[From the impact of French guidelines to reduce episiotomy's rate]. / De l'impact des RPC pour réduire le taux d'épisiotomie.

OBJECTIVES: Following the publication of the French Guidelines on episiotomy in 2005 by the French National College of Gynaecologists and Obstetricians (CNGOF), our unit decided to adopt a restrictive politics to replace the former liberal one. The goal of this study was to evaluate the impact of this modification of trend in the Unit of Gynaecology and Obstetrics of the teaching hospital from Caen. This was the start point of an internal audit with the objective of an enhancement of the care during delivery. PATIENTS AND METHODS: It was a retrospective study concerning the period going from January, 2004 till December, 2009, measuring the impact of the guidelines on the episiotomy rates and perineal tears. The totality of the population of the women naturally delivered at a term superior or equal to 37 weeks of gestation and a cephalic presentation was included. To modify the practices, after diffusion of the guidelines by some obstetrical leaders, we imposed to notify the indication of the episiotomy in the computerized obstetrical files. Moreover, we published monthly screenboards with all the detailed results to all the practioners acting in the delivery room (obstetricians, midwives). RESULTS: Between 2004 and 2009, we observed a dramatic decline of the episiotomy rates from 55.7 to 13.3%. This trend was the same for primiparae and multiparae, as wall as for spontaneous or assisted delivery (mostly vacuum extraction in our unit). We noticed a slight increased in minor perineal tears without functional consequences. There was no statistically significant difference between severe perineal tear (1.3% vs. 1.1%). By contrary, the rate of intact perineum significantly raised (17.6% vs. 21.7%, p<0.001), especially in vacuum extractions. DISCUSSION: Our results are in accordance with those of the national guidelines. However, our rate does not decrease in 2007 and 2008 (20%), contrary to some results obtained in the literature. Some reports mentioned the weak impact of the publication of national guidelines to modify the usual practice. However, we believe that retro-information to practitioners has a real impact on their daily current practice. Hence we insisted again on the importance of these national guidelines at the end of 2008 and we could demonstrate a real decline of the rate of episiotomy. Our efforts have to be continued, especially for instrumental delivery.

[Ogilvie's syndrome following cesarean section: Just think! Report of two cases and review of the literature]. / Syndrome d'Ogilvie après césarienne : savoir y penser ! À propos de deux cas post-césarienne et revue de la littérature.

OBJECTIVES: To identify clinical and radiological signs of the post-cesarean Ogilvie's syndrome in order to establish the appropriate treatment. PATIENTS AND METHODS: Based on the Medline research, we listed 41 cases of Ogilvie's syndrome after cesarean section. We analyzed the patient's age, the clinical and radiological signs, the time to diagnosis, and the treatments and their efficiency. RESULTS: The clinical signs generally appear in the first 72 h after cesarean. Diagnosis of Ogilvie's syndrome is based on a clinical picture of acute obstruction of the large bowel and by X-ray showing a large caecum without pathological lesion. If the caecal diameter is under 12 cm, conservative treatment is done with colonoscopic decompression when necessary, however if there are signs of peritonitis surgery is recommended. CONCLUSION: Ogilvie's syndrome after cesarean section is uncommon. Diagnosis must be fast in order to avoid the caecum to burst causing faecal peritonitis, which carries slight mortality rate.

[History of pubic symphysis separation and mode of delivery]. / Antécédent de disjonction pubienne et modalités d'accouchement.

Pubic symphysis separation is an underestimated and badly treated pathology. It can be responsible for an important morbidity and therefore requires a fast and specialized management. In case of subsequent pregnancy, mode of delivery will have to be discussed due to traumatic past and maternal fear of recurrence. After two cases of patients who experienced preventive cesarean delivery after symphyseal separation in a prior pregnancy, a retrospective study reporting pubic disjunction cases during the last 10 years in our unit was made. Few data are available in the literature and risks of recurrence are not well-defined. Vaginal delivery may be proposed, leaving a wide place to discussion with the patient, evoking prevention and therapeutic possibilities.

[Surgical treatment for female stress urinary incontinence by transobturator tape (outside in). Study of 70 cases]. / Cure chirurgicale de l'incontinence urinaire d'effort de la femme par bandelette transobturatrice (de dehors en dedans). Etude de 70 cas.

OBJECTIVES: To evaluate the feasibility, the efficacy and the innocuousness of suburethral transobturator support using multifilament polypropylene transobturator tape (TOT) inside out for stress urinary incontinence in women. MATERIALS AND METHODS: The study concerns 70 patients representing our team's first experience of this technique. The inclusion criterion was persistent SUI despite perineal rehabilitation. There were no exclusion criteria. Among the 70 patients, 22 (31%) presented with associated genital prolapse. Mean parity was 2.6 (extremes ranging from 0 to 6). Thirty-five patients were menopaused (50%), of whom 12 (34%) were under hormone replacement therapy. We retained five judgement criteria to evaluate this surgical act: duration of surgery and hospitalisation, per- and postoperative complications and functional results on SUI (via a telephone questionnaire). RESULTS: The rate of positive results (healing or improvement) was 84% with a mean follow-up of 14.5 months. The rate of peroperative complications was very low: 1.4% (only one case of bladder injury). The mean duration of surgery was 23 minutes. The mean duration of hospitalisation in the case of isolated TOT was 1.25 days. CONCLUSION: The transobturator approach is a feasible, safe and efficient short-term surgical technique. Results inferior to those observed in the literature are probably due to the learning curve in a university hospital unit. None of the preoperative data (age, parity, body mass index, history of SUI treatment or hysterectomy, hormonal status, associated prolapse, mean urethral closure pressure, clinical vesical hyperactivity syndrome) appears to influence results; however, the study strength is poor due to the small study population.

[Uterine and ovarian necrosis following embolisation of the uterine arteries for postpartum haemorrhagia]. / Nécrose utérine et ovarienne après embolisation des artères utérines pour hémorragie de la délivrance.

We report here the case of a young woman who presented with pain, fever and apparent cutaneous sub ischaemia following embolisation of the uterine arteries for postpartum haemorrhagia. This embolisation was carried out by bilateral selective catheterism of the uterine arteries using 45 to 150 micron polyvinyl alcohol particles. Investigative laparotomy was decided in view of the persistence of the symptoms, and the patient underwent hysterectomy with ablation of the right adnexa to treat uterine necrosis and adnexal atrophy. Because of the information that we have actually, we can explain that this complication is linked with the use of polyvinyl alcohol small size particles. The migration of those embolisation agents might be responsible for obliteration of a large number of distal vessels. Those embolisation agents must, because of recommendation for good practice published in 2004, be reserved to exceptional cases to minimize the complication of embolisation.

[A rare complication of vomiting in pregnancy: Wernicke's encephalopathy]. / Une complication rare des vomissements gravidiques: l'encéphalopathie de Gayet-Wernicke.

Gayet-Wernicke syndrome is a rare neurological pathology due to a deficit in vitamin B1. It occurs in alcoholics but several reports have been published of cases in a context of intractable vomiting. The frequency is probably under-estimated because there have been many cases described at autopsy. The diagnosis is clinical with the triad (found in 60% of cases) of mental confusion, oculomotor disorders and ataxia. MRI can confirm the diagnosis by hyper signal images most frequently in a peri-acqueductal location, the thalamus and mamillary bodies. We report 3 observations of Gayet-Wernicke encephalopathy discovered in a context of hyperemesis gravidarum. These 3 cases, which occurred within the past two years in the West of France, give us the opportunity to assess 3 different outcomes for this pathology. In a second section we review the main publications in the literature. Hyperemesis gravidarum is a frequent pathology and can be the cause of serious neurological complications. Early vitamin supplementation should be instituted in case of severe vomiting in order to ensure the pregnancy can continue together with the mother's well-being.