[Severe post-partum hemorrhage: descriptive study at the Robert-Debré Hospital maternity ward]. / Hémorragie grave du post-partum. Etude descriptive à la maternitè de l'hôpital Robert-Debré.

OBJECTIVE: To analyze the prevalence, cause, treatment, and risk factors of severe post-partum hemorrhage (transfusion, surgery, radiology) observed at the maternity ward of the Robert-Debré Hospital, Paris. Method. This retrospective cohort was collected from a database including 19182 deliveries from 1992 to 1998. The entire medical file was reviewed in cases of severe hemorrhage. RESULTS: The prevalence of severe post-partum hemorrhage was 23 per 10,000 deliveries (44 patients). Transfusion was performed in 44/44 and hysterectomy in 3/44. Three patients were transferred to the intensive care unit. There were no deaths. At multivariate analysis, risk factors for severe post-partum hemorrhage were: abnormal placental insertion (OR=7.2; 95CI: 2.18-18.3), cesarean (OR=5.8; 95CI: 2.9-11.6), multiple pregnancy (OR=3.2; 95CI: 1.3-7.8), prematurity (OR=3, 95CI: 1.5-6.2), hypertension (OR=2.9; 95CI: 1.3-6.3). Twenty-six percent of the patients had no risk factors. CONCLUSION: The prevalence of severe pot-partum hemorrhage is low in our experience. The methodology used for this retrospective cohort does not enable an explanation. Intensive obstetrical care is necessary in case of abnormal placenta insertion. In 10 out of 44 cases, severe post-partum hemorrhage occurred in a context of insufficient monitoring, late or erroneous diagnosis, or incorrect treatment.

Utero-vaginal anastomosis in women with uterine cervix atresia: long-term follow-up and reproductive performance. A study of 18 cases.

BACKGROUND: Atresia of the uterine cervix is an uncommon Müllerian anomaly. Total hysterectomy remains the classical treatment of this malformation. The purpose of this study was to evaluate functional results and reproductive performance of women who had conservative surgical procedure. METHODS AND RESULTS: The medical records of 18 patients admitted to our centre between 1969 and 1998 for the treatment of uterine cervix atresia, were reviewed. Seven women had an associated high vaginal aplasia. Fifteen women had a history of abdominal or pelvic surgery before referral, with an unsuccessful attempt at canalization in five cases. Associated pelvic endometriosis or adhesions were observed in 12 cases. The utero-vaginal anastomosis procedure was performed successfully in all cases. A secondary stenosis of the anastomosis occurred in one case and this required canalization. Median follow-up after surgery was 4.5 years. Sexual intercourse was satisfactory for the 12 patients who began sexual activity. Ten patients had a pregnancy, four of which resulted in a total of six successful spontaneous pregnancies. Of the six remaining women, five had an evident cause of infertility. CONCLUSIONS: Utero-vaginal anastomosis should be proposed in women with congenital atresia of the uterine cervix, even when it is associated with vaginal aplasia. Early diagnosis and surgery appear necessary to avoid the development of pelvic associated lesions.

Pregnancy outcome and deliveries following laparoscopic myomectomy.

Uterine rupture after myomectomy by laparotomy is not a common occurrence. Some case reports of uterine rupture after laparoscopic myomectomy (LM) raise the question of the quality of the uterine scar produced when this technique is performed. In order to assess the outcome of pregnancies and deliveries after LM and to assess the risk of uterine rupture, we performed an observational study. Questionnaires were mailed to all women who had had LM for at least one intramural or subserosal myoma of more than 20 mm diameter and who were aged <45 years. Ninety-eight patients became pregnant at least once after LM, giving a total of 145 pregnancies. Among the 100 patients who had delivery, there were three cases of spontaneous uterine rupture. Because only one of these uterine ruptures occurred on the LM scar, the risk of uterine rupture was 1.0% (95% CI 0.0-5. 5%). Seventy-two patients (72.0%) had trials of labour. Of these, 58 (80.6%) were delivered vaginally. There was no uterine rupture during the trials of labour. Spontaneous uterine rupture seems to be rare after LM. This risk should not deter the use of LM if needed. When performing LM, particular care must be given to the uterine closure.