[Heterotopic pregnancy: a report of 5 cases and review of the literature]. / Grossesse hétérotopique: à propos de 5 cas et revue de la littérature.

Heterotopic pregnancy, also called combined pregnancy, associates extra-uterine pregnancy and intra-uterine pregnancy. We report five cases of heterotopic pregnancy illustrating this condition and reviewed the recent literature from 1994 to 1999. We compared the results of this review with earlier data in the literature from 1971 to 1993. We observed that therapeutic management of the extra-uterine pregnancy and course of the intra-uterine pregnancy have changed little over this period. Conversely, the frequency of heterotopic pregnancy has steadily increased since the development of medically assisted reproduction, although spontaneous cases continue to occur. The diagnosis of heterotopic pregnancy is often difficult as the symptomatology is often misleading. Transvaginal ultrasound generally gives the diagnosis which may be confirmed by laparoscopy, allowing treatment of the extra-uterine pregnancy. Maternal and intra-uterine fetal prognosis depends on early diagnosis which should be made, if possible, prior to termination of the extra-uterine pregnancy.

[Early menopause]. / Les ménopauses précoces.

Early menopause due to an exhaustion of the ovarian follicles before the age of 40 years occurs in approximately 1% of women in this age range. Clinical signs of estrogen deficiency with amenorrhea and sterility are usually confirmed by hypergonadotrope hypogonadism at laboratory tests. The syndrome is to be differentiated from gonadotrophine resistant ovaries and rare gonadotrope adenomas. Ovary biopsy shows more or less complete destruction of the follicles. There are many causes of early menopause including abnormal number or structure of chromosome X in 15-20% of the cases. Certain metabolic disorders and viral infections can also be incriminated. Finally surgery, radiotherapy or chemotherapy can be the cause of iatrogenic menopause. To determine prognosis, the woman's follicular capacity must be estimated. Estrogen therapy is currently the best choice to preserve chances for ovulation and pregnancy. When there is no remaining follicular capacity, ovum donation may be a solution. Finally, all patients should be given hormone substitution therapy due to the long-term risk of estrogen-progesterone deficiency.

[Folates and the neural tube. Review of the literature]. / Folates et tube neural. Revue de la littérature.

There are two types of neural tube fusion abnormality (NTFA)--craniorachischisis and rachischisis--with a prevalence of 11.2/10,000 in continental Europe. Their prevalence varies widely and is influenced by many factors, including geographical, racial and seasonal components. The transmission of NTFAs is usually polygenic and affected by many factors, and far more rarely of the mendelian monogenic type. The occurrence of NTFAs has been shown to be due to folic acid (FA) deficiency. First suspected in 1965, FA deficiency was proved to be a cause of NTFAs both occurring and recurring in the 1980s. FA deficiency might act by preventing the remethylation of homocysteine to methionine, the latter is known to play an essential role in fusion of the neural tube in animals. Primary prevention of NTFAs therefore requires that FA supplementation be given to women planning a pregnancy and after conception. Two possible ways of preventing FA deficiency can be envisaged, ie. via folic acid supplementation or systemic enrichment of the basic diet. Neither of the two alternatives is sufficient by itself and probably a combination of the two would provide the best means of preventing neural tube defects.

[The history of cesarean section]. / Histoire de l'opération césarienne.

The origins of the Cesarian section date back to the Classical era, and possible even earlier. Ancient India, the Hebrews, the Grecks and the Romans were all familiar with post-mortem Cesarian section. The operation marked time during the Middle Ages. The name "Cesarian section" was first used to designate this operation during the Renaissance period, when it was first carried out in live women. However, until the middle of XIX th century, a Cesarian remained a last chance option which was cautioned against by most obstetricians. It was only after the advent of the "surgical golden tripod" that the Cesarian was gradually rehabilitated through the work of Poro, Kherer and Sanger and the German School. In the XIXth century, segmental incision became the norm and fetal indications for a Cesarian emerged.

[Cryopreservation of the ovary and ovarian tissue]. / La cryoconservation d'ovaire et de tissu ovarien.

Cryopreservation followed by grafting of ovarian tissue should enable prevention of the irrevocable loss of ovarian function sometimes associated with radio and/or chemotherapy in young women with malignant neoplasms. Cryopreservation of the oocyte should improve the general results of medically assisted procreation by enabling the creation of an oocyte bank. Three research areas have been developed in terms of preservation of the ovary or of the ovarian tissue by refrigeration. Freezing of the whole organ, or of fragments, was the first technique to be studied and did not lead to any practical applications. Freezing of the oocyte is being widely studied at present. Despite some successes, it is still far from possible to create an oocyte bank. Freezing of primary follicles is the latest ovarian cryopreservation technique described. Preliminary results are interesting and this method may offer the solution to the total restoration of ovarian function.

[Ovarian grafts and transplantations in women: current status]. / Greffes et transplantations ovariennes chez la femme: le point.

Ovarian grafts and transplants were performed at the end of the last century to prevent the side effects of bilateral ovariectomy or of the menopause. Fundamental studies (until around 1935) showed that autografts were possible with poor results while allografts were associated with bad results. This was followed by a long period during which these techniques were abandoned. Thanks to recent progress in organ storage, microsurgery and the "management" of grafts in general, it is reasonable to hope for new advances in the area of ovarian grafting and transplantation.

[Perineal rehabilitation of female urinary incontinence. Long term results]. / Rééducation périnéale au cours de l'incontinence urinaire féminine. Résultats à distance.

The results of perineal rehabilitation in 101 women with urinary incontinence are evaluated with a follow-up of 18 months (9-37 months). The authors try to precise the clinicals and urodynamicals initials factors of a bad pronostic.

[Diagnosis and treatment of cervical dysplasia. Report of 42 cases]. / Diagnostic et traitement des dysplasies cervicales. A propos de 42 cas.

The authors present a retrospective study of 42 cases of conization carried out between January 1987 and October 1989 in the Department of Gynaecology 1 of Dupuytren University Hospital in Limoges. The average age of the population was 42 years and 7 months, with an average parity of 1.9 children per woman. Conization was carried out using either a cold knife (37 cases) or an electric knife (5 cases). Complications consisted of 4 stenoses, 2 secondary haemorrhages and 1 perineal burn. 4 microinvasive cancers, 7 CIN III, 10 CIN II, 4 CIN I and 3 pieces of tissue free from any dysplastic lesion were found on histological examination of the conization tissue. 17 patients (40.4%) had flat condylomas. There was perfect agreement between the diagnoses from the smears and biopsies in 82.1 p. cent of cases; there was 57.1 p. cent agreement when the smear result was compared with the histological study of the conization tissue, and 39.2 p. cent agreement when the latter was compared with biopsy results. On the other hand, false diagnosis due to overevaluation of the severity of the dysplasia was predominant using the least invasive examination (42.8 p. cent when comparing the smear results with those from the study of conization tissue, and 39.2% for biopsies with respect to the conizations). According to the authors, the therapeutic strategy to be used in treating dysplasia must take the severity of the dysplasia, the presence of infection due to HPV and its serotyping, the location and size of the dysplasia, the visibility of the endo-exocol junction line and the psychological context of the patient into consideration.

[Diabetes in pregnancy]. / Le diabète gestationnel.

Following a review of the literature, often too conflicting, the authors are attempting to define a coherent approach to the problem of diabetes in pregnancy. Described as a diabetic condition occurring during pregnancy, diabetes should be looked for in all pregnant women, using the O'Sullivan's screening test performed between the twenty sixth and thirtieth weeks of amenorrhea. The diagnosis of diabetes will only be confirmed by an oral glucose tolerance test.

[Endometriosis localized in the sigmoid. Apropos of a case]. / Endométriose à localisation sigmoïdienne. A propos d'un cas.

Colic endometriosis is a classical but rare localization. The authors present one case treated by partial colectomy associated with a total hysterectomy and preservation of ovarian parenchyma. The hysterectomy was necessary because of adenomyosis and inflammatory adhesions undissociable from the sigmoid.

[Lymphangioma of the uterus. Apropos of a case]. / Lymphangiome du corps utérin. A propos d'un cas.

Lymphangioma of the uterine corpus is a rare tumor and the authors report one case discovered per-operatively. A review of the literature permits to bring out its essential characteristics as far as clinic, etiopathogenesis, evolution and therapy are concerned. This completely benign tumor is more an anatomo-pathological curiosity than a true gynecological problem.

[Antibiotic prophylaxis in surgery by vaginal route]. / Antibioprophylaxie dans la chirurgie par voie basse.

The authors study 56 cases of vaginal hysterectomy divided in two groups of 28, one of which received antibiotics prophylaxis at the time of the procedure. The incidences on post-operative fever, infection of the vaginal section and the number of urinary infections are significantly much lower in the group treated.

[Rupture during pregnancy of the rudimentary horn of a pseudo-unicorn uterus. Apropos of a case]. / Rupture per-gravidique de la corne rudimentaire d'un utérus pseudo-unicorne. A propos d'un cas.

The rupture of the rudimentary horn of a pseudo-unicorn uterus is a rare accident. The case reported here is very similar to most of those published. It is usually during the fifth month of a pregnancy, normal until then, that a state of shock appear suddenly, requiring a surgical procedure and disclosing this exceptional diagnosis.

[A rare form of benign tumor of the liver possibly related to the use of oral contraceptives: focal pediculated nodular hyperplasia]. / Une forme rare de tumeur bénigne du foie en relation possible avec l'utilisation de contraceptifs oraux: "l'hyperplasie nodulaire focale pédiculée".

Following a recent case, the authors review the literature of hepatic nodular hyperplasia. The incidence of this condition increases regularly with the consumption of oestrogens. They attempt to define the methods of detection for patients at highest risk. Without exaggerating the incidence of this complication of oral contraceptives, the authors believe that it will become increasingly more common than the vascular complications which, although frequently discussed, are relatively rare.

PIP: This article describes a case of focal pedunculated nodular hyperplasia, a rare form of benign liver tumor, and reviews the literature on focal nodular hyperplasia (FNH) and hepatocellular adenoma. Focal pedunculated nodular hyperplasia is the rarest form of FNH and accounts for fewer than 20% of cases. Hepatocellular adenoma is usually a single encapsulated tumor ranging in size from 1-30 cm in diameter. FNH is usually also a single tumor which is always polylobed and multinodular. The size is variable and it is well defined although not encapsulated. Microscopically neither FNH nor hepatocellular adenoma has normal portal spaces or centrolobular veins. A peliose (intratumoral pseudomicrocysts) is often observed in oral contraceptive (OC) users in both cases. Atypical, dysplasic, or neoplasic cells are observed in about 10% of cases of hepatocellular adenoma but have never been reported in FNH. Considerable hypervascularization is found in hepatocellular adenoma but not in FNH, although in FNH large vascular pedicel may be observed at the periphery. Both tumors are most frequently seen in fertile aged women. Over 1/3 of cases of hepatocellular adenoma are discovered due to intraperitoneal bleeding. FNH is asymptomatic in 73.5% of cases and hemoperitoneum is very rare. The case reported was that of a 40-year-old woman with no significant medical history who had used a combined OC containing ethinyl estradiol and norgestrel for 6 years until 2 years previously, when she terminated use due to subsequently controlled hypertension. A 6-month history of menorrhagia was uncontrolled despite use of an OC containing levonorgestrel only. The liver tumor was discovered in the course of a total hysterectomy performed because of a large polymyomatous uterus associated with significant menorrhagia. The FNH was surgically removed 2 months later. The tumor was highly vascularized and connected to segment 4 by a voluminous pedicel containing numerous thick vascular elements. The postoperative course was smooth. The relationship between OC use and benign hepatic tumors is now well established. Their overall frequency has been estimated at 4.9/million women aged 15-45. The duration of exposure to OCs seems to be a determining factor. The risk is negligible at durations of OC use under 1 year but is multiplied by 7 for FNH and by 5 for hepatocellular adenoma after 5 years. EE, mestranol, and 19 norsteroids all seem to play etiologic roles. 58% of hepatocellular adenomas in OC users are discovered because of hemoperitoneum following rupture. Bleeding is usually massive and the mortality rate is about 6%. FNH is revealed by bleeding in 15% of cases in OC users and is asymptomatic in 49% of users. Tumor development depends on whether OC use is continued. It is not currently known whether the tumors tend in the long run to degenerate into hepatic carcinoma, and whether OC use plays a role. The occurrence of liver cancer in OC users does not seem to be greater than in the general population, but OC users are younger at diagnosis, their survival time is longer, and alpha fetoprotein levels are not elevated. Surveillance of OC users is difficult because FNH is so often asymptomatic. Periodic sonograms after 5 years of OC use may be indicated.

[Acupuncture in obstetrics]. / Acupuncture en obstétrique.

Acupuncture has been used in China as a treatment modality for one thousand years and is becoming increasingly important in the western world. Through a special effect on the reticular formation, acupuncture is becoming a first choice among the various methods available to relieve pain, especially in the pregnant woman. It can be useful, in fact, during the three periods of a pregnancy: before delivery: it can effect all the functional and psychiatric problems a pregnant woman may develop; during delivery: there is a definite analgesic and oxytocic effect; after delivery: it can be beneficial in all difficulties with breast feeding. Acupoints used in obstetrics are not very numerous. There are approximately thirty which are located along the body meridians or on the ear.

[The "usual" forms of urinary infection in pregnant women]. / Les formes "habituelles" de l'infection urinaire de la femme enceinte.

Urinary infections, normally due to Escherichia coli, are extremely common in pregnant women. Including nonapparent forms, the incidence is 75 per cent. While the apparent forms are not difficult to diagnose, the non-apparent forms have to be looked for, as they may lead to premature births, an essential complication of "gravidic pyelonephritis".

[Infertility caused by uterus bipartitus. Value of the Bret-Palmer operation]. / Infertilité par cloisonnement corporéal de l'utérus. Intérêt de l'opération de Bret-Palmer.

Among the uterine malformations responsible for infertility, uterus bipartitus is one of the most amenable to surgery. The operation devised by Bret and Palmer is intended for those cases where the malformation is due to non-resorption of the medial septum and not for those where it is due to lack of fusion of the Mullerian ducts. The results are excellent, since 70% or 80% of previously infertile women subsequently became pregnant.