G. Ducarme

Pregnancy in women with known and treated Budd–Chiari syndrome: Maternal and fetal outcomes

BACKGROUND/AIMS Budd-Chiari syndrome (BCS) mainly affects women of childbearing age. We aimed to clarify whether pregnancy, a thrombotic risk factor, should be contraindicated in patients with known and treated BCS. METHODS A retrospective study of pregnancy in women with known and treated BCS. RESULTS Sixteen women had 24 pregnancies. Nine women had undergone surgical or radiological treatment. Anticoagulation was administered during 17 pregnancies. Seven fetuses were lost before gestation week 20. Deliveries occurred between week 20 and 31 in two patients, week 32 and 36 in eleven and after week 37 in four. There was one stillbirth, but 16 infants did well. Factor II gene mutation was a factor for a poor outcome of pregnancies. In two patients, symptomatic thrombosis recurred during pregnancy or postpartum. All patients were alive after a median follow-up of 34 months after the last delivery. Bleeding at delivery, although non-lethal, occurred only on anticoagulation therapy. CONCLUSIONS When known and treated BCS is well controlled, pregnancy should not be contraindicated as maternal outcome, and fetal outcome beyond gestation week 20, are good. The risk-benefit ratio of anticoagulant therapy needs to be further clarified. Patients should be fully informed of the persistent risks of such pregnancies.

Risk of synechiae following uterine compression sutures in the management of major postpartum haemorrhage

Please cite this paper as: Poujade O, Grossetti A, Mougel L, Ceccaldi P, Ducarme G, Luton D. Risk of synechiae following uterine compression sutures in the management of major postpartum haemorrhage. BJOG 2011;118:433–439.

Laparoscopic adenectomy: a novel technique for managing benign prostatic hyperplasia.

The prostatic capsule is opened 3–4 cm transversally according to prostate size. Haemostatic sutures are placed at the 5 and 7 o’clock positions. Coagulation is obtained by bipolar diathermy. For the first three patients the right index finger was introduced through a 2-cm suprapubic incision into the capsule, permitting enucleation of the adenoma as with the open technique (Fig. 3). After closing the incision, CO 2 was again insufflated to control the section of the adenoma at the apex, which is always visible with the laparoscope. For the last two patients, enucleation was entirely under laparoscopic control without using the finger. The specimen was then placed in the lateral prostatic fossa to await removal. A 22 F irrigation catheter is then introduced (Fig. 4) and a running suture of 2–0 polyglactin used to close the prostatic capsule (Fig. 5). A suction drain is placed in the Retzius space by a lateral trocar. The bladder is irrigated as before with a saline solution. At the end of the procedure, the specimen is placed in a laparoscopic bag and extracted through the enlarged umbilical incision.

Characteristics and outcome of fetal cystic hygroma diagnosed in the first trimester

Objective. The aim of this study was to determine the course of pregnancy and the neonatal outcome of fetuses with cystic hygroma diagnosed at 10–14 weeks’ gestation. Methods. Maternal and fetal data (nuchal translucency, karyotype, pregnancy outcome) in cases of fetal cystic hygroma, admitted or referred to our antenatal diagnostic centre, were prospectively entered into a computer database. Paediatric outcome was analysed when relevant. Results. Some 72 fetuses had cystic hygroma. The mean size of the cystic hygroma was 7.9 mm. Chromosomal abnormalities were present in 52.7% of cases (38/72), including 14 cases (36.8%) of Down syndrome. A total of 34 chromosomally normal pregnancies gave rise to 18 live births (52.9%), with no visible serious structural abnormalities. The outcome of pregnancy was unfavourable (miscarriage, elective termination, serious structural abnormalities) in 77.7% of cases (56/72). The 18 live‐born infants were followed up for 17–98 months. Sixteen infants developed normally, while 1 developed Noonans syndrome and 1 had a urinary tract abnormality (pyelo‐ureteral junction; PUJ). Conclusion. These data suggest that the prognosis of fetal cystic hygroma detected during the first trimester is poor, and show that sonographic evaluation of fetal nuchal translucency thickness in the first trimester is crucial.

Intérêt du gel d'acide hyaluronique dans la prévention des synéchies intra-utérines après hystéroscopie opératoire : Étude cas-témoin

OBJECTIVES To evaluate the efficacy of auto-cross-linked hyaluronic acid gel in the prevention of adhesions after operative hysteroscopy using a case-control study. MATERIALS AND METHODS Fifty-four patients with an intrauterine lesion (myoma, polyp, uterine septa and adhesions) undergoing hysteroscopic surgery were divided into two groups: group A (30 patients) with intrauterine application of hyaluronic acid gel at the end of the surgical procedure and group B, which was considered as control (24 patients). The rate of adhesion formation, the score and the adhesion severity were estimated for each group using American Fertility Society (AFS) classification, by diagnostic hysteroscopy two months after surgery. No other treatment was associated. RESULTS Age, weight, parity, hysterometry were comparable in the two groups. Surgery indications were polyp(s), myoma(s), uterine septa, and adhesions (11, 8, 1, and 10 patients in group A and 6, 6, 4, and 8 patients in group B, respectively). No difference was observed in intrauterine adhesion formation between the two groups (33.3% for group A and B; p = NS). The median adhesion scores using AFS were comparable in the two groups (1.30+/-2.35 vs 1.42+/-2.47; respectively, p = NS). The severity of the adhesions showed no significant difference between the two (70% stage I, mild adhesions; 20% stage II, moderate adhesions; 10% stage III, severe adhesions and 62.5% stage I; 25% stage II; 12.5% stage III in the group A and B, respectively). No adverse effect with the ACP gel was detected. CONCLUSION ACP gel does not reduce the incidence and the severity of intrauterine adhesions after hysteroscopic surgery.Resume Objectif Evaluer l’efficacite du gel d’acide hyaluronique pur reticule dans la prevention des synechies intra-uterines apres hysteroscopie operatoire a l’aide d’une etude cas-temoin. Materiels et methodes Cinquante-quatre patientes, en âge de procreer, porteuses d’une pathologie intra-uterine (polype, myome de type 0 ou 1, cloison, synechies) ont beneficie d’une hysteroscopie operatoire et ete reparties en 2 groupes : groupe A avec application d’un gel d’acide hyaluronique dans la cavite uterine en fin d’intervention (30 patientes) et groupe B, considere comme controle (24 patientes). Le taux de synechies intra-uterines, le score et le stade adherentiel selon l’American Fertility Society (AFS) ont ete compares a l’issue d’une hysteroscopie diagnostique de controle, realisee 2 mois apres le geste operatoire. Aucun autre traitement pouvant avoir une influence uterine n’a ete associe. Resultats L’âge moyen, le poids, la parite et l’hysterometrie etaient comparables dans les 2 groupes. L’indication operatoire etait la presence d’un ou plusieurs polypes, de myome (s), de cloison uterine, et de synechies (11, 8, 1, et 10 patientes dans le groupe A et 6, 6, 4, et 8 patientes dans le groupe B, respectivement). Le taux de synechies lors de l’hysteroscopie de controle etait comparable dans les 2 groupes (33,3 % dans les 2 groupes ; p = NS). Le score moyen des adherences selon l’AFS etait comparable dans les 2 groupes (1,30 ± 2,35 vs 1,42 ± 2,47; p = NS). La severite des synechies n’etait pas differente entre les 2 groupes (70 % de stade I, 20 % de stade II et 10 % de stade III pour le groupe A et 62,5 % de stade I, 25 % de stade II et 12,5 % de stade III pour le groupe B). Aucun effet secondaire du gel n’a ete observe. Conclusion La mise en place d’un gel d’acide hyaluronique ne modifie pas l’incidence et la severite des synechies intra-uterines apres hysteroscopie operatoire.

Iodine deficiency in northern Paris area: impact on fetal thyroid mensuration.

Introduction Iodine is essential for normal fetal and neonatal development. We studied the prevalence and impact on fetal thyroid development of iodine deficiency in pregnant women in the northern part of the Paris conurbation. Materials and Methods 110 patients underwent several determinations of urinary iodine excretion (UIE) and of serum FT4, FT3, and TSH. Fetal thyroid gland size was assessed using ultrasonography. Results We found evidence of widespread iodine deficiency (mean UIE, 49.8 µg/L [standard deviation, 2.11]). Iodine deficiency did not correlate significantly with maternal thyroid parameters but showed a significant negative correlation with fetal thyroid gland size (rho = 0.25, P = 0.02). Conclusion Iodine deficiency during pregnancy is still a problem in our geographical area and affects the fetal thyroid gland. Clinical Trials.gov NCT00162539

Pregnancy in women with portal vein thrombosis: Results of a multicentric European study on maternal and fetal management and outcome

BACKGROUND & AIMS Women of childbearing age account for approximately 25% of patients with non-cirrhotic portal vein thrombosis (PVT). We aimed at assessing maternal and fetal outcome in pregnant women with known PVT. METHODS We performed a retrospective analysis of the files of women with chronic PVT in three European referral centers between 1986 and 2010. RESULTS Forty-five pregnancies, 28 (62%) treated with low molecular weight heparin, occurred in 24 women. Nine (20%) were lost before gestation week 20. Preterm birth occurred in 38% of deliveries: there were 3 births at week 24-25, 7 at week 32-36, and 26 after week 37. A term birth with a healthy infant occurred in 58% of pregnancies. Cesarean section was used in 53% of deliveries. Two women developed HELLP syndrome. A favorable outcome happened in 64% of pregnancies. Pregnancies with an unfavorable outcome were associated with a higher platelet count at diagnosis. Bleeding from esophageal varices occurred in 3 patients during pregnancy, all without adequate primary prophylaxis. Genital or parietal bleeding occurred postpartum in 4 patients, only one being on anticoagulation therapy. Thrombotic events occurred in 2 patients, none related to lower limbs or mesenteric veins. There were no maternal deaths. CONCLUSIONS In pregnant PVT patients treated with anticoagulation on an individual basis, the rate of miscarriage and preterm birth appears to be increased. However, fetal and maternal outcomes are favorable for most pregnancies reaching gestation week 20. High platelet counts appear to increase the risk for unfavorable outcome. Pregnancy should not be contraindicated in stable PVT patients.

Foie et prééclampsie

HELLP syndrome complicates PE in 5 to 20 % of cases. The clinical manifestations (i.e. epigastric pain, elevated liver enzymes, thrombocytopenia and hemolysis) are secondary to the fibrin deposit within the peri-portal sinusoids. The clinical presentation of HELLP syndrome can be misleading. It is therefore necessary to suspect this complication whenever a PE patient develops gastro-intestinal pain. The interruption of pregnancy is the only effective treatment against HELLP syndrome. If it can be safely performed passed the 34(th) week of amenorrhea, a protective attitude should be adopted prior to reaching this date. This consists of the administration of corticosteroid therapy for fetal pulmonary maturation, intensive clinical, biological and sonographic monitoring of the mothers parameters. The administration of corticosteroids or performing a plasmapharesis is not recommended for the treatment of established HELLP syndrome because neither improves the maternal or neonatal outcome. The differential diagnosis may also include acute fatty liver of pregnancy. An early liver impairment, polyuria-polydipsia syndrome and a rise in INR support this diagnosis.

Amniocentèse et risque viral (hépatites virales B, C et VIH)

Very few studies have properly addressed to the risk of fetal hepatitis B (HBV), hepatitis C (HCV) or human immunodeficiency virus (HIV) infection through amniocentesis. For HBV, this risk is low. However, knowledge of the maternal hepatitis B e antigen status is valuable in the counselling of risks associated with amniocentesis. For HCV, the risk is not well known but cannot be excluded. For HIV, it seems rational to propose a viral test before amniocentesis for patients with contaminations risk and to postpone the sampling in cases with positive results in order to obtain an undetectable HIV-1 RNA viral load. For these reasons, it can be useful to analyse for each virus the benefit of amniocentesis and the risk of mother-to-infant transmission, and to inform the patient.

Intérêt de l’instillation pariétale unique de ropivacaïne dans la prévention des douleurs après césarienne

OBJECTIVE To assess the efficiency of single-shot ropivacaine wound infiltration during cesarean section for postoperative pain relief, using a prospective, randomized, double-blinded study. PATIENTS AND METHODS One hundred consecutive patients with planned cesarean section were enrolled between September 2007 and May 2008 and randomized into two groups: single-shot wound infiltration of 20mL of ropivacaine 7.5mg/mL (Group R; n=56) or single-shot wound infiltration of 20mL of saline solution (group T; n=44). The primary goal of this study was the double-blinded evaluation of the postoperative pain after coughing and leg raise using the 100-mm visual analog scales (VAS) during the first 48 postoperative hours after cesarean delivery. The secondary goals were the occurrence of nausea and vomiting and the morphine consumption. RESULTS Numerical pain rating scale for pain evaluation was significantly lower (P<0.05) in the ropivacaine group than in the control group at M0, M20, M40, M60, H2 and H4. But, at H8, H12 and H24, no significant difference for VAS was noted between the two groups. The occurrence of nausea and vomiting and the total morphine consumption were not significantly different between the two groups during the first 48 postoperative hours. DISCUSSION AND CONCLUSION Single-shot ropivacaine wound infiltration during planned cesarean section is a simple and safe procedure that provides effective reduction of post-partum pain within the first 4hours.