C. Malartic

Conservative management of a Cesarean scar ectopic pregnancy: a case report.

IntroductionCesarean scar pregnancy is the rarest kind of ectopic pregnancy. The immediate prognosis depends on the risks associated with uterine rupture and massive bleeding.Case presentationA 32-year-old woman (gravida 2, para 1) presented with massive vaginal bleeding. A Cesarean scar pregnancy was diagnosed. She was treated by local methotrexate injection, followed by uterine artery embolization. Recurrence of bleeding necessitated two repeat embolizations. Hysteroscopy four months later revealed the presence of a uterine defect within the Cesarean section scar.ConclusionCesarean scar pregnancy should be diagnosed and treated as soon as possible to prevent severe complications and spare fertility.

Conservative two-step procedure including uterine artery embolization with embosphere and surgical myomectomy for the treatment of multiple fibroids: Preliminary experience

OBJECTIVE To evaluate the feasibility and safety of combined uterine artery embolization (UAE) using embosphere and surgical myomectomy as an alternative to radical hysterectomy in premenopausal women with multiple fibroids. MATERIALS AND METHODS Mid-term clinical outcome (mean, 25 months) of 12 premenopausal women (mean age, 38 years) with multiple and large symptomatic fibroids who desired to retain their uterus and who were treated using combined UAE and surgical myomectomy were retrospectively analyzed. In all women, UAE alone was contraindicated because of large (>10 cm) or subserosal or submucosal fibroids and myomectomy alone was contraindicated because of too many (>10) fibroids. RESULTS UAE and surgical myomectomy were successfully performed in all women. Myomectomy was performed using laparoscopy (n=6), open laparotomy (n=3), hysteroscopy (n=2), or laparoscopy and hysteroscopy (n=1). Mean serum hemoglobin level drop was 0.97 g/dL and no blood transfusion was needed. No immediate complications were observed and all women reported resumption of normal menses. During a mean follow-up period of 25 months (range, 14-37 months), complete resolution of initial symptoms along with decrease in uterine volume (mean, 48%) was observed in all women. No further hysterectomy was required in any woman. CONCLUSION In premenopausal women with multiple fibroids, the two-step procedure is safe and effective alternative to radical hysterectomy, which allows preserving the uterus. Further prospective studies, however, should be done to determine the actual benefit of this combined approach on the incidence of subsequent pregnancies.

Delayed hysteroscopic resection of retained tissues and uterine conservation after conservative treatment for placenta accreta

Conservative management of both the uterus and the abnormal placenta, which is left inside the uterus at the time of delivery, is one option of placenta accreta management. Complete elimination of the residual placenta is the main challenge of this procedure.

Uterine conservation despite severe sepsis in a case of placenta accreta first treated conservatively: 3-month delayed successful removal of the placenta

OBJECTIVE To report a case of successful delayed removal of a placenta accreta first treated conservatively. Secondary infectious complications can occur after conservative management in cases of placenta accreta, most often leading to hysterectomy. DESIGN Case report. SETTING A French teaching hospital. PATIENT(S) A 33-year-old woman. INTERVENTION(S) A healthy 33-year-old woman underwent Cesarean section for her first pregnancy. Diagnosis of placenta accreta was made at ultrasound scanning for her second pregnancy. She was first treated conservatively. Hysterectomy was planned 3 months after conservative treatment because of sepsis attributed to uterine retention. (Hysterotomy was first realized.)-?? MAIN OUTCOME MEASURE(S) Uterine conservation. RESULT(S) The placenta was easily and successfully removed with no subsequent bleeding. The uterus was sutured and conserved. CONCLUSION(S) In cases of delayed sepsis because of uterine retention after conservative treatment for placenta accreta, when medical treatment remains unsuccessful, manual removal of the placenta should be attempted. This approach might allow improved uterine conservation rates in women with placenta accreta treated conservatively.

Routine use of abdominopelvic ultrasonography in severe postpartum hemorrhage: retrospective evaluation in 125 patients

OBJECTIVE The purpose of this study was to analyze the potential of abdominopelvic ultrasonography at the initial examination in women with severe postpartum hemorrhage. STUDY DESIGN One hundred twenty-five women were included in the study. The therapeutic approaches that were performed to stop the bleeding were evaluated for each category of ultrasonographic finding. RESULTS Seventy-one women (56.8%) had normal ultrasonography; 30 women (24%) had echogenic endometrial lining; 17 women (13.6%) had echogenic intrauterine mass, and 7 women (5.6%) had abdominopelvic free fluid effusion. Medical therapies allowed the bleeding to stop in 90.1% of women with normal ultrasonography, in 66.6% of women with echogenic endometrial lining, and in 29.4% of women with echogenic intrauterine mass. Pelvic embolization and surgery were performed less frequently in women who had normal ultrasonography results (9.9%) than in women with abnormal ultrasonography results (46.8%; P < .0001). CONCLUSION A normal abdominopelvic ultrasonography is associated with a favorable outcome and can be considered to be a predictor for the effectiveness of conservative, noninvasive therapeutic approaches.

Evaluation of symptomatic uterine fibroids in candidates for uterine artery embolization: comparison between ultrasonographic and MR imaging findings in 68 consecutive patients.

Ultrasonographic and magnetic resonance (MR) imaging examinations of 68 women with uterine fibroids were reviewed to determine whether MR imaging may alter the therapeutic approach based on ultrasonography alone before uterine embolization. Therapeutic decisions based on ultrasonography alone were compared to those obtained after MR imaging. Discordant findings between both examinations involved 51 women (75%), and 19 (28%) had their therapeutic approaches based on ultrasonography alone altered by MR imaging. Ultrasonography and MR imaging showed concordant findings in 17 women (25%) for whom no changes in therapeutic option were made. MR imaging alters the therapeutic approach based on ultrasonography alone in 28% of candidates for uterine artery embolization.

Ventouse Kiwi® versus forceps et spatules: évaluation de la morbidité maternelle et fœtale. À propos de 169 cas

AIM To evaluate maternal and fetal complications resulting from the use of the Kiwi vacuum extractor and to compare them with those resulting from the use of forceps or spatula. PATIENTS AND METHODS Patients who had instrumental extraction between November 2006 and April 2007 were included in a unicentric retrospective study. Complications resulting from the use of Kiwi vacuum extractor and those of other instruments were compared. RESULTS One hundred and sixty-nine patients where included, 79 had extraction with Kiwi vacuum extractor. The two populations (women having extraction with Kiwi and woman having extraction with spatula or forceps) were similar in terms of maternal characteristics, progress of labour and delivery. The rate of episiotomies was significantly lower with KIWI (73.1% versus 94.4%; P=0.0001), as well as was postpartum haemorrhage rate (8.9 % versus 18.9%; P=0.04). No perineal tear of second or third degree occurred with Kiwi. Kiwi vacuum extractor was associated with a higher rate of shoulder dystocia (12.8% versus 6.7%, NS), but related fetal complication rates were similar in the two groups. The extraction failure rate was significantly higher with Kiwi (11.4% versus 4.4%; P=0.04), but cesarean section rate was similar for the two groups (1.3 % versus 4.4%). DISCUSSION AND CONCLUSION This study is the first comparing complications occurring after extraction with KIWI vacuum extractor to those occurring with other instruments. Although the results are limited by the retrospective nature of the study and the small size of the workforce, our study suggests that Kiwi vacuum extractor is associated with a lower rate of maternal complications and a rate of fetal complication similar to other kind of instruments. This instrument should be promoted and taught to younger patricians. Our study also revealed higher failure and shoulder dystocia rates. Larger studies are needed to better evaluate risks factor concerning these two complications in order to optimise the use of Kiwi vacuum extractor.

La technique du ganglion sentinelle dans le cancer de la vulve : état des lieux

In vulvar cancer, lymph node status is a major prognostic factor. Currently, the reference regarding nodal exploration is the groin lymphadenectomy responsible for a significant morbidity. The sentinel node technique in breast cancer has become a standard of care. This technique has been studied for fifteen years in vulvar cancer, on small numbers because of its low incidence. There is not yet consensus about its use in practice. This article is a focus on this technology, its feasibility and the benefits of sentinel node detection applied to vulvar cancer.

OC14.02: The practice of abdominal ultrasound in cases of severe or life‐threatening post‐partum haemorrhage: evaluation in 137 patients in a French tertiary care center

O. Morel1, R. Lousquy2, C. Malartic1, E. Gayat3, Y. Fargeaudou4, P. Soyer4, E. Barranger2 1Obstetrics and Gynecology, Maternite Regionale Universitaire de Nancy, Nancy, France; 2Obstetrics and Gynaecology Department, Lariboisiere Hospital, AP-HP, Paris, France; 3Anesthesiology Department, Lariboisiere Hospital, AP-HP, Paris, France; 4Interventional Radiology Unit, Lariboisiere Hospital, AP-HP, Paris, France

OP30.06: Interest of pelvic magnetic resonance imaging for the pre therapeutic evaluation of symptomatic uterine fibroids: evaluation in 68 cases

Objectives: To evaluate the effect of Mirena intrauterine device (IUD), depot medroxyprogesterone acetate (Depo Provera) and Progestin only pills on endometrial thickness, uterine artery Doppler and subendometrial blood flow. Methods: A prospective controlled trial was done including 120 patients from July 2006 to July 2008. They were classified into 4 groups (30 each); Group I: patients not using any contraceptives (controls), Group II: patients using Mirena IUD, Group III: patients using Depo-Provera and Group IV: patients using Progestin-only pills. All patients were subjected to transvaginal sonography (TVS) to measure endometrial thickness (ET), uterine artery (UA) pulsatility index (PI) and resistance index (RI) and the presence or absence of subendometrial flow (SEF). Results: ET was significantly less in Group II and III when compared to Group IV (p < 0.001 for both) and when compared to Group I (p < 0.001 for both). On the other hand, there was no significant difference between Group IV and Group I regarding ET (p = 0.923). UA RI and PI were significantly higher in Group II and III compared to Group IV (p < 0.001 and 0.001 respectively) and to Group I (p = 0.009 and p = 0.013 respectively). There was no significant difference between Group IV and the Group I regarding UA RI and PI. The presence of subendometrial blood flow was more frequent in Group IV (86.7%) in comparison to Group II (36.7%) and Group III (40.0%) (p < 0.001). Incidence of amenorrhea was directly related to the degree of increase in RI and PI of the UA. Conclusion: ET was significantly reduced in users of Mirena and Depo Provera but not in Progestin only pills users when compared to controls confirming their local effect on the endometrium. Thus, both can be effectively used in the treatment of endometrial hyperplasia. The combination of local endometrial effect and diminished uterine artery blood flow would explain the increased prevalence of amenorrhea among those patients.