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Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 35 - N° 8 - p. 822-825

Reduction mammaplasty (RM) can be performed during adolescence if the functional capacity of the breast is preserved. Future breast feeding must be carefully considered in the therapeutic decision making process. Purpose of the study : Breast feeding after reduction mammaplasty performed during adolescence was assessed to determine surgical factors influencing outcome and patient reception of information concerning breast feeding. Methods : A questionnaire was sent to 109 women who had undergone reduction mammaplasty between 1981 and 1997 when they were 15–17 years old to ascertain their reasons for having surgery, their satisfaction, and their attitude towards breast feeding. Results : Sixty-five questionnaires (60%) could be analyzed. Mean delay since surgery was 8.1 years. Seventeen women (26%) had delivered 25 infants (mean 1.5). Mean delay after surgery to first delivery was 7.68 years. Five women (29%) nursed their first infant for a mean 11.3 days. None of the women interrupted breast feeding for a reason related to a nipple anomaly or difficult sucking. Twelve women (71%) did not nurse their first infant, because of the prior breast surgery for six of them. Among the 48 nulliparous women, 24 (50%) stated they would nurse their future infant. Although information on breast feeding was systematically delivered, 41 women (63%) stated they had not been informed. There was no statistical relationship between breast feeding and degree of satisfaction, patient-assessed scar quality, or nipple disorders. Conclusion : Adolescents who undergo reduction mammaplasty can nurse their future infants with a complication rate similar to that in the general population. Special attention must be given to delivery of information on breast feeding.

Resume En raison du nombre croissant d’uterus cicatriciels, les ruptures uterines risquent de devenir plus frequentes. Cependant peu de cas decouverts dans le post-partum sont decrits dans la litterature. Nous presentons un cas de rupture uterine survenue lors d’un accouchement rapide par voie basse, chez une patiente avec uterus cicatriciel. Le diagnostic a ete pose quelques jours apres l’accouchement, devant des douleurs pelviennes et une fievre. Nous ne remettons pas en question le principe de ne reviser la cicatrice uterine que sur signe d’appel, mais nous soulignons qu’une endometrite en post-partum sur un uterus cicatriciel necessite la recherche d’une rupture uterine par des examens d’imagerie adaptes.

Vegan diet in lactating women can induce vitamin B12 deficiency for their children with risk of an impaired neurological development. A 9.5-month-old girl presented with impaired growth and severe hypotonia. She had a macrocytic anemia secondary to vitamin B12 deficiency. MRI showed cerebral atrophy. She was exclusively breastfed. Her mother was also vitamin B12 deficient, secondary to a vegan diet. She had a macrocytic anemia when discharged from the maternity. Vegan diet is a totally inadequate regimen for pregnant and lactating women, especially for their children. Prevention is based on screening, information and vitamin supplementation.

Because of the increasing number of cicatricial uteruses, uterine ruptures are likely to become more frequent. However, few cases discovered in the postpartum period are described in literature. Our case report describes a uterine rupture, which occurred during a quick vaginal delivery, in a patient with previous cesarian section. The diagnosis has been made few days after delivery, the patient presenting pelvic pain and fever. We do not disagree with the principle to check uterine scar only when suspicion of rupture, but we should keep in mind that in case of endometritis in the postpartum period, with cicatricial uterus, it would be necessary to research uterine rupture by fitted imaging.

Gayet-Wernicke syndrome is a rare neurological pathology due to a deficit in vitamin B1. It occurs in alcoholics but several reports have been published of cases in a context of intractable vomiting. The frequency is probably under-estimated because there have been many cases described at autopsy. The diagnosis is clinical with the triad (found in 60% of cases) of mental confusion, oculomotor disorders and ataxia. MRI can confirm the diagnosis by hyper signal images most frequently in a peri-acqueductal location, the thalamus and mamillary bodies. We report 3 observations of Gayet-Wernicke encephalopathy discovered in a context of hyperemesis gravidarum. These 3 cases, which occurred within the past two years in the West of France, give us the opportunity to assess 3 different outcomes for this pathology. In a second section we review the main publications in the literature. Hyperemesis gravidarum is a frequent pathology and can be the cause of serious neurological complications. Early vitamin supplementation should be instituted in case of severe vomiting in order to ensure the pregnancy can continue together with the mother's well-being.

Vegan diet in lactating women can induce vitamin B12 deficiency for their children with risk of an impaired neurological development. A 9.5-month-old girl presented with impaired growth and severe hypotonia. She had a macrocytic anemia secondary to vitamin B12 deficiency. MRI showed cerebral atrophy. She was exclusively breastfed. Her mother was also vitamin B12 deficient, secondary to a vegan diet. She had a macrocytic anemia when discharged from the maternity. Vegan diet is a totally inadequate regimen for pregnant and lactating women, especially for their children. Prevention is based on screening, information and vitamin supplementation.

Breast and ovarian cancer occur more frequently in young women with BRCA 12 mutations (respective cumulative risks from 37 to 85% and 10 to 20%), and raise specific gynaecologic problems as prophylactic surgery and hormonal treatments. Two medical files from 2 sisters with BRCA 1 mutation (exon 11) are presented and the authors discuss the therapeutic options chosen. BRCA 12 tumour suppressor genes seem to play a major role in the repair of cellular damages inducing by the estrogenic proliferative signal. The prophylactic mastectomy is effective for the breast cancer prevention but its acceptance is low. The oophorectomydecreases the ovarian risk (knowing the occurrence of peritoneal carcinomatosis in 1.8% of cases) and currently the breast cancer risk (RR = 0.47) by the hormonal privation: the hormone replacement therapy does not seem to increase the breast cancer risk in the small series published. The HRT is possible in women with BRCA mutation under medical supervision and if the doses of hormones are light. The first results concerning the chemoprevention by Tamoxifen are encouraging (RR = 0.38) in these patients, but more studies are needed. The oral contraception exerts an uncertain effect against ovarian cancer, but possibly enhances the breast cancer risk in this group of women (RR = 3.3). The management of women with BRCA mutation is varying according to their own priorities, which can change during their life.

This study was carried out in Rennes's maternity hospitals (France), to determine the breastfeeding rate for newborns hospitalized after birth, as well as the factors associated with the choice to breastfeed or not in these conditions.Three hundred and twenty mothers delivered in Rennes Teaching Hospital, whose neonates were transferred in neonatal care unit, were questioned about their choice for neonate feeding.Three hundred and eight of the 320 mothers concerned by the study answered our interview. Fifty one percent of them chose to breast feed, which is near the breastfeeding rate of the general population of Rennes' maternity hospitals (52%). A high sociocultural level, a mother previously breastfed herself, and a previous breast feeding (RR = 5.2; P10(-8)) were associated with the choice of breastfeeding. Factors concerning the information of the mothers were also associated with the choice of breastfeeding information during the preparation to birth sessions (RR = 1.7; P10(-5)), individual information on the breastfeeding of an ill newborn (RR = 1.5; P0.01), and the simple advice to breastfeed given by a health care professional (RR = 2; P10(-8)). Of the four qualities named, the more breast-milk qualities a mother knew, the higher breastfeeding rate was (10% for none, 27% for one, 54% for two, and 76% for three or four). Concerning the postnatal factors, gestational age below 31 weeks multiplied breast feeding by 1.5 (P0.05), and an early contact mother-child (first day) by 1.3 (P0.05).This study pointed out the populations at risk of no breastfeeding. Informations on the properties of breastfeeding given to mothers by health care professionals may influence them in their choice of breast feeding or not their ill newborn.

To assess the efficacy of a co-program of care in gestational diabetes conducted by the obstetrical and endocrinological units of the Rennes South Hospital (Hopital Sud) and the possibility of adapting obstetrical care to existing risk factors.A retrospective analysis was made of 200 cases of gestational diabetes diagnosed between January 1993 and December 1996 in the obstetrical units.Instrumental extraction and cesarean section were required for 13.5% and 20.5% of the deliveries respectively. Shoulder dystocia occurred in 2%. 19.9% of the infants had macrosomia and 5. 3% were small for gestational age. Neonatal morbidity required transfer to the pediatric intensive care unit for only 2.9% of the infants. Frequency of cesarean section and macrosomia correlated with poor blood glucose control and excess maternal weight for gravidic hypertension. At 3 months post-partum, glucose intolerance and non-insulin-dependent diabetes were diagnosed in 13% and 2% respectively.Systemic screening and obstetrical and endocrinological care allowed patients to prevent maternal and fetal complications in gestational diabetes and to initiate hygiene and dietary habits for the prevention of post-partum non-insulin-dependent diabetes. Obstetrical care can be adapted to risk factors such as overweight, late screening or poor blood glucose control.

Polyamines are ubiquitous cellular compounds which are required for estradiol induced proliferation in breast cancer. Complete polyamine deprivation, using 2 alpha-difluoromethyl-ornithine (DFMO, Eflornithine), a specific inactivator of ornithine decarboxylase (key-enzyme of the polyamine biosynthesis) combined with inhibition of the bacterial production of gastrointestinal polyamine and a polyamine free regimen, was demonstrated to exhibit a cytostatic effect and a decrease of the three tumoral polyamine concentrations in a MCF-7 tumor model. In this experiment, complete polyamine deprivation has been tested on a standard MCF-7 tumor and on a variant MCF-7 tumor (i.e. with a tamoxifen acquired resistance). Polyamine deprivation was effective on the tumor growth, both on standard and variant sub-types. The polyamine contents of two types of tumor were similar, and identically, polyamine deprivation has caused a decrease of putrescine, spermidine and also spermine tumoral concentrations measured by the HPLC method in standard and variant MCF-7 tumors. Acquired tamoxifen resistance is common in patients undergoing hormonal therapy for advanced breast cancer. It has been hypothesized that the direct stimulation of polyamine pathway without estradiol involvement could be one of the mechanisms responsible for the tamoxifen resistance. The ability of polyamine deprivation to inhibit the growth of tumors becoming tamoxifen resistant could offer a therapeutic advantage in case of tumor with acquired tamoxifen resistance and could be tested to prevent or delay the hormonal responsiveness to breast cancer.

By who, why and how are done hysterectomies for benign lesions.and methods. The 413 medical files of all the patients who underwent an hysterectomy for benign lesion during the last trimester of 1997 were recorded by the Medical Information Departments of the 53 health establishments of the Brittany Region. Surgical procedures, medical indications, pathological findings were analyzed according to the guidelines encountered in the medical literature.Hysterectomies were done by many surgeons (112). Inaugural signs noted in the medical files were classical, but various and often associated without a main indication of hysterectomy. Histological diagnose were identical with those found usually in the literature. The abdominal route was mainly used, particularly when the operation was done by a generalist surgeon and in case of uterus weight superior to 250 g. The post operative outcome has revealed the same nature and frequency of complications as usually described.In this study, it appears that efforts remain necessary to clarify the indications for hysterectomy in the medical files (in order to promote the alternative procedures to the hysterectomy), and that the proportion of hysterectomies performed by the abdominal route should be reduced in aid of the others surgical routes.

Experimental evidence suggest an important role of polyamines in breast cancer development. Polyamines have been determined in tissue and erythrocyte samples from 100 patients with primary invasive breast cancer and 30 patients with fibroadenomas. Statistical analysis was performed in order to determine the prognostic value of the polyamine patterns of tumor tissues and erythrocytes in comparison with clinical and histological prognostic factors. In malignant tissues, polyamine levels were significantly higher than in benign tissues. They correlated with markers of tumor aggressivity (axillary node involvement and especially with markers of high mitotic rate as Ki-67 staining, histological grade). No correlation was found between estrogen and progesterone status, tumor size and polyamine concentrations. Erythrocyte polyamines levels were identical between cancer patients and controls. The knowledge of the polyamine pattern in breast cancer could become useful in clinical practice particularly if polyamine metabolism is targeted as a therapeutic approach.

To summarize the methods encountered in a gynecological department for teaching medical students.Review of the Medline literature underlying the benefits and disadvantages of each method using the issues of the modern theories of teaching.All the methods are helpful for learning, with different and complementary objectives. Students can constitute a set of skills using a teaching program containing clear objectives and evaluation on which the future medical practice will be based.Students have immediate benefits from an active clinical learning involving them and are prepared to the Continued Medical Education.

Nineteen clinical stage I adenocarcinoma of the uterus with favourable histological prognosis factors (low grade, no myometrial extension, and no pelvic node involvement) were diagnosed using a preoperative hysteroscopy. During the laparotomy, a peritoneal cytology was performed systematically. The frequency of positive peritoneal washings was abnormally high (7 cases) with cytologic findings showing grouped cells in large clusters. However, these patients have not experienced peritoneal recurrences. The endoscopic procedures may have facilitated the transtubal malignant cell dissemination and are questionable in front of endometrial carcinoma.

The Model of Assistance and Orientation of a User within a System of Coding (MAOUSSC) used to describe activity in human medicine was used to analyse French medical nomenclature in Gynecology and Obstetrics.French medical nomenclature for gynecology and obstetrics was translated with the multiaxial model (MAOUSSC) to allow critical analysis.All the 119 medical acts in the French nomenclature involving the female genital tract and obstetrics could be translated with the model. 24% of the acts were imprecise, ambiguous or implicit: the nature of the procedure was not explicit in 7 cases, the surgical route was not given in 86 and the surgical instrumentation not named in 75. Activities involving numerous medical specialties and ambulatory activity can be described with the MOUSSC model.The MAOUSSC model is still in the experimental stage. It is however easy to implement, has a high potential for describing various medical acts and is suitable for the description of gynecological and obstetrical activity both in terms of economical and medical efficacy.

Intracystic breast carcinoma is a malignant which develops within breast ducts. The clinical examination reveals a breast cyst containing a blood fluid which persists after the puncture. Fine-needle aspiration cytology may be benign. The endocystic mass is detected well by the ultrasound and US-guided puncture is possible. Papillary carcinoma is the most frequent histological type. Conservative prophylactic radiotherapy with surgery can be proposed. Prognosis is poorer with stromal involvement.

Nineteen clinical stage I adenocarcinoma of the uterus with favourable histological prognosis factors (low grade, no myometrial extension, and no pelvic node involvement) were diagnosed using a pre-operative hysteroscopy. During the laparotomy, peritoneal cytology was performed systematically. The frequency of positive peritoneal washings was abnormally high (7 cases) with cytologic findings showing grouped cells in large clusters. However, these patients have not experienced peritoneal recurrences. The endoscopic procedures may have facilitated the transtubal malignant cell dissemination and are questionable in endometrial carcinoma.

To evaluate management and outcome of the treatment of uterine leiomyosarcoma.Retrospective study of a series of 9 patients treated for uterine leiomyosarcoma in this hospital from 1982 to 1994.The condition is rarely suspected preoperatively, diagnosis is usually made on histological examination of the operative specimen. The outcome is related to the mitotic activity of the tumour and to the infiltration of nearly structures. Surgery is the only effective treatment, chemotherapy is ineffective, adjuvant radiotherapy improves local control of the tumour but has no incidence on survival.In the absence of an effective adjuvant treatment uterine leiomyosarcoma bears a poor prognosis with the only exception of small non infiltrating tumours with a low mitotic activity.

Seminal fluid allergy is a possible diagnosis in front vulvovaginal inflammations occurring rapidly after coitus. The type I reaction (revealed by the immediate hypersensitivity Prick-test) is most frequently encountered. In case of systemic symptoms, the circulating Ig E specific antibodies can be increased. Treatment is palliative (condoms, antihistamines cream). In case of systemic disease, desensibilisation can be proposed. This infrequent but uncomfortable syndrome is also in question in some cases of immunologic infertility.

The aim of this work was to study the predictive value of 50 gram glucose O'Sullivan test for systematic screening of gestational diabetes. To confirm the diagnostic the test positivity was controlled by a 100 g, 3 hours oral glucose tolerance test. During a 12-month period, 751 women were included in the 7th month pregnancy consultation. The O'Sullivan test was positive in 18% of cases. The oral glucose tolerance test confirmed the diagnostic in 14% of these positive tests. The frequency of gestational diabetes was about 2.5% in this population. We compared then the results of the test with the other available screening modes. For this purpose, we analysed retrospectively 50 gestational diabetes diagnosed during the same time in the entire pregnant population of the clinic. In our experience, the O'Sullivan's test is a reliable and useful test. It is easy to perform. Less women are selected than in analysis of risk factors (18% versus30%), and with better sensitivity.

Seventeen cases of mixed Muller tumours (tumours of the uterus with malignant epithelial and mesenchymal components) are presented. These recently described tumours are rare and occur in menopaused women. Bloody discharge is the usual clinical manifestation, together with an increase of the volume of the uterus. Pathology examination of the surgical specimen is required for diagnosis using immunolabeling to distinguish between homologous tumours (the sarcomatous component occurs in the primary mesenchyma) and heterologous tumours (the mesenchymatous component results from a metastasis). Prognosis, usually poor, depends on the stage of the tumour. Overall survival at 5 years is about 30%. Survival in early stage I and state II tumours is no greater than 50% at 5 years. Treatment is based on radiosurgical techniques in less advanced tumours and requires radiochemotherapy in more advanced stage tumours. Recurrence is usually seen within 2 years, involving the pelvis alone in 10% of the cases and metastasis in most of the others. Because of their rapid development and poor prognosis, these tumours should be identified separately as a separate entity within a larger group of mixed mesodermic tumours.

The initial manifestations of two cases of non-Hodgkin malignant lymphoma of the uterine body were a cauda equina syndrome in one and bowel occlusion in the other. A review of the literature on isolated non-Hodgkin malignant lymphomas of the uterine body was discussed.

Development of diagnostic, therapeutic and preventive measures for breast cancer after cure of Hodgkin disease.Presentation of 4 patients treated conjointly by the Radiotherapy and Gynaecology Surgery Departments of the Rennes University Hospital.Illustrations of difficult management of breast cancer at different stages of diagnosis and therapy.A past history of treated Hodgkin disease is a factor of risk for breast cancer and suggests the need for annual mammography screening 10 years after the end of treatment. Though more difficult, mastectomy is recommended over conservative radiosurgical treatment. The choice of drugs for adjuvant chemotherapy should rely on Hodgkin protocols and take into account heart function. Long-term carcinogenic effects of Hodgkin disease treatments requires modulation of the different treatment protocols as a function of stage, clinical and histological factors of prognosis and patient age.

A case of juvenile tumour of the granulosa occurred in a pregnant woman. Outcome was rapidly fatal. These tumours are classed as mesenchyma tumours of the sexual cords of the ovaries. The juvenile form occurs before the age of 30 years in 97% of the cases and has characteristic endocrine and anatomic features. The tumour remains localized in the ovary for a long period and may be treated with conservative surgery to preserve fertility in these young patients. Follow-up is aimed at detecting relapse which may occur early. Prognosis in such cases is very poor. Pregnancy does not modify the prognosis which is generally good.

OBJECTIVE. Diagnostic value of breast clustered microcalcifications discovered by mammography. DESIGN. A retrospective study. SETTING. Oncology Center of Rennes. SUBJECTS. 58 women (study group) with breast clustered microcalcifications without palpable tumour were operated. SURGERY. Prior to surgical removal of microcalcification, needle localization was performed. Histological results. We observed, 36 benign lesions (59%), 25 carcinomas (45%), 10 of them in situ and 15 infiltrative. RESULTS. Different radiological parameters were studied in relation to histological results, the vermicular morphology of microcalcification, an increased number, their triangular aspect, provide clue to the presence of breast carcinoma. The cluster of stippled calcification is not, in our series suggestive of a carcinoma, but also requires histopathological study, owig to the fact that in such cases, we have as many carcinomas as benign lesions. FINDING. Careful analysis of microcalcifications, within the clinical context, ensures a safe attitude, and enables one to operate only carcinomas.

The authors report a case of pregnancy of the uterine horn occurring after total salpingectomy, i.e. including resection of the intramural portion of the tube. They identify the epidemiological, pathophysiological and clinical features of this complication with the help of a review of the literature of cases occurring after partial salpingectomy and total salpingectomy. They discuss the usefulness of resection of the interstitial portion of the tube and feel that prophylactic cesarean section is justified in patients who have remained fertile.

Immature teratoma of the ovary is a rare tumour (1% of cancer of the ovary) usually seen in adolescents or young women. It is a malignant tumour derived from an abnormal germ-cell which undergoes meiotic division. The diagnosis is based on the pathological examination which reveals immature tissue derived from two or three types of embryonic tissue (endo-, meso- and ectoderm). Intraperitoneal dissemination occurs and immature or mature recurrence is observed. The prognosis was particularly severe before the use of polychemotherapy which has also made conservative surgery possible. At the present time, the consensus is to reduce the duration of the chemotherapy with a regular clinical and laboratory (tumour markers, aFP) monitory. A second look laparotomy verifies successful treatment.

Having treated a case which resulted in the delivery at term of an intrauterine twin when the other twin had been lost after the rupture of a uterine cornu which itself followed a salpingectomy without removal of the interstitial portion of the tube brings the authors to discuss the physiopathology and the symptomatology of such cases. They also discuss the value of resecting the interstitial portion of the tube and what management should be when there is a live intrauterine pregnancy.

The authors have evaluated the risk of neonatal infection (NNI) by materno-fetal contamination when a rise in temperature occurs in labour and they have worked out the prophylactic measures that should be taken. This has been the results of a prospective study carried out on 6305 deliveries. Any significant conditions associated with NNI are stained liquor and a low Apgar score at birth. When high temperature develops in labour it is important to deliver the infant as quickly as possible particularly if the labour is a premature one. Prevention carried out by very early diagnosis of amniotic fluid infection in pregnancy and by careful attention to the high risk conditions of: early rupture of the membranes, a high level of vaginal infection particularly with Beta streptococci.

The authors report nine personal cases in a review of the literature concerning cancers of the breast associated with pregnancy and lactation (until a year post-partum). The diagnosis of the illness is reported to be difficult in pregnant women and it is necessary to use fully all the diagnostic procedures available and in particular cytology and histology. Surgery is urgent. It is classical practice to carry out a mastectomy with axillary clearance. Nevertheless more conservative treatments are now being suggested. The principal problem of therapy is linked to the effects of adjuvant therapy on the fetus be they radiotherapy or chemotherapy, particularly because it is very important that treatments should be thorough and start early in the pregnancy. The overall prognosis is bad because pregnancy seems above all to aggravate serious forms of the disease.

Perinatal mortality for infants born to diabetic mothers has dropped in the years from the 1950's when it was 20% to less than 3% by the end of the 1980's. In spite of this considerable reduction which is due to careful observation and multidisciplinary management in this type of pregnancy, the congenital malformation rate is 4 times greater than with the general population (3%) and the rate of spontaneous abortions is double (13%). The caesarean section rate is 5 times higher (18%). In bringing out a retrospective study we have attempted to analyse the endocrinological and obstetrical features of the cases.

Having had a case themselves the authors report a rare complication of epidural anaesthetic, namely pneumocephaly. When it occurs it is usually after a difficult puncture; and usually thought of if headaches are unusually severe of there is a picture of intracranial rise in pressure. Then a tomodensitometry will lead to the diagnosis. Literature shows that it can be a serious condition, sometimes fatal, which means that the case has to be followed up very carefully and tomodensitometry has to be repeated until complete cure has been obtained.

The authors use two personal cases to review the etiological circumstances, pathology and clinical and paraclinical manifestations, stressing in particular the current value of diagnostic and therapeutic hysteroscopy. Advice is given concerning prevention and treatment.

The authors present 54 cases histories of therapeutic terminations of pregnancy. The mean age of the patients was 28.6 years at the time of diagnosis with the following in indications for the antenatal diagnosis in order of decreasing frequency: clinical history, age of the mother, seropositive for toxoplasmosis or rubella, a high fetal alpha protein level and ultrasound signs. They highlight the usefulness of ultrasound in reaching a decision as to whether pregnancy should be terminated (as it was in 25 cases out of 49) and the predominance of diagnoses of karyotype abnormalities. They also compare the various prostaglandin s used in this study (analogs of PGE1 and PGE2, diniprost). Their results, in accordance with the literature were good for gemeprost and sulprostone with expulsion in 29 out of 32 cases within 24 hours and in 9 cases out of 11 within 20 hours respectively.

Hydranencephaly is the total or virtually total absence of the cerebral hemispheres, which are reduced to a membranous sac of glial tissue, with no ependymal coating, in an intact skull. This is rare disorder (0.5 per thousand births). It is classified as a circulatory encephalopathy. Two opposing theories are generally advanced: the encephaloclastic or destructive theory and the theory of dysontogensis or malformation, due to early disruption of organogenesis. It has many causes (vascular, viral, parasitic, genetic, toxic, estrogenic...). It appears to be readily diagnosed by ultrasound, the neurological findings may be normal at birth, but transillumination of the skull remains a simple and reliable diagnostic test. Transfontanellar ultrasound, CT scanning and anatomical confirmation alone can establish the diagnosis. The prognosis is hopeless and there is no treatment.

A retrospective study of the notes of 253 deliveries was carried out in the two maternity units attached to the University of Rennes between 1980 and 1985. This followed a review of the literature on delivery of babies presenting with a persistent occipito posterior position. Tarnier's forceps were used in each case with full rotation of the presenting part carried out or else delivery in the occipito posterior position. There were five cases of failed forceps. We have not been able to show that there was a significant statistical difference as far as the neonatal state of the babies was, because to the methods of delivery. On the other hand, there was a greater frequency of urinary-vaginal lesions after full rotation. We therefore suggest that a trial of forceps delivery should be carried out in the operating theatre when the optimal obstetrical conditions have been fulfilled, so long as the manoeuvres are carried out technically easily and so long as Caesarean section is resorted to if all the obstetrical conditions are not fulfilled, or if it seems difficult to deliver the baby with a forceps.

In situ canalicular carcinomas are defined as malignant, galactophoric epithelial cells, do not invade the basal membrane. The author saw 21 cases of in situ canalicular carcinomas which were treated surgically at the University Hospital of Rennes. It is possible from these cases to include certain themes: there is a pathology of an early carcinoma of the breast which will go on growing. It concerns patients in the menopausal age who 1 in 3 have a family history of neoplasia. Medical examination is important because in 1 out 2 cases leads to complimentary examinations which help to make the diagnosis. Mammography is essential because it leads to the diagnosis of a finding of suspicious microcalcifications as well as arranges an outline. The histology will indicate what the therapy should be. Comedocarcinomas (cellular proliferation with central necrosis) has to be considered as separate from other better differentiated types (solid, cribriform, papillary and clinging carcinomas). In fact comedocarcinomas often have a poor prognosis and the factors are: the size, the mitotic activity, the poor cellular differentiation, perigalactoriphic reaction, and stromal and multi centre micro-invasion. Treatment has to be adapted to features of this pathology. Mastectomy which used to be routine in these cases because of the high incidence of multiple centres, are to be reserved for cases with a poor prognosis. At present conservative treatment is being evaluated, but it seems logical to recommend it in non-invasive cancers with a good prognosis when a large lumpectomy followed up by radiotherapy to the whole breast can be used, particularly because this form of treatment is now given to invasive tumours. It is very important to follow-up these patients regularly and for a long time, clinically and with mammography if conservative treatment is carried out, in any case when the opposite breast is at risk. Conclusion. Now that treatments have become varied the improvement in prognosis will depend on early diagnosis. This means that mammography screening will proceed to an increasing number of non-invasive cancers of the breast that are discovered, and to a need to work out acceptable and effective treatment for these cancers.

The authors report three cases of percutaneous fetal blood sampling at 38 weeks of pregnancies complicated by immunologic thrombocytopenia. In each case, the purity was perfect which is essential for using the examination with a view to the obstetrical management. The birth is programmed 24 or 48 hours later. In two cases, the neonatal control is in agree with the fetal blood sampling. In the third observation, the fetal platelet count in 142,000/mm3 and the newborn control 55,000/mm3: the only explanation is a very active process as usually state with newborns. There was no accident, and these samplings led to natural births. This approach seems to be the more effective for the evaluation of fetal platelet count and allow the choice of birth management. A cesarean section is decided in case of fetal thrombopenia lower than 50,000/mm3.

The authors present their results as far as successful vaginal delivery (in 39.9% of cases) carried out in 884 cases with a scar in the uterus. They also give the morbidity and maternal and fetal mortality as well as those that developed a rupture of the uterus. No mother died in their series and there was no fetal death that could be ascribed to a complete rupture or a uterine dehiscence. Both fetal and maternal mortality was considerably higher when the trial of scar failed or when a Caesarean section was carried out prophylactically, as compared with the results from vaginal delivery. 2.17% of all the 884 patients with a uterine scar had a complete or incomplete rupture of the scar. Finally the describe their criteria for selecting patients for attempts at vaginal delivery and they show that it is necessary to test the ability of the fetus to pass through the pelvis after looking very carefully at the partogram made for the previous Caesarean operation. In this way they were able to use a trial of labour in slightly contracted pelves or where the fetus was big in such a manner as to obtain a vaginal delivery in, respectively, 68 and 72% of cases.

The authors present a case of primary pure carcinoid tumour of the breast and point out how rare it is and how they made their diagnosis mainly by histology. A review of the literature makes it possible to assess the prognosis which should be good and they also describe the anatomo-pathological findings in these tumours. Finally these tumours show a strange histogenesis which if it is understood makes it possible to understand certain processes of cellular differentiation in breast tissue.

After the last 50 years, the problems raised by breech presentation may be summarized as follows: during this period, foetal prognosis has been notably improved, the improvement is, nevertheless, considered to be insufficient in the present sociocultural context, the improvement has been brought about by various means and methods for which it is not easy to establish a ranking of values, too many differences remain concerning the significance of the presentation itself, as well as the results obtained with the various therapeutic approaches, these uncertainties prevent definition of the best management approach and, consequently, prevent fresh progress from being made, these uncertainties can only be removed by making an effort to integrate and summarize all that has been or will be published concerning the subject.

A case is reported of an infection with Streptococcus pyogenes, occurring 24 hours after an elective Caesarean section in a 30 year old woman. She worsened during the first 48 h, with shock (Pasys less than 70 mmHg, pH 7.28) as well as abdominal tenderness and guarding. Laparotomy revealed peritonitis, and subtotal hysterectomy was carried out. Gram positive cocci were found in the peritoneal exudate, with bacterial cultures yielding Streptococcus pyogenes. Histopathological examination of the specimen revealed necrosing endomyometritis with septic thrombophlebitis. During the immediate post-operative period, there were several prolonged episodes of circulatory arrest treated with dobutamine, adrenaline, and noradrenaline. Multiple organ failure occurred during the next five days, despite antibiotic therapy (vancomycin, tienamycin, amikacin) and intensive care. It included jaundice, thrombocytopaenia (10 G.l(-1] adult respiratory distress syndrome (ARDS). A further laparotomy was carried out because of abdominal and thigh cellulitis, with completion of the hysterectomy and bilateral salpingo-oophorectomy. Streptococcus pyogenes was still present in the peritoneal cavity. There followed an improvement, with a return to normal of the platelet count, haemodynamic stability such that vasoactive drugs were no longer needed, and a decrease in the degree of jaundice. However, the ARDS worsened, and the patient died 15 days after the Caesarean section. There have been recent reports of similar cases, suggesting an increase in the virulence of group A streptococci linked to a re-emergence of exotoxin A.

We made a prospective study using vaginal suppository of Géméprost (analogue of PGE1) and intravenous infusion of Sulprostone (analogue of PGE2) in thirty second- and third-trimesters pregnancy terminations. The efficacy was excellent for both procedures: only one failure, mean duration of abortion of 15 h 15 with Sulprostone, interval of 17 hours with Géméprost. In this case, the delay was shorter when vaginal administration was made every 6 hours. The evacuation of the uterus was very good, however one aspiration was made three days after abortion. Few side effects were observed with these two drugs: one case of fever, one case of vomiting, both with Sulprostone: two cases of nausea, one case of diarrhoea with Géméprost. We think that the effectiveness is marked and comparable, allowing the use of epidural anesthesia.