L. Marpeau

Magnesium sulphate given before very‐preterm birth to protect infant brain: the randomised controlled PREMAG trial*

Objective  To evaluate whether magnesium sulphate (MgSO4) given to women at risk of very‐preterm birth would be neuroprotective in preterm newborns and would prevent neonatal mortality and severe white‐matter injury (WMI).

Adnexal torsion: a report on forty-five cases

OBJECTIVES To evaluate the clinical findings, evolution of treatment and ovarian function following conservative therapy. STUDY DESIGN A case series of 45 patients presenting with adnexal torsion between January 1989 and June 1999. All patients were surgically treated, either conservatively or radically. Patients who had received conservative treatment, interviewed by phone and underwent ovarian sonographic examination. RESULTS Adnexal torsion is more frequent in young women with adnexal pathology. Conservative therapy by laparoscopy has gained increasing preference as a surgical procedure. It is safe and preserves ovarian function. CONCLUSIONS Conservative therapy by laparoscopy is recommended to preserve ovarian function in young women.

Direct proportional relationship between endometrioma size and ovarian parenchyma inadvertently removed during cystectomy, and its implication on the management of enlarged endometriomas

BACKGROUND The aim of this study was to estimate whether or not the size of an endometrioma is related to the thickness of the ovarian parenchyma inadvertently excised along with the cyst wall. METHODS We performed a retrospective study including 35 women who had undergone endometrioma cystectomy, using an ovarian tissue sparing procedure. In total 38 specimens were studied by three pathologists as three women presented bilateral localizations, and all cyst diameters measured at least 30 mm. For each endometrioma, serial sections were performed, and on each section four different sites were randomly chosen to measure the thickness of glandular epithelium and stroma, of subjacent fibrosis, depending on the cyst, and of the ovarian parenchyma removed with the cyst. The diameter of the ovary was measured preoperatively either by MRI or ultrasound, and the area of the internal wall was then calculated. The relationships between the mean thickness of ovarian parenchyma removed and the variables were estimated and a multiple regression model identified independent predictors for ovarian parenchyma thickness. RESULTS Adjacent ovarian tissue was found in 37 cases (97%). The mean thickness of ovarian tissue removed was 1173 +/- 711 microm and that of the cyst wall was 851 +/- 499 microm. The thickness of the ovarian parenchyma removed presented a direct proportional relationship with cyst diameter (P = 0.015), and consequently with cyst wall area (P = 0.032). This relationship with cyst diameter was independent after adjustment on other variables (P = 0.032). CONCLUSION Endometrioma cystectomy even though performed with an accurate surgical technique leads to significant ovarian tissue removal, the thickness of which increases proportionally with cyst diameter.

Abnormal placentation and selective embolization of the uterine arteries

OBJECTIVE Abnormal placentation accounts for more than 50% of uterine artery embolization failure. The authors report their experience in this situation. STUDY DESIGN Seven women presented with abnormal placentation. Uterine artery embolization was carried out in emergency or prophylactic control of postpartum bleeding. RESULTS In five patients, control of postpartum hemorrhage was obtained without hysterectomy. In two cases with no placental removal and prophylactic procedures, hysterectomy and blood transfusion were not necessary. The manual removal of the placenta was achieved secondarily, respectively on the 25th and the 12th day. CONCLUSIONS The success rate of uterine artery embolization for postpartum bleeding appears to be lower with abnormal placentation. In none of the cases with the placenta present was it possible to leave the residual placenta in place. However, embolization may permit a safe waiting period and spontaneous migration of the placenta. When the diagnosis is made before delivery, prophylactic uterine artery embolization without placental removal should be considered to reduce blood transfusion and preserve fertility.

False aneurysm of the uterine pedicle: an uncommon cause of post-partum haemorrhage after caesarean section treated with selective arterial embolization

We report three cases of post-partum haemorrhage following caesarean delivery attributed to a false aneurysm of the uterine pedicle and treated with artery embolization. These lesion were probably post-traumatic in origin related to hysterotomy. Angiographic study of the anterior division of hypogastric arteries confirmed the diagnosis and embolization of the false aneurysm was successful in controlling the haemorrhage.

Mid-term outcome of laparoscopic sacrocolpopexy with anterior and posterior polyester mesh for treatment of genito-urinary prolapse

OBJECTIVES To evaluate the anatomical and functional outcomes of laparoscopic sacrocolpopexy using an anterior and a posterior polyester mesh, for the cure of genital prolapse at one year or longer. STUDY DESIGN This is a consecutive 5 year prospective observational study in which 119 patients presented with at least a Stage 2 apical prolapse, with an anterior or a posterior vaginal wall prolapse, who underwent a double sacrocolpopexy. Two large pore size (≥ 1mm) heavyweight (115 g/m(2)) multifilaments of polyester prostheses (Parietex Prosup PAC/GK 06, Sofradim-Covidien) were exclusively used for this technique. The prostheses were fixed on the levator ani muscles, the vagina and the sacrum with permanent extracorporeal laparoscopic sutures. Pre- and post-operative data referring to international pelvic organ prolapse quantitation classification (POP-Q), scores of quality of life and sexuality (French equivalent of the Pelvic Floor Distress Inventory (PFDI), Pelvic Floor Impact Questionnaire (PFIQ) and Pelvic organ prolapse-urinary Incontinence-Sexual Questionnaire (PISQ-12)) were compared. RESULTS With a mean follow-up of 34 months, 116 patients were accessible for evaluation. For these patients, the anatomical success rates (Stage 0 or 1) on the apical, anterior or posterior compartments were respectively, 97%, 89% and 98%. On the functional level, all the scores of quality of life and sexuality were improved. CONCLUSIONS This study confirms the effectiveness of laparoscopic sacrocolpopexy for the repair of the apical compartment prolapse. It also shows its effectiveness for the anterior compartment repair when the cystocele is moderate and limited to a median defect. In our experience, laparoscopic sacrocolpopexy with heavyweight polyester prosthesis is an effective treatment of the posterior defect.

Laparoscopic myomectomy during pregnancy resulting in septic necrosis of the myometrium

Case reportA 35 year old primiparous woman attended the emer-gency department at 17 weeks of gestation for acute rightiliac fossa pain with guarding. Rebound pelvic examinationwas painful. The patient’s temperature was 38.6jC andlaboratory tests showed no leucoytosis. Ultrasound re-vealed a single intrauterine viable pregnancy equivalentto dates and additionally a uterine mass in the left lateralwall of the uterus, 5 cm in length. Due to a suspectedadnexal torsion, a laparoscopy was performed, whichrevealed a degenerating pedunculated uterine leiomyomawithout torsion of the pedicle. It was situated on theanterior surface of the uterus below the right uterine cornu.Because the woman was so symptomatic, myomectomywas performed by resection of the myoma using monopolarcutting diathermy via a hook electrode with a 40 W poweroutput. Despite the insertion of an endoloop constrictingthe pedicle prior to electroresection, the top of the pediclewas slightly electrocoagulated to ensure perfect hae-mostasis. The uterine cavity was not opened. The myomawas extracted via a transumbilical approach, by morcella-tion. Histological examination confirmed the diagnostic ofaseptic degeneration of uterine leiomyoma. Abdominalpain occurred six days post-operatively, with associatedileus and pus at the umbilical incision but with no fever.The umbilicus was irrigated with Betadine and penicillin Vwas started. Clinical improvement occurred and she wasdischarged from hospital. She returned two weeks laterwith an intestinal obstruction mass in the right iliac fossaand a recurrence of umbilical infection. Ultrasound exam-ination showed collection of 10 cm diameter, comparedwith the area of myomectomy extending to the neighbour-ing myometrium. Laparotomy was performed via an umbil-ical median incision and revealed an abscess on the anteriorsurface of the uterus. It was situated on the scar of thepedicle of the resected myoma. Following peritoneal lavage,a full thickness of myometrium was lost due to uterinenecrosis. An area approximately 7 2 cm of the amnioticsac was clearly visible (Fig. 1). The edges of the defectwere brought together with three slow absorption stitches.The remainder of the abdominopelvic cavity was normal.The right iliac fossa was drained using a natural rubbercorrugated drain (Peters Laboratories, France). Parenteralantibiotics were initiated with piperacilline and tazobactam,gardenerella vaginalis, peptostreptococcus and anaerobicnegative gram bacillus were obtained on bacteriology. Oralmedication (amoxicilline and clavulanic acid) was contin-ued for three weeks. Tocolysis was achieved using indo-methacin following laparatomy. The remainder of thepregnancy was normal. The woman was readmitted at ges-tation for 37 weeks to elective caesarean section. The babyweighed 3530 g with an Apgar score of 10 at 5 minutes oflife. During the caesarean section, adhesions were identifiedin the right iliac fossa and were divided. There was noobvious defect in the uterine wall. There was a placentaaccreta and removal of placenta was distinct. The area ofaccreta was adjacent to the previous myomectomy. Due toprofuse arterial bleeding from this area, the uterine pedicles,

Thrombophilia and immunological disorders in pregnancies as risk factors for small for gestational age infants

Objectives To determine if inherited thrombophilia and immunological disorders represent risk factors for small for gestational age infants, and to assess their relationship with neonatal status.

Combined transanal and laparoscopic approach for the treatment of deep endometriosis infiltrating the rectum

BACKGROUND Two surgical approaches are employed in the treatment of deep infiltrating endometriosis of the rectum (DIER): colorectal resection and nodule excision. In 2009, we introduced a new technique for transanal full thickness disc excision of endometriotic nodules infiltrating the low and middle rectum, using the Contour® Transtar™ stapler (Ethicon Endo-Surgery inc., Cincinnati, OH, USA). The aim of this retrospective study was to describe the technique and to present data on the feasibility of this technique. METHODS From April 2009 to October 2010, all patients presenting with DIER and undergoing full thickness excision using the Contour® Transtar™ stapler were enrolled in the study. Pre-, intra- and post-operative data were collected and reported. RESULTS Six nulliparous women were managed using this technique during the study period. The rectal wall discs removed measured from 40 × 45 to 60 × 50 mm. In two cases, microscopic foci were noted on one of the margins but in four cases the limits were clear. Operating time varied from 180 to 450 min. Four women were completely free of post-operative digestive complaints. CONCLUSIONS Despite the small numbers in this series, our data suggest that the new technique of transanal rectal disc excision using the contour stapler may be applied in patients with infiltrating endometrial nodules of the rectum up to 10 cm from the anal margin and up to 5 cm in diameter. This new procedure promises to be a useful addition to the surgeons armamentarium in a multidisciplinary approach to deep pelvic endometriosis.

Acceptabilité de l’implant contraceptif à l’étonogestrel (Implanon®)

Resume Objectifs Evaluer la satisfaction exacte des femmes vis-a-vis d’Implanon®, seul implant contraceptif disponible en France. Preciser les indications de ce type de contraception. Materiel et methode Sur une population de 182 Implanon® places dans un meme centre de planification entre le 22 mai 2001 et le 14 fevrier 2003, 108 femmes ont accepte de repondre a un questionnaire de satisfaction. Les implants ont ete places dans un tiers des cas apres un accouchement, dans un autre tiers apres un avortement. La duree moyenne d’utilisation de l’implant a ete de 16 mois (2 a 24 mois). Vingt-neuf retraits sur 108 (27 %) ont ete constates. Resultats La possibilite d’une contraception longue et peu contraignante constituait la motivation principale pour 74 % des femmes. Quatre-vingt-un pour cent des femmes etaient globalement satisfaites d’Implanon® avec cependant une femme sur deux ayant des effets secondaires. Seules 62 % des femmes envisageaient de se faire poser un nouvel implant. Les effets indesirables etaient en premier lieu des troubles des cycles dans 83 % des cas a type d’amenorrhee (26 %) ou de metrorragie (40 %). Les metrorragies etaient un des motifs principaux de retrait de l’implant dans 41 % des cas. Excepte pour la prise de poids presente chez 37 % des patientes, les autres effets secondaires, meme s’ils etaient frequents, ont ete moins souvent a l’origine d’un retrait. Il s’agissait essentiellement de cephalee, acne, mastodynie, instabilite emotionnelle et baisse de la libido. Conclusion Implanon® a certainement une place parmi les methodes contraceptives actuelles. Du fait de la frequence elevee des effets indesirables et de leur tolerance mediocre en Europe, cette place doit rester limitee aux insuffisances des methodes classiques. Une consultation d’information prealable a la pose annoncant les benefices et les inconvenients d’Implanon® est necessaire pour minimiser les risques de retrait premature.