Christine Louis-Sylvestre

Congenital adenomatoid malformation of the lung: When is active fetal therapy indicated?☆☆☆★

OBJECTIVE Although aggressive fetal therapies such as thoracoamniotic shunting can be applied to cystic adenomatoid malformations of the lung diagnosed in utero, there is no clear consensus regarding their indications. Our purpose was to evaluate a management policy in which aggressive fetal therapy was restricted to those cases complicated by major polyhydramnios or hydrops; all other cases were managed conservatively. STUDY DESIGN A prospective cohort study of 33 cases with a prenatal diagnosis of cystic adenomatoid malformations of the lung was performed. Thoracoamniotic shunting was offered only in nine macrocystic cases with acute polyhydramnios or hydrops. RESULTS Four cases were diagnosed postnatally as sequestrations. Of 12 cases complicated by acute polyhydramnios or hydrops, 5 survived (1 type III with spontaneous incomplete resolution in utero, 4 type I with substantial volume reduction after shunting). The 17 cases without acute polyhydramnios or hydrops were managed conservatively and survived. CONCLUSION Conservative management is indicated in cases of cystic adenomatoid malformations of the lung without acute polyhydramnios or hydrops.

Paget’s disease of the vulva: results of different conservative treatments

OBJECTIVE To evaluate three conservative treatments for vulvar Pagets disease: wide excision, laser alone, or limited surgery associated with laser. STUDY DESIGN A retrospective analysis of 52 patients treated with wide excision (31 cases), limited surgery, and peripheral laser [Br J Obstet Gynecol 1995;102:359], or laser alone [Gynecol Oncol 1975;3:46]. RESULTS Mean time to recurrence was 1+/-0.6 years after laser alone, 1.9+/-1.5 years after the association limited excision and peripheral laser, and 2.7+/-1 years after wide excision alone. At 1 year recurrence rates were 67% after laser alone, 33% after the association laser plus surgery, and 23% after wide excision. CONCLUSION Conservative management preserves vulvar anatomy and function, but recurrence rates are high.

Longitudinal vaginal septum: a retrospective study of 202 cases

OBJECTIVE To assess issues and management of longitudinal vaginal septum. STUDY DESIGN The charts of 202 patients referred for a longitudinal vaginal septum over a 24 year period were reviewed. RESULTS The most common septa were complete and high partial. Associated uterine malformations were frequent (87.8% of the cases), especially in complete or partial high septum (99.4%). The septum was asymptomatic in 56.4% of the cases. Obstetrical concerns are mainly related to a uterine malformation, but a thick septum may be responsible for dystocia. CONCLUSION Less than half of the vaginal septa are symptomatic enough to require surgical treatment. However, for obstetrical issues management should include a thorough evaluation of uterine anatomy and preventive section of the septum even when asymptomatic.

Creation of a sigmoid neovagina: technique and results in 16 cases

OBJECTIVE For correction of the absence of vagina, sigmoidal colpoplasty is believed to provide a neovagina immediately adequate and with permanent patency. We present one of the largest series and discuss advantages and drawbacks of this procedure. STUDY DESIGN Our personal technique is described and 16 consecutive cases are reviewed. Anatomical (depth and width of the neovagina) and functional (existence of discharge and coital function) aspects are addressed. RESULTS An adequate neovagina was obtained in every case, however, in nine cases iterative dilatations were previously required. Two prolapses of the nevagina were noticed and required surgical treatment. The follow up ranges from 6 to 36 months. At this point, only nine patients report intercourse. In five cases a psychological brake is strongly suspected to interfere. Four patients experience significant discharge. CONCLUSION Despite satisfactory anatomical results, the sigmoid neovagina is not always immediately suitable. Complete adequacy for coital function often requires prolonged care and support.

In vitro studies of the interactions between platelets and amniotic membranes: a potential treatment for preterm premature rupture of the membranes.

OBJECTIVE Thus far there is no satisfactory treatment for preterm premature rupture of the amniotic membranes. To evaluate the use of platelets to seal the membranes, we investigated in vitro interactions between platelets and the membranes. STUDY DESIGN Platelet aggregation in the presence of amnion, chorion, and amniotic fluid was quantified. Platelet adhesion to the fetal membranes was investigated by electron microscopy. In addition, a model system was designed to evaluate the capacity of platelets to seal a standardized puncture in the membranes. RESULTS Platelets aggregated in response to amnion but not to chorion or amniotic fluid. Adhesion and activation occurred on connective tissues underlying amnion and chorion but not on the amniotic epithelium. Platelets sealed a puncture in fetal membranes, and the platelet plug was visualized by electron microscopy. CONCLUSIONS Exposed connective tissue of amniotic membranes was demonstrated to trigger platelet adhesion, aggregation, and activation, and platelets were shown to seal a standardized puncture in fetal membranes. Our results indicate that platelets might be useful for treatment of ruptured membranes after needle puncture.

Surgery is not superior to dilation for the management of vaginal agenesis in Mayer-Rokitansky-Küster-Hauser syndrome: a multicenter comparative observational study in 131 patients

BACKGROUND: Vaginal agenesis in Mayer‐Rokitansky‐Küster‐Hauser syndrome can be managed either by various surgeries or dilation. The choice still depends on surgeon’s preferences rather than on quality comparative studies and validated protocols. OBJECTIVE: We sought to compare dilation and surgical management of vaginal agenesis in Mayer‐Rokitansky‐Küster‐Hauser syndrome, in terms of quality of life, anatomical results, and complications in a large multicenter population. STUDY DESIGN: Our multicenter study included 131 patients >18 years, at least 1 year after completing vaginal agenesis management. All had an independent gynecological evaluation including a standardized pelvic exam, and completed the World Health Organization Quality of Life instrument (general quality of life) as well as the Female Sexual Function Index and Female Sexual Distress Scale‐Revised (sexual quality of life) scales. Groups were: surgery (N = 84), dilation therapy (N = 26), and intercourse (N = 20). One patient was secondarily excluded because of incomplete surgical data. For statistics, data were compared using analysis of variance, Student, Kruskal‐Wallis, Wilcoxon, and Student exact test. RESULTS: Mean age was 26.5 ± 5.5 years at inclusion. In all groups, World Health Organization Quality of Life scores were not different between patients and the general population except for lower psychosocial health and social relationship scores (which were not different between groups). Global Female Sexual Function Index scores were significantly lower in the surgery and dilation therapy groups (median 26 range [2.8–34.8] and 24.7 [2.6–34.4], respectively) than the intercourse group (30.2 [7.8–34.8], P = .044), which had a higher score only in the satisfaction dimension (P = .004). However, the scores in the other dimensions of Female Sexual Function Index were not different between groups. The Female Sexual Distress Scale‐Revised median scores were, respectively, 17 [0–52], 20 [0–47], and 10 [10–40] in the surgery, dilation therapy, and intercourse groups (P = .38), with sexual distress in 71% of patients. Median vaginal depth was shorter in dilatation therapy group (9.6 cm [5.5–12]) compared to surgery group (11 cm [6–15]) and intercourse group (11 cm [6–12.5]) (P = .039), but remained within normal ranges. One bias in the surgery group was the high number of sigmoid vaginoplasties (57/84, 68%), but no differences were observed between surgeries. Only 4 patients achieved vaginas <6.5 cm. Delay between management and first intercourse was 6 months (not significant). Seventy patients (53%) had dyspareunia (not significant), and 17 patients all from the surgery group had an abnormal pelvic exam. In the surgery group, 34 patients (40.5%) had complications, requiring 20 secondary surgeries in 17 patients, and 35 (42%) needed postoperative dilation. In the dilation therapy group, 13 (50%) needed maintenance dilation. CONCLUSION: Surgery is not superior to therapeutic or intercourse dilation, bears complications, and should therefore be only a second‐line treatment. Psychological counseling is mandatory at diagnosis and during therapeutic management.