Guillaume Ducarme

Obstetric outcome following laparoscopic adjustable gastric banding.

Objective: To evaluate obstetric outcomes following laparoscopic adjustable gastric banding (LAGB) in obese women. Methods; Obstetric outcomes were compared in a retrospective case‐control study with 427 obese women, 13 who underwent LABG and 414 who did not. Results: The mean weight gain during pregnancy was significantly lower in the LABG group than among controls (5.5 kg vs. 7.1 kg; P < 0.05). The incidence of pre‐eclampsia, gestational diabetes mellitus, low birth weight, and fetal macrosomia was less in the LABG group (P < 0.05), and the incidence of cesarean deliveries during labor was half in the LAGB group (15.3% vs. 34.4%; P < 0.01). Neonatal outcomes were not significantly different in the 2 groups. Conclusions: Among obese women, the incidence of adverse obstetric outcomes was less in those who underwent LABG than in those who did not. These results suggest that obese women who wish to become pregnant would decrease their risk of obstetric complications if they first underwent LAGB.

Hydrosalpinx and infertility: what about conservative surgical management?

OBJECTIVE The aim of this study was to assess and validate a management protocol for infertile patients affected by at least one hydrosalpinx. STUDY DESIGN Eighty-one consecutive infertile normo-ovulatory patients with uni or bilateral hydrosalpinx planed to be surgically managed were included in the protocol from November 2003 to May 2007. During laparoscopy, a systematic evaluation of the tubes was firstly conducted and the local management protocol based on validated tubal prognostic scores was applied. Surgery for hydrosalpinx was either conservative by neosalpingostomy or radical by salpingectomy. The primary end-point was the cumulative clinical pregnancy rate. RESULTS 115 hydrosalpinges out of 153 present tubes were confirmed during laparoscopy. Neosalpingostomy was possible in 35 patients featuring 50 hydrosalpinges (43.2% and 43.5%, respectively). Salpingectomy was necessary for the others (46 patients representing 65 hydrosalpinges). The mean follow-up period was 31.8 ± 12.4 months. The overall cumulative pregnancy rate was 61% per couple who completed the protocol (33/54 patients). The cumulative pregnancy rate was 50% after IVF in patients who underwent bilateral salpingectomy. Among patients with at least one functional tube, the overall cumulative pregnancy rate was 63.3%, with a spontaneous pregnancy rate of 30.4%. CONCLUSION Hydrosalpinx management can be conservative with a tubal conservative of 43.5% and fair chances for spontaneous conception. An integrated management of hydrosalpinx including ART actually leads to a cumulative pregnancy rate of 61% per patient.

Maternal and Neonatal Morbidity After Attempted Operative Vaginal Delivery According to Fetal Head Station.

OBJECTIVE: To compare severe short-term maternal and neonatal morbidity associated with midpelvic and low pelvic attempted operative vaginal delivery. METHODS: Prospective study of 2,138 women with live singleton term fetuses in vertex presentation who underwent an attempted operative vaginal delivery in a tertiary care university hospital. We used multivariate logistic regression and propensity score methods to compare outcomes associated with midpelvic and low pelvic delivery. Severe maternal morbidity was defined as third- or fourth-degree perineal laceration, perineal hematoma, cervical laceration, extended uterine incision for cesarean delivery, postpartum hemorrhage greater than 1,500 mL, surgical hemostatic procedures, uterine artery embolization, blood transfusion, infection, thromboembolic events, admission to the intensive care unit, and maternal death; severe neonatal morbidity was defined as 5-minute Apgar score less than 7, umbilical artery pH less than 7.00, need for resuscitation or intubation, neonatal trauma, intraventricular hemorrhage greater than grade 2, neonatal intensive care unit admission for more than 24 hours, convulsions, sepsis, and neonatal death. RESULTS: From December 2008 through October 2013 there were 2,138 attempted operative vaginal deliveries; 18.3% (n=391) were midpelvic, 72.5% (n=1,550) low, and 9.2% (n=197) outlet. Severe maternal morbidity occurred in 10.2% (n=40) of midpelvic, 7.8% (n=121) of low, and 6.6% (n=13) of outlet attempts (P=.21); and severe neonatal morbidity in 15.1% (n=59), 10.2% (n=158), and 10.7% (n=21) (P=.02), respectively. Multivariable logistic regression analysis found no significant difference between midpelvic and low attempted operative vaginal delivery for either composite severe maternal (adjusted odds ratio [OR] 1.01, 95% confidence interval [CI] 0.66–1.55) or neonatal morbidity (adjusted OR 1.25, 95% CI 0.84–1.86). Similarly, propensity score matching found no significant difference between midpelvic and low operative vaginal delivery for either severe maternal (adjusted OR 0.69, 95% CI 0.39–1.22) or neonatal morbidity (adjusted OR 0.88, 95% CI 0.53–1.45). CONCLUSION: In singleton term pregnancies, midpelvic attempted operative vaginal delivery compared with low pelvic attempted operative vaginal delivery was not associated with an increase in severe short-term maternal or neonatal morbidity. LEVEL OF EVIDENCE: II

Efficacy of transient abdominal ovariopexy in patients with severe endometriosis.

OBJECTIVE To assess adhesion formation and fertility outcome after transient abdominal ovariopexy performed in patients with severe endometriosis. STUDY DESIGN Retrospective study including 218 patients who underwent surgery for severe endometriosis from 1997 to 2009. One hundred and thirty-nine (64%) patients were infertile. The initial ASRM stage was IV in 139 cases, III in 43 cases and II in 36 cases. Adnexal adhesions were scored by using the Operative Laparoscopy Study Group (OLSG) and modified AFS scoring systems. Unilateral or bilateral transient abdominal ovariopexy of 336 ovaries was performed to prevent adhesion formation or reformation for extensive surgery. In patients who underwent a second operation, adnexal adhesion scores were reported. Fertility outcome was evaluated by a questionnaire. RESULTS Second-look surgery was performed after 11.7 ± 2.4 months in 24 patients (11%) who had undergone 38 ovariopexies. Transient abdominal ovariopexy significantly decreased adnexal adhesion scores (p<0.05). Regarding fertility outcome, the median follow up was 19.6 ± 1.5 months. Fifty-eight patients, out of 105 infertile women who actively tried to conceive after surgery, conceived, 21 (36%) spontaneously and 37 (64%) after ART. The median time interval for conception was 8.6 ± 1 months. CONCLUSION In patients with severe endometriosis, transient abdominal ovariopexy is an effective technique in preventing postoperative adhesion formation and in improving fertility outcome. CONDENSATION In 218 patients with severe endometriosis, transient abdominal ovariopexy was an effective technique in preventing adhesion formation and improving fertility outcome.

Cornual heterotopic pregnancy: a case report.

IntroductionCornual heterotopic pregnancy is a very rare condition; its incidence remains unknown. We report a case of cornual heterotopic pregnancy managed by laparoscopy and guided methotrexate injection into the cornual sac.Case presentationA cornual heterotopic pregnancy was diagnosed at 9 weeks of amenorrhoea in a 31-year-old healthy woman. Ultrasound examination showed a well-formed intrauterine gestation without detectable fetal heart pulsation, together with a gestational sac situated in the right cornual region. After uterine evacuation under ultrasound guidance, the diagnosis of cornual pregnancy was confirmed on laparoscopy followed by methotrexate injection into the cornual gestational sac.ConclusionsCornual heterotopic pregnancy is a very rare and potentially dangerous condition. Diagnosis of cornual pregnancy could be made on ultrasound examination in this patient. Laparoscopy was useful as an alternative in confirming the diagnosis and aided further treatment.

Pregnancy outcomes after laparoscopic sleeve gastrectomy among obese patients

To analyze pregnancy outcomes after laparoscopic sleeve gastrectomy (LSG) according to body mass index (BMI) at conception and the interval between LSG and pregnancy.

Pregnancy and delivery in patients with portal vein cavernoma.

Background: Portal vein cavernoma (PVC) is a rare disease resulting from extrahepatic portal vein thrombosis and development of collateral venous circulation. The management of pregnancy and delivery in woman with PVC has rarely been described. Cases: Two primiparous women are presented to illustrate the management of PVC during pregnancy and discuss the delivery route according to the symptoms and the PVC complications. The first patient presented PVC associated with large jejunal varices and high anticardiolipid antibodies. She was treated with β-blocker therapy and low molecular weight heparin during pregnancy, and delivered by cesarean section. The second patient presented protein S deficiency complicated by PVC and thrombocytopenia and delivered vaginally without complications. Conclusion: Many issues should be considered when counseling women with PVC, including the management before and during pregnancy according to symptoms and PVC complications. A multidisciplinary approach seems to be key to the management of delivery. Our advice to caregivers is that elective cesarean section seems necessary in cases with digestive varices. Vaginal delivery, with a passive second stage, seems to be relatively safe and less morbid in women without digestive varices, when maternal and fetal tolerance permits.

Apport du bistouri à ultrasons dans la reconstruction mammaire autologue par lambeau de grand dorsal

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 35 - N° 8 - p. 762-766

Safety of transient abdominal ovariopexy in patients with severe endometriosis

To evaluate complications of transient ovariopexy performed to reduce adhesions in patients with severe endometriosis.

Acute rectal ischemia following failed uterine artery embolization and emergency hysterectomy for postpartum hemorrhage

Acute rectal ischemia is rare. The rectum is often spared in cases of ischemic colitis owing to its abundant collateral blood supply [1]. Uterine artery embolization is an effective second-line therapy used to control massive postpartum hemorrhage when medical treatment has failed to stop the bleeding [2,3]. However, the transitory subischemic conditions induced by embolotherapywhen a patient is in hemorrhagic shock may disturb the pelvic arterial blood flow. The present case describes an acute full-thickness ischemic proctitis following failed uterine artery embolization and subsequent emergency hysterectomy for postpartum hemorrhage. A 34-year-old patient (G3,P2) was admitted in November 2013 in spontaneous labor at 41 weeks of pregnancy and delivered vaginally four hours later. The patient had no significant personal or family history of disease. Immediately after delivery the patient suffered uterine atony and a postpartum hemorrhage of greater than 500 mL of blood,which necessitated promptmedicalmanagement (active resuscitation, manual exploration of the uterine cavity, and administration of the uterotonic drugs oxytocin and sulprostone), which was unsuccessful at controlling the bleeding. The uterine arteries were selectively catheterized and bilateral uterine artery embolization was performed— two hours after the hemorrhage had begun—using a semi-gelatin sponge on each side (Gelita-Spon, Gelita Medical GmbH, Eberbach, Germany), but without success. Uterine bleeding remained uncontrollable and the patient’s vital signs were unstable; therefore, total hysterectomy with blood transfusion was performed. Postoperative recovery was uneventful. Nine days after surgery the patient experienced diarrhea and pelvic pain. MRI showed full-thickness rectal necrosis associated with a voluminous left ischiorectal abscess and a transsphincteric fistula between the abscess and the rectum (Fig. 1). Endoscopic examination of the anal canal and lower rectum under general anesthesia confirmed acute ischemic proctitis extending 15 cm proximally from the dentate line, and a left ischiorectal abscess that was treated by excision and drainage. Laparoscopic sigmoid colostomy was performed to maintain a clean environment for healing. Testing for Clostridiumdifficile colitis was negative. A repeat lower endoscopy at day 24 after delivery showed a low transsphincteric rectovaginal fistula, which was drained using a loose seton stitch. Postoperative recovery was uneventful, and the patient was discharged 30 days after delivery. Six months later, healthy rectal tissue was present; however, the anal sphincter remained inefficient. Acute ischemic colitis commonly occurs in the splenic, descending, and sigmoid colon. The rectum is involved in less than 2% of all cases [1]. Ischemic proctitis is most commonly described in 70year-old men (75%) and secondary to radiotherapy, severe aortoiliac occlusive disease, tumor encasement of the rectum, or prior vascular surgery with interruption of the collateral blood supply [1,4]. In the present case, the transitory subischemic conditions in the pelvic area induced by embolotherapy in a patient with hypotension and in hemorrhagic shock may explain the occurrence of acute ischemic proctitis. Diagnosis of acute ischemic proctitis may be indicated by pelvic pain associated with diarrhea and lax or absent anal sphincter tone in a patient with a major illness or hemodynamic disturbance [1,4]. It requires pelvic imaging (computerized tomography, color flow Doppler imaging, angiography, or MRI) and a definitive diagnosis is obtained by proctosigmoidoscopy [1]. Adequate management of acute ischemic proctitis is controversial, depends on the clinical status of the patient, and on the assessment of the degree of ischemia at proctosigmoidoscopy. Conservative management with antibiotics is appropriate for uncomplicated acute ischemic proctitis. Patients with more severe degrees of rectal ischemia may develop bowel perforation necessitating a proctectomy or colonic diversion [1,4]. Acute ischemic proctitis is an exceptional complication of transitory subischemic conditions in the pelvic area following failed uterine artery embolization for postpartum hemorrhage. Hypotension and hemorrhagic shock should be controlled in patients with massive postpartum hemorrhage to prevent low pelvic arterial flow.