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There have only been thirty cases of total post-partum hypopituitarism published in the literature and these have nearly all been secondary to Sheehan's syndrome. The authors report a case of partial anterior hypopituitarism associated with diabetes insipidus which arose after an uneventful Caesarean operation and the origin of which seems to lie in auto-immune hypophysitis. The authors first describe the morphological and endocrine changes that the hypophysis undergoes during pregnancy and then point out that auto-immune hypophysitis seems to have been only recently recognised. This can be used to explain some cases of post-partum hypophyseal insufficiency occurring almost silently without any history of third haemorrhage. Research has been made systematically for anti-hypophyseal antibodies and for specific antibodies of the organ, but has not always been positive. So the diagnosis of auto-immune hypophysitis is often made only after eliminating other reasons for it. A brief review of the physiopathological mechanisms of diabetes insipidus makes it possible to suggest that vasopressinase coming from the placenta together with prostaglandins could play a role.

We report our experience concerning the laparoscopic treatment of ectopic pregnancy (EP). One-hundred and nine women with EP were treated in our department over a 4 year period, between February 1988 (date of our first laparoscopic surgery for EP) and December 1991. Twenty-two of these women underwent laparotomy and the remaining 87 laparoscopic surgery alone. Four therapeutic failures were noted in women treated by laparoscopy. Our results are compared with those of other series and the indications, as well as the modalities of laparoscopic treatment are detailed. It is concluded that laparoscopic surgery of EP is a reliable method which must always be considered, except for a few rare indications.

The authors report a case of a patient who in the 24th week of a twin pregnancy became sero-positive for toxoplasmosis. This was diagnosed by cordocentesis as being infected, and the treatment was therefore started with pyrimethamine and sulfadiazine and folic acid at the 28th week of pregnancy. At 35 weeks, the patient had an acute medullary aplasia due to the absence of the folates. The mother's state was improved rapidly by giving her folinic acid and the twins were normal haematologically. In this case, the authors point out how important the folates are in a pregnancy, especially in twin pregnancies, and point out the precautions that have to be taken when treatment with pyrimethamine and sulfadiazine is started for congenital toxoplasmosis.

Aim: A review of the literature concerning the very rare anti-PP1Pk isoimmunisation with a personal case., Clinical Material: Anti-PP1k antibody gives rise to the high risk of abortion in the first and the second trimester (in a different series the risk is 50-70%). A 19-year-old patient who had this antibody was helped by a plasmaphoresis repeatedly between the 6th and the 25th week of pregnancy. Cordocentesis was carried out to estimate fetal haemoglobin from the 25th week onwards. A set caesarean section was carried out at 36 weeks because of intrauterine growth retardation and the development of fetal anaemia., Discussion: The authors suggest research based on the known immunohaematological factors concerned with this isoimmunisation and on the main treatments available (plasmaphoresis, cordocentesis, and delivery at a set time)., Conclusion: Until now there have been very few cases and only four similar cases to ours have been reported in the literature. That is why it is so difficult to suggest a well defined strategy for treating these patients.

Sevellar cellular types are involved together in the cyclical functioning of the ovary. Regulating this co-operation between cells are intercellular systems of communication both autocrine and paracrine. The immune system that is present in the ovary seems to have an important role among the regulatory factors. Cytokines are the vectors of intercellular communication. The authors after studying the recent literature show how the immune system elements undergo cyclical variations corresponding to the ovulatory cycle. Reciprocal co-operation between the different cells is brought in to play at all stages of growth and of atrophy of the follicle. The knowledge of these networks for regulation make it possible to understand what is going on better and to work out a more appropriate treatment for certain pathologies such as premature menopause and unforeseen responses to certain forms of stimulation of ovulation.

The outcome of 87 pregnancies obtained by fertilisation in vitro and progressing beyond 20 weeks of amenorrhea monitored in the Victor-Olivier Ward (Prof. Monnier, Lille Teaching Hospital Group) was analysed. Results were compared with those in the literature. The group was characterised by three features: age, the number of primipara and above all the multiple pregnancy rate. One quarter of FIV pregnancies are multiple pregnancies and almost two newborn out of live are the result of multiple pregnancies. Almost 70 per cent of clinical pregnancies progressed beyond six months. Pregnancy pathology was represented by a marked worsening of the prematurity rate and by a slightly increased risk of fetal under-development. The cesarean section rate was very markedly increased. Sex ratio, and perinatal mortality, malformation and chromosomal aberration rates were similar to those for spontaneous pregnancies. Results are reassuring overall, the pathology being encountered in pregnancies of this type being only partially explained by age, the number of primipara and the multiple pregnancy rate. This pathology could possibly be explained by the underlying situation in which sterility occurred.

It is extremely rare for pregnancy to occur spontaneously in a woman with a mosaic or non-mosaic karyotype 45 x 0. (Till now only 13 patients with a homogeneous x 0 karyotype have been reported out of 62 patients who between them have had 138 pregnancies). Furthermore these pregnancies have been plagued by a number of important complications or fetal malformations (21% have had chromosome anomalies). It is therefore clear that in vitro fertilization with donor oocytes is a tempting solution for these women. The authors having three personal cases try and point out the conditions under which this technique can be used. It is important to realise that from the age of 10 or 12 years these patients have to have hormone treatment in order to avoid hypoplasia and hypovascularization of the uterus. Those conditions explain why so many these women had premature labours and also suffer from pre-eclampsia. Caesarean section was often found to be necessary because of feto-pelvic disproportion.

Endometriosis is thought to result from implantation of endometrial tissue swept back into the pelvic cavity during menstruation, or from coelomic metaplasia of the peritoneum. Yet not all women with menstrual reflux develop endometriosis. The authors present and analyse the arguments in favour of immune system involvement in the physiopathology of this frequent disease. A knowledge of the antigens that have been recognized and of the operative mechanisms will probably make it possible to understand better the repercussions of endometriosis on fertility, to develop diagnostic methods less traumatic than those available at present and to modulate treatments and improve their effectiveness.

Several biological systems originating in the fetus and in the mother are involved in embryo implantation, maintenance of the pregnancy, protection of the fetus against outside influences and the start of labour (these are the immune system, endocrine system, and the endothelial system). In order to work efficiently there has to be some co-ordination. Cytokines which were first described by immunologists make it possible for information between the systems to be exchanged. The authors, referring to recent publications, show that there are several cytokines with specific receptors at the feto-placental interface. The place and the physiological role of these molecules in co-ordinating the links are discussed. These cytokines can be involved in many pathological situations.

The authors report a case of severe post-transfusion anti-Duffy (Fya) allo-immunization which required a treatment of four intrauterine exchange transfusions. The child was born at 32 weeks of amenorrhoea and he benefited from an exchange perfusion at birth. The outcome was fully satisfactory. On the basis of this case, the authors present a review of immuno-haematology concerning the Duffy system. This system holds fourth rank, after the ABO, rhesus and Kell systems, on the clinical importance scale of group systems. It concerns two alleles, Fya and Fyb, located on the first chromosome. The anti-Duffy antibodies are IgG immune antibodies; they may be responsible for haemolytic accidents, sometimes lethal, during transfusions, and they are an occasional cause of haemolytic disease of the newborn. A review of the literature yielded only 25 cases of haemolytic disease of the newborn, thereby showing that this allo-immunization is very rare, and it demonstrated its potential danger. Finally, the authors present the therapeutic methods used to treat the haemolytic disease of the newborn caused by anti-Duffy antibodies. Plasmapheresis and intrauterine exchange perfusion have dramatically improved the prognosis of this disease.

The authors analyse a series of 23 multiple pregnancies (19 triplet pregnancies, 3 quadruplets and 1 quintuplet). The first objective is to fight prematurity. Over and above all use of drugs as tocolytics (beta-mimetic drugs and progesterone) should routinely be advised and as soon as there is any threat of premature labour hospitalisation is needed. Twenty one of the 23 patients had prophylactic cerclage (Shirodkar's stitch). In 77% of the cases respiratory distress in the newborn was avoided by using cortico-therapy. Vaginal delivery can be carried out under certain conditions in triplet pregnancies. If certain precautions are taken there does not seem to be any immediate difference in the post delivery period of these children if they are born vaginally or by caesarean. Perinatal mortality is raised (at 5.6% for triplets and 58.3% for quadruplets). The psychological implications of these pregnancies are important. Problems appear as soon as the diagnosis is made and continue for years afterwards. On the social level, help given by the social services are usually inadequate. If the couples belong to the National Association for Mutual Aid of Parents of Children of Multiple Births, a system of mutual support is available. We recommend that these pregnancies should be looked after by several disciplines. These consist not only of obstetricians, paediatricians, anaesthetists, those who resuscitate together, but also psychologists, dietitians, social workers, community workers and physiotherapists.

The authors report a case of twins conjoined at the umbilicus and diagnosed by ultrasound after 19 weeks of amenorrhoea in whom an assessment in utero was carried out using magnetic resonance imaging after the patient had been curarized. A review of the literature on this very difficult problem of conjoined twins has given us the possibility to assess the diagnostic measures as well as the prognosis of this pathology. In particular we point out the results that can be obtained using MRI in utero during the second and third trimesters of the pregnancy.

It used to be rare for multiple pregnancies to occur but we have seen a spectacular rise in them in France between 1970 and 1986. Triplet deliveries increased threefold. The authors analyse a personal series of 23 pregnancies (19 triplets, 3 quadruplets and 1 quintuplet pregnancy). Sixteen of these 23 were medically induced. The main complications that have been observed were: threatened premature delivery in 86%, high blood pressure in 34.7%, anaemia in 50%, and urinary tract infections in 30.4%, 6.8% of the babies had congenital malformations. Reviewing the literature has made it possible to discern the epidemiological factors causing multi-fetal pregnancies: family history, high female fertility, maternal age, ethnic factors, hormonal contraception etc... At present it is medically assisted reproduction that is the big supplier of multi-fetal pregnancies in developed countries. We have reviews of several maternal as well as fetal complications: the ovarian hyperstimulation syndrome, extra-uterine pregnancy, hypertension, anaemia, spontaneous abortion, prematurity, intra-uterine growth retardation and malformations.

Multiple clinical studies require a structured synthesis of their results, especially where heterogeneous results are reported. Meta-analysis is a method that does just that. Such an epidemiological study of results across studies replaces the traditional narrative review of literature, and its study completes, but does not replace medical record linkage. Diuretics in pre-eclampsia, progestational agents in the control of major failures of pregnancy and fetal monitoring as a possible trigger for more frequent caesarean sections are given as examples of interest in gynaecology and obstetrics.

The authors describe the different elements that can change the immunological response at the feto-maternal interface having studied the increasingly large literature on the subject. They consider first the nature of the interface and how trophoblastic antigens occur and then they point out the type and the role played by the different numerous decidual cells that take part in recognising, activating and regulating the immune system there. This general review is justified because local immunological phenomena seem to be important for the survival and the development of the feto-placental unit. They are also for immuno-suppressant mechanisms and immuno-tropic mechanisms. These phenomena, however important they may be, make it necessary to recognise one or more embryonic or trophoblastic antigens acting on the maternal immunological system.

The authors studied the course of pregnancy in 112 adolescents under the age of 15 years 3 months seen over the last decade. 10% of pregnancies were marked by anaemia, 23% by excessive weight gain and 20% by toxaemia of pregnancy. Although the delivery is often premature, it is usually simple, with rapid labour and expulsion. Forceps were required in 8% of cases and the ventouse was used in 11% of cases. Epidural anaesthesia was performed in 50% of deliveries. Despite an almost normal pregnancy and a eutocic delivery, 21% of babies presented a malformation.

The discovery of a tumour of the heart on fetal ultrasound is a rare event. 60% of heart tumours in the fetus are rhabdomyomas. 50% of rhabdomyomas are associated with Bourneville's tuberous sclerosis. The inherited element of the effect of the gene is variable but often severe (75% of patients die before the age of 25 and 60-80% are disabled). Tuberous sclerosis Bourneville is a multifocal pathological condition of which only the presence of rhabdomyomata in the heart make it possible to diagnose the condition antenatally. Monitoring the fetus consists of looking carefully for the complications that can occur and of planning the health care of the newborn including the need to consider surgical intervention at birth.

Description of a case of supraventricular tachycardia at 33 1/2 weeks of pregnancy following a treatment with salbutamol. After failure of digoxin alone then in association with propranolol, amiodarone allowed control of this tachycardia. A baby was born at 36 weeks, his cardiac and thyrodial assessment were normal. Different problems are discussed: the part of salbutamol on the onset of the tachycardia, the limits of fetal monitoring, the use of echocardiography and the various treatments available.

It is rare for a twin pregnancy to consist of a normally growing fetus and a hydatidiform mole. A differential diagnosis between a partial mole and a degenerating fibroid together with a normal pregnancy has to be made. This can be made using ultrasound pictures but also using cultures from trophoblast samples, or cultures from amniotic cells obtained by amniocentesis. These will eliminate the possibility of the triploidy by showing that there is a normal caryotype present. The complications and the risk of degeneration are the same as with a plain hydatiform mole. The uterus has to be evacuated and a follow-up has to be carried out to screen for trophoblastic proliferation.

This is a retrospective study carried out on 117 cases of extra-uterine pregnancy that occurred between 1976 and 1983. The authors review the different aspects of the pathological aetiology, the diagnoses, the treatments and the prognoses for this condition. Over all the incidence was 1 in 105 deliveries but this incidence had increased greatly to 1 in 68 in the last two years. The most frequent cause that was found was pelvic inflammatory disease in 42% of cases. 32% were recurrent cases of inflammatory disease and there is a correlation between ectopic pregnancy on the right side and previous appendicectomy. About a quarter of all the patients could have conservative surgery which the follow-up shows does increase the likelihood of fertility but also 37% of these had recurrent ectopic pregnancies. The discussion, which is supported by a review of the recent literature, points out that there is a recrudescence of extra-uterine pregnancy. It also shows how important it is to look out for this condition and what the risks are of conservative surgery. The indication for the latter should take into account many factors including the age, the general condition, the parity, the fertility, the wish for a pregnancy and the state and condition of the tube on each side.

Steinert's syndrome and pregnancy with delivery are rarely associated. It is a dominant autosome disease. Certain signs in pregnancy may suggest that the fetus is affected. One case made it possible to demonstrate these facts. Hydramnios with infrequent fetal movements and a slow fetal heart rate may lead to a suspicion of fetal involvement. This is always serious. The presence of the disease in the mother should be sought if it is not already known. If there is already a known family history the patient should see a geneticist so long as early amniocentesis has not yet been performed.

In 1982 Weinstein described the Hellp-Syndrome in pre-eclampsia. Two personal case histories have led the authors to discuss the need to specify this syndrome. Apart from the classical elements of pre-eclampsia, which are: arterial hypertension, proteinuria and oedema, there are bowel symptoms in 86% of cases and on the biological level there is thrombocytopenia and a rise in the transaminases as well as a haemolytic anaemia. Some cases of rupture of the liver have been described. Treatment is that of pre-eclampsia. This involves treatment with cortisone and sometimes with heparin. Delivery of the fetus is, however, the only really effective treatment. The characteristic three elements of the Hellp-Syndrome seem to be linked to disseminated intravascular coagulation and have long been considered very serious factors in pre-eclampsia. On the other hand it does seem to be useful for the clinician to know about the Hellp-syndrome in order to estimate the seriousness of a case where there are vasculo-renal elements in the syndrome and in order to avoid diagnosis mistakes in cases where the symptoms are often deceptive.

The authors, in clinical, epidemiological and experimental studies, point to the extent to which defence mechanisms are depressed during pregnancy. Viral, parasitic and bacterial infections are more common and more serious in pregnancy; but it does not seem to be possible to speak of an immunodeficient syndrome that is acquired in pregnancy. The nutritional and hormonal status as well as racial and geographical factors have their effects on numbers of defense mechanisms. The immune system cannot be relied on in these changes of the defences entirely, insofar as the arrival of antibiotics has had a big effect on the consequences of pregnancy.

Thyroid cancer is very rare during pregnancy, but a thyroid nodule is more likely to be cancerous if discovered during pregnancy (43 p. cent versus 15 p. cent). The diagnosis is more difficult. Tests using radioactive substances are contraindicated during pregnancy. Ultrasonography does not permit to specify the nature of the nodule and aspiration biopsy with cytological examination becomes the examination of choice. One should not hesitate to operate on these nodules, during pregnancy, if the diagnosis is made. It is difficult to assert that the prognosis is aggravated by pregnancy since there are so few cases, but several authors report a few cases with an abnormally fast progression during pregnancy. Forms which are properly treated and occurred before the age of 40, are not a contraindication to subsequent pregnancies, if they are not anaplastic or metastatic forms. However, a reasonable delay of the surgery is advised in order to stabilize the hormonal treatment and the calcium-phosphorus balance.

We have seen a patient who became pregnant. She was suffering from cystic fibrosis diagnosed late in life at the age of 26 years. Her case has allowed the authors to make some observations on this association of pregnancy with cystic fibrosis which will become increasingly common. 5% of individuals are heterozygous for this condition. The prospect for these patients surviving gets better and better. Although their fertility seems to be lowered it is possible for them to become pregnant. They are caught in the web of almost constant episodes of broncho-pulmonary infection with lasting effects on their respiratory capacities in 50% of cases. About 83% of these patients will deliver prematurely because of the respiratory distress they suffer. It is difficult to predict the long-term effects of pregnancy on the survival of these patients since the mortality rate anyhow is about 10% per year. According to the literature pregnancy will cause a permanent deterioration in respiratory function in about 37% of cases. The history of this particular case should be able to give new hope to some women suffering from this condition. All the same, there are a large number of problems that still have to be dealt with.

The practitioner has many difficult questions to resolve when he has placed in front of him more and more diagnostic and screening tests. Which is, in a given situation, the best test, by which is meant useful, least costly and most acceptable by the patient? Having chosen the test, at what level is the result to be considered positive or negative? The authors, having explained the principles and having taken some examples out of the literature of gynaecology and obstetrics, present a technique that shows on a receiver operating characteristic curve sensitivity and specificity sharing as a function of the possible levels for making decisions according to the test. The curve inordinate shows the sensitivity of the test or the number of true positives and on the abscissa the complement of specificity or the rate of false positives ford each decision threshold of the test. A simple glance gives the practitioner a view of the characteristics of the test over the whole band that this test can use. Using these curves it is possible to adopt more elaborate techniques to select the best threshold and to compare different tests.

The authors undertake a review of the literature so that they can point out present knowledge of the immunological relationship between mother and fetus. The fetus is a true allograft since it carries paternal antigens. Total harmony occurs so that immunisation of the mother against the feto-placental unit is recognised. This immunological reaction must occur to allow smooth development of the fetus with, at the same time, protection of the mother against trophoblastic invasion. Many regulatory mechanisms are summoned up to bring about this immunological response. While the progress in immunological knowledge has enabled us to glimpse this immunological relationship, it seems strongly probable that knowledge of these mechanisms can have applications outside gynaecology and obstetrics and be of equal value in the interpretation of immunological reactions which are found on oncology and parasitology.

The state of pregnancy changes the immune system by allowing the trophoblast to go on developing without letting the mother's body be invaded by it, and by keeping intact immune defences against the usual assaults. The non specific immune system is the first bulwark against invaders. The elements of this system, which do not depend on immunological memory, are: the macrophage-monocyte system, Natural Killer cells (NK), the complement component and other bactericidal substances such as lysozyme, fibronectin and interferon. Pregnancy improves the working of the monocyte-macrophage system. In fact, the macrophages of th reticulo-endothelial system, which can be found in different strategic places in the body, phagocytose abnormal particles more intensely. The monocytes in the circulation are more aggressive in pregnancy. They are drawn to the feto-placental interface where they are activated by different lymphokines and cytokines which can be found in quantity at this site. The role of these local active monocytes is not limited only to phagocytosis because among the hundred substances that they can elaborate are some that will regulate trophoblastic proliferation. The activity of the Natural Killer cells that are circulating and which can control tumour cell growth and cells infected by viruses is lowered in pregnancy. The serum taken from pregnant women seems to have a substance that counters the maturation of the Natural Killer cell lines. The complement system of protein synthesis, which normally acts to lyse bacteria in the chemotaxis during opsonisation, is raised in pregnancy. At the feto-placental interface it does seem to activate this system but not elsewhere in the general circulation. Interferon, which is a molecule that normally activates NK cells, has been found at the feto-placental site, without seeming to have a particular role. Pregnancy changes the quantity and the distribution of other elements in the non specific immune system such as transferrin , fibronectin and beta-lysin.

46 late interruptions of pregnancy (16 to 33 weeks of amenorrhea) were performed with the use of prostaglandins E1 ovules, of 1 mg, placed in the posterior vaginal cul-de-sac every 12 hours. It concerned 13 deaths in utero or extremely premature rupture of the membranes, 25 fetal indications (9 chromosomal abnormalities and 16 severe malformations), and 8 maternal indications. The efficacy was good either with ovules alone (84.7%) or associated with a balloon probe (5.3%). Expulsion is faster in the case of fetal deaths (average = 8 hours), than in therapeutic interruptions of pregnancy (average = 20 hours). The necessary doses did not exceed 3 mg of PgE1. There were very few side effects, essentially gastro-intestinal in nature and the course was simple. No obstetrical complication was noted. This method is therefore particularly effective with minimal side effects. Easy to use, it must be reserved for very precise indications.

The authors report on 18 cases of anencephalus, studied from April, 1976 to December, 1982. Possible etiologies, morphological characteristics, circumstances leading to its discovery, and diagnostic tools are presented. Emphasis is placed on the usefulness of ultrasonography to diagnose this condition as early as the 13th to 14th week of gestation. Evacuation of the uterus is always difficult as it involves a second trimester abortion, but is one of the best indications for the use of prostaglandins. In a woman with a previous history of an anencephalic child, careful monitoring of subsequent pregnancies is necessary as the recurrence rate is approximately 4 p. 100 (13 p. 100 in the case of a second anencephalic child). Dosing of alpha-fetoprotein and acetylcholinesterase in amniotic fluid and repeated sonograms are indispensable.

The study is based on 51 observations of fibromas of diameter 3 cm or more associated with pregnancy. The authors report the characteristics of this pathology, which occurs at a frequency of one in two in women over 35 years of age, half of whom are primiparae. The frequency varies with the size of the fibroma and falls between 0.3 and 2%. The circumstances of detection vary but echography both improves detection and allows the development of the fibroma to be monitored. The only frequent complication is aseptic necrobiosis (25% of cases), but it is usually latent or moderate. Abortions, low insertions of the placenta and faulty presentations are more frequent, especially where large fibromas are involved, but nonetheless 3/4 of such pregnancies come to term without any serious problems. Fetal prognosis is, therefore, excellent and perinatal mortality is close to that of a control population. The proportion of cesarean sections is high (30 to 75%) and depends on the circumstances, the size of the fibroma and the occurrence of dystocias. Myomectomy should remain exceptional during pregnancy but will be frequently used towards the end of a cesarean section; indications for hysterectomy on the other hand remain very limited.

The authors present statistical data on 120 medical abortions performed at "Pavillon Victor Olivier" between April, 1976 and June, 1983. A precise study was performed on the maternal and fetal indications, the different techniques employed according to gestational age, and their follow-up since 1976. The principal purpose of this article is to arouse reflexion on the consequences of the law of 1975, as well as the appropriateness of the maternal and especially of the fetal indications. A major portion of these could be avoidable with prophylactic measures and adequate contraception.

Studying the literature, which is becoming larger and larger, the authors note that there is increasing understanding about the immune response that allows a harmonious development of the feto-placental unit. After the recognition of certain trophoblastic antigens there followed the activation of lymphocytes which synthesize substances favourable to trophoblastic growth. At the same time protective mechanisms which inhibit the generation and activation of immunological factors which are normally found when allografts are rejected, were recognized. Also recognized were other systems able to suppress aggressive features that can become active during pregnancy.