained amniotic fluid, less interventions for fetal distress and neonates with meconium below the vocal cords has been found in the infused group. Further prospective evaluation is needed to confirm these results in case of particulate meconium-stained amniotic fluid and to compare the advantage of prophylactic versus therapeutic amnioinfusion performed in case of oligohydramnios and abnormal fetal heart rate.

To verify the importance of a wait-and-see attitude after premature rupture of the membranes before 34 weeks of amenorrhoea when allowed by the initial physical examination and of an intervening attitude after 34 weeks.A prospective study included 218 cases of premature ruptures of the membranes divided into four groups according to the weeks of amenorrhoea: Group 1, before 32 weeks (n = 11); Group 2, between 32 and 34 weeks (n = 26); Group 3, between 34 and 37 weeks (n = 18); Group 4 after 37 weeks (n = 163).Before 34 weeks of amenorrhoea, the frequency of premature rupture of the membranes was 0.72%, of germ-positive infants 8% and of infected infants, 11%. Perinatal mortality was 80% and 17.4% of the infants were delivered by cesarian section. Labour was induced in 100 cases (46%), when there was evidence of infection, after a 24-hour waiting period or at 34 weeks of amenorrhoea. When the aspect of the cervix was unfavourable, cervical maturation was induced by intravenous injection of prostaglandins in 75 cases (34%).When the rupture occurred before 34 weeks of amenorrhoea and without signs of infection, tocolysis should be entertained. From 28 to 34 weeks and when a favourable outcome is expected, maturation by corticoids can be proposed. When chorio-amniotic infection is suspected and is not confirmed by the laboratory, antibiotic prophylaxy does not appear to improve fetal outcome. The beneficial effect of a conservative wait-and-see attitude before 34 weeks and of intervening thereafter can only be demonstrated with a large randomized study. Thus each case must be managed individually, making it difficult to establish a standard recommended attitude.

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

This comparative study carried out on 550 patients has made it possible for us to show how valuable prophylactic antibiotic therapy is when certain intra-uterine manipulations (such as forceps delivery, manual removal of the placenta or exploration of the cavity of the uterus) are carried out during vaginal delivery. Furthermore, we have been able to show that there are certain risk factors of which the most important are premature rupture of the membranes, infected liquor, birth weight of the infant less than 2,500 g and epidural analgesia. The financial study has shown that it is cheaper to use prophylactic antibiotics when the comparison is made with the cost of treating complications of infection associated with these intra-uterine procedures.

A total of 168 out of 196 pregnancies that were obtained after A.I.D. have been followed up. Six cases were lost for follow-up (3%). The mean age was 30 years and 65% of the women had their ovulation induced. 130 nullipara were delivered. They were compared with a series of nullipara of the same age group and selected from 300 primiparous pregnancies who delivered in the department in the same year. The abortion rate was 12.5%. 79% of the pregnancies were normal in the 2nd and 3rd trimesters as compared with 83% in the control series. 94% delivered at term as compared with 97% in the control series. 21% of the women had Caesarean section as compared with 19.2% in the control series. The sex ratio was 1.08 as compared with 1.06 in the control series. There was no significant difference between the two series. It does seem, however, that the age factor is the most important factor of all in determining how frequent pathological conditions will be and the number of Caesareans that will have to be carried out. 14% were under 30 years of age as compared with 28.5% who were over 30 years of age, which is a significant difference. These results should be followed up in a larger series.

Marfan's syndrome is a dominant autosome transmitted disease with different degrees of seriousness. When it is associated with pregnancy there is a considerable increase in the rate of cardio-vascular complications which are responsible for a serious rate of maternal mortality due to aortic dissection. It is therefore very important that the patient, before starting a pregnancy, should be examined very carefully clinically and with ultrasound. A woman with dilatation of the aorta less then 40 mm as measured ultrasonically and who has no major clinical signs can start a pregnancy but even then she should be considered as a high risk case. In other cases therapeutic termination of pregnancy or prophylactic surgical treatment of the condition should be considered. Apart from the serious genetic risks (50%) the risks for the fetus are dominated by prematurity and by fetal death resulting from maternal death.

Although tumours of the ovary are rare in woman under the age of 35 they are not exceptional and they form 15 p. 100 of the cases (17 patients) out of a series of 112 tumours of the ovary which were collected in 7 years. 11 of these patients had only one ovary affected and were able to be treated conservatively. In this way 5 of them were able to carry one or more pregnancies to term and another patient who was lost from observation for two years had to have a second operation to deal with a recurrence in the opposite ovary. Conservative treatment is only permissible if one is absolutely sure that the contro-lateral ovary is normal, and if there is the slightest doubt ovariotomy should be carried out to perform a biopsy. Furthermore the authors suggest that in view of the difficulties of strict supervision for a long term the opposite ovary and tube should be removed and hysterectomy carried out once the patient has had one or two children or when they have reached the age of 40.Out of 112 ovarian tumors observed by the authors during a 7 year period, only 17, or 15%, were on women below 35. In 6 of these 17 cases total hysterectomy was necessary; in the remaining 11 cases only one ovary was affected by the tumor, so that it was possible to treat the disease with unilateral ovariectomy, allowing 5 patients to become pregnant. Conservative treatment by unilateral ovariectomy is advisable only in cases when the controlateral ovary is normal. Postoperatory surveillance of such cases is difficult and must go on for years; in cases where the patient is over 40 and has children the opposite ovary should also be removed.

Umbilical circulation can be explored by Doppler ultrasound methods very easily. The umbilical arteries spectrum provides information on the placental circulation. The diastolic flow is directly related to the vascular resistances of the placenta (Rp). In cases of pathological pregnancies with hypertension the decrease in the diastolic flow and the increase in the resistance index Rp have been correlated with intra-uterine fetal growth retardation. The specificity of this index Rp is of 95% but the sensitivity much more lower (approximately 70%). For that reason Doppler assessment of the fetal circulation in other areas has been recently carried out. Fetal cerebral arteries have been explored during normal pregnancies. The index of cerebral resistances as defined by Pourcelot Rc = S-D divided by S (with S systolic amplitude and D diastolic amplitude) show similar variations to the placental index but later in the pregnancy. During the pregnancy the cerebral index is higher than the placental one and the cerebro placental ratio (CPR) superior to 1. During pathological pregnancy (hypertension) with fetal growth retardation one of the index Rc or Rp may be out of the normal range but the cerebro placental ratio CPR is always lower than 1. The follow up of both the umbilical and cerebral circulation increases notably the accuracy of the Doppler method for the detection of intra-uterine fetal growth retardation.

The authors studied the literature for similar findings in order to try to classify the different types of pneumoperitoneum when they had a case of pneumoperitoneum of genital origin. They then went on to study the mechanism by which these rare cases of genital pneumoperitoneum occurred: the insufflation or aspiration of air through the tubes, tubal antiperistalsis and uterine or vaginal perforations. From the clinical angle it is essential to eliminate pneumoperitoneum secondary to perforation of a hollow organ, and then to look for signs of peritonitis which only occur in genital pneumoperitoneum due to uterine perforation. The case usually cures spontaneously but recurrences are not uncommon. If there are no signs of peritonitis expectant treatment should usually be undertaken.