M. Uzan

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

OBJECTIVESnTo evaluate the efficacy of auto-cross-linked hyaluronic acid gel in the prevention of adhesions after operative hysteroscopy using a case-control study.nnnMATERIALS AND METHODSnFifty-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.nnnRESULTSnAge, 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.nnnCONCLUSIONnACP 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.

Thrombophlébite de la veine ovarienne et fièvre du post-partum

Resume Introduction.xa0– La thrombophlebite de la veine ovarienne (TVO) est une complication rare mais potentiellement grave du post-partum. Le diagnostic en est parfois difficile notamment en presence d’une symptomatologie evocatrice d’une appendicite ou d’une pyelonephrite aigue. Exegese.xa0– Nous rapportons 2 observations de TVO droite au decours immediat d’un accouchement. Le tableau clinique etait domine par une fievre et une douleur, siegeant dans la fosse lombaire dans un cas et dans le flanc dans l’autre. Elle etait compliquee d’une embolie pulmonaire dans les deux cas. Conclusion.xa0– La prise en charge diagnostique et therapeutique de la TVO a ete transformee par les progres de l’imagerie medicale dans les annees 1980. Il reste cependant quelques inconnues notamment quant a la duree optimale du traitement anticoagulant ou a l’indication d’une prevention secondaire.

Virological and biological characteristics of cervical intraepithelial neoplasia grade i with marked koilocytotic atypia

The aim of this study was to evaluate virologic and biological significance of marked koilocytotic atypia observed in some cases of grade I cervical intraepithelial neoplasia (CIN I). Thirty-one CIN I cervical biopsy specimens with marked koilocytotic atypia, defined by the presence of meganuclei in the superficial epithelial layers, were compared to 37 CIN I biopsy specimens with usual koilocytes for (1) the human papillomavirus (HPV) type and signal pattern as detected by nonisotopic in situ hybridization (ISH); (2) the proliferation index assessed by Ki 67 immunostaining and (3) the p53 labeling pattern. Interobserver agreement for meganuclei was excellent (k = 0.9). Twenty-five out of 68 biopsies (37%) were positive by ISH for the 6 of 11 HPV probe, 30 (44%) for the 16-18 probe, and 7 (10%) for the 31/33 HPV probe, 6 (9%) were negative for ISH. The presence of meganuclei was strongly related to high and intermediate risk HPV type (P = 0.0001). The sensitivity and specificity of meganuclei for the detection of high or intermediate risk HPV in CINI were 73 and 87%, respectively. Loss of p53 immunostaining in the lower third of the epithelium was also related to the presence of meganuclei (P < .05), but the MIB-1 index and ISH labeling pattern were not. In conclusion, marked koilocytotic atypia in CIN I is a reliable and sensitive marker for infection by high or intermediate-risk HPV, and might be a guide to therapy.

Prééclampsie et syndrome des antiphospholipides. Intérêt du Doppler utéroplacentaire

INTRODUCTIONnWomen with persistently high resistance in uterine arteries have an increased risk of the subsequent development of preeclampsia. Doppler investigation provides a non-invasive method for the study of the uteroplacental blood flow. In pregnant women the antiphospholipid syndrome is associated to an increased risk of preeclampsia and complications related to uteroplacental insufficiency, and the role of uterine artery Doppler is discussed.nnnCURRENT KNOWLEDGE AND KEY POINTSnIn normal pregnancy, impedance to flow in the uterine arteries decreases with gestation, as the likely consequence of the physiologic change of spiral arteries into low-resistance vessels. In women with preeclampsia or related complications, the abnormal persistence of high resistance to flow in the uterine arteries correlates with maternal and neonatal outcome. In one study including patients with antiphospholipid syndrome, a high resistance index in the uterine arteries at 22-24 weeks gestation strongly predicted the subsequent development of preeclampsia. In another study including patients with lupus anticoagulant, persistent bilateral notches at 22-24 weeks gestation may identify preeclampsia and fetal growth restriction with a high sensitivity, specificity, positive and negative predictive value. The treatment may improve the uteroplacental blood flow and is a possible confounding factor which needs further evaluation. FUTURE PROSPECTS AND PROJECTS; In patients with antiphospholipid antibodies a higher impedance has been observed in the uterine artery, suggesting a possible vascular dysfunction precluding to impaired trophoblastic invasion and placental thrombosis, as probable mechanisms in the complications. If confirmed, these findings might have important implications for the management of these patients.

Rupture utérine : facteurs de risque, complications maternelles et fœtales

OBJECTIVESnTo determine risk factors, maternal and perinatal morbidity and mortality associated with uterine rupture in women with previous caesarean delivery.nnnMATERIAL AND METHODSnWe conducted a population-based, retrospective cohort analysis, comparing deliveries with and without uterine rupture in women with uterine scar during a 12-year period. Women attempting a trial of labour were selected with precise criterion. We analysed obstetric history, characteristics of labour, mode of delivery, maternal and perinatal complications.nnnRESULTSnThirty-six uterine ruptures were registered of which 11 were complete. These complete ruptures occurred at a rate of 0.4% among deliveries in women with previous caesarean delivery (n=2718) and 0.5% among women attempting a trial of labour (8/1440). Twenty-one ruptures (58%) were diagnosed during a trial of labour. Some risks factors were identified like a labor after 41weeks of amenorrhea and no medical history of natural childbirth. There were neither maternal nor neonatal deaths. The major maternal complications were postpartum haemorrhage (13.8%, n=5) and blood transfusion (8.3%, n=3), significantly most frequent than in the control group (p<0.01). No hysterectomy was required. Concerning neonatal morbidity, mean lactate rate was significantly higher for the rupture group.nnnCONCLUSIONnThe low rate of uterine rupture, maternal and neonatal complications supports a rigorously selection of women attemping a trial of labor. A labor after 41weeks of amenorrhea and no medical history of natural childbirth should be added to common criterion.

Mise au pointPrééclampsie et syndrome des antiphospholipides. Intérêt du Doppler utéroplacentairePreeclampsia and antiphospholipid syndrome. Uterine artery Doppler evaluation

INTRODUCTIONnWomen with persistently high resistance in uterine arteries have an increased risk of the subsequent development of preeclampsia. Doppler investigation provides a non-invasive method for the study of the uteroplacental blood flow. In pregnant women the antiphospholipid syndrome is associated to an increased risk of preeclampsia and complications related to uteroplacental insufficiency, and the role of uterine artery Doppler is discussed.nnnCURRENT KNOWLEDGE AND KEY POINTSnIn normal pregnancy, impedance to flow in the uterine arteries decreases with gestation, as the likely consequence of the physiologic change of spiral arteries into low-resistance vessels. In women with preeclampsia or related complications, the abnormal persistence of high resistance to flow in the uterine arteries correlates with maternal and neonatal outcome. In one study including patients with antiphospholipid syndrome, a high resistance index in the uterine arteries at 22-24 weeks gestation strongly predicted the subsequent development of preeclampsia. In another study including patients with lupus anticoagulant, persistent bilateral notches at 22-24 weeks gestation may identify preeclampsia and fetal growth restriction with a high sensitivity, specificity, positive and negative predictive value. The treatment may improve the uteroplacental blood flow and is a possible confounding factor which needs further evaluation. FUTURE PROSPECTS AND PROJECTS; In patients with antiphospholipid antibodies a higher impedance has been observed in the uterine artery, suggesting a possible vascular dysfunction precluding to impaired trophoblastic invasion and placental thrombosis, as probable mechanisms in the complications. If confirmed, these findings might have important implications for the management of these patients.

Travail originalRupture utérine : facteurs de risque, complications maternelles et fœtalesUterine rupture: risk factors, maternal and perinatal complications

OBJECTIVESnTo determine risk factors, maternal and perinatal morbidity and mortality associated with uterine rupture in women with previous caesarean delivery.nnnMATERIAL AND METHODSnWe conducted a population-based, retrospective cohort analysis, comparing deliveries with and without uterine rupture in women with uterine scar during a 12-year period. Women attempting a trial of labour were selected with precise criterion. We analysed obstetric history, characteristics of labour, mode of delivery, maternal and perinatal complications.nnnRESULTSnThirty-six uterine ruptures were registered of which 11 were complete. These complete ruptures occurred at a rate of 0.4% among deliveries in women with previous caesarean delivery (n=2718) and 0.5% among women attempting a trial of labour (8/1440). Twenty-one ruptures (58%) were diagnosed during a trial of labour. Some risks factors were identified like a labor after 41weeks of amenorrhea and no medical history of natural childbirth. There were neither maternal nor neonatal deaths. The major maternal complications were postpartum haemorrhage (13.8%, n=5) and blood transfusion (8.3%, n=3), significantly most frequent than in the control group (p<0.01). No hysterectomy was required. Concerning neonatal morbidity, mean lactate rate was significantly higher for the rupture group.nnnCONCLUSIONnThe low rate of uterine rupture, maternal and neonatal complications supports a rigorously selection of women attemping a trial of labor. A labor after 41weeks of amenorrhea and no medical history of natural childbirth should be added to common criterion.

Should we allow a trial of labor after a previous cesarean for dystocia in the second stage of labor

The conclusion of Bujold et al that “a trial of labor is reasonable in women whose previous cesarean was for dystocia in the second stage of labor” appears to overlook the fact that 50.8% of these women were excluded from a trial of labor in the study. The authors only admit that this type of observational study “has a potential selection bias,” without any more detail about the (good but unclear) selection performed by physicians in the study. However, the real challenge would have been to identify the exact criteria used to exclude half of the patients. Otherwise, the reported success rate is of little clinical interest. Given that the failure rate of a trial of labor after cesarean is correlated with maternal morbidity, risk of uterine rupture, and cost-effectiveness, any unqualified interpretation of that abrupt conclusion might lead to a high rate of adverse effects and hence widespread rejection of the “vaginal-birth-aftercesarean” policy by women and medical staff. Conversely, the definition of clear guidelines based on precise selection criteria would help patients and physicians to make informed decisions about the risks and benefits of attempting a vaginal delivery.