Is there a justification for hysterectomy in patients with borderline ovarian tumors?

OBJECTIVE: To determine the frequency of uterine involvement in patients with borderline ovarian tumors (BOT) and to evaluate the recurrence risk and survival after hysterectomy. MATERIALS AND METHODS: In two French hospitals: A tertiary referral centre (University hospital centre of Tours, France) and the Alliance community hospital of Tours (France), we reviewed data of consecutive women undergoing surgery for presumed stage I BOT between January 1997 and December 2012. Patients were divided into two groups: patients treated with fertility sparing surgery (group 1) and those treated with radical surgery (group 2). RESULTS: A total of 135 patients were evaluated. 35 had fertility sparing surgery, 81 had radical surgery with hysterectomy and 19 had previous hysterectomy for other reasons. There were more recurrent borderline ovarian disease and more ovarian invasive disease developed in group 1 (p = 0.02, p = 0.04, respectively). Hysterectomy affected favorably borderline disease-free survival, OR = 0.09 95%CI (0.005-0.69), p = 0.04, but perceived benefits may be related to bilateral salpingo-oophorectomy and not hysterectomy directly.

Course of migraine during pregnancy and postpartum: a prospective study.

The aim of this study was to investigate prospectively the course of migraine during pregnancy and postpartum. Of all the pregnant women consecutively attending an obstetrics and gynaecology department for a routine first-trimester antenatal check-up, 49 migraine sufferers--two were affected by migraine with aura (MA) and 47 by migraine without aura (MO)--who had experienced at least one attack during the 3 months preceding pregnancy were identified, enrolled in the study and given a headache diary. Subsequent examinations were performed at the end of the second and third trimesters and 1 month after delivery. Migraine was seen to improve in 46.8% of the 47 MO sufferers during the first trimester, in 83.0% during the second and in 87.2% during the third, while complete remission was attained by 10.6%, 53.2%, and 78.7% of the women, respectively. Migraine recurred during the first week after childbirth in 34.0% of the women and during the first month in 55.3%. Certain risk factors for lack of improvement of migraine during pregnancy were identified: the presence of menstrually related migraine before pregnancy was associated with a lack of headache improvement in the first and third trimesters, while second-trimester hyperemesis, and a pathological pregnancy course were associated with a lack of headache improvement in the second trimester. Breast feeding seemed to protect from migraine recurrence during postpartum.

Uterine necrosis after arterial embolization for postpartum hemorrhage.

BACKGROUND: Selective embolization is an effective and reputedly safe method of managing pregnancy-related bleeding. However, we report an ischemic uterine necrosis after arterial embolization. CASE: The patient had heavy postpartum bleeding treated by embolization of the uterine arteries using polyvinyl alcohol particles (diameter 150-250 and 300-600 microm) and gelatin sponge pledgets. Her postoperative recovery was complicated by menorrhagia and pelvic pain. Because of the persistent menorrhagia and risk of infection, a hysterectomy was performed. Histopathology of the hysterectomy specimen revealed massive ischemic myometrial necrosis. CONCLUSION: This complication is most likely related to the small size of the particles used. In the management of postpartum bleeding by arterial embolization, the material of choice is gelatin sponge pledgets, and the use of small particles should be avoided.

Parkinson's disease and reproductive life events.

Onset, progression and duration of Parkinson's disease (PD) seem to be similar in men and women but gender differences have been suggested concerning clinical aspects, such as more severe disease in men and more dyskinesia in women. Taking into account the multiple influences of sex hormones, estrogens in particular, on basal ganglia function, the present work compared the characteristics of reproductive events in PD subjects and in healthy women, with regard to onset and clinical aspects of the disease with respect to the milestones of reproductive life. A total of 150 PD women and 200 healthy women matched for age were interviewed about reproductive life and disease characteristics (if patients). As a group, the women with PD had menarche later than the controls, but in the normal range. Menopause was similar to the controls for time, type (natural) and onset (slow), but with less hormonal therapies. Women with PD had fewer children, while breast feeding and gynecological diseases were comparable to controls. The characteristics of menses were similar as far as dysmenorrhea and premenstrual syndrome (PMS). The women with PD onset before menopause had a longer disease duration, with a more frequent fluctuating stage, and longer treatment with both levodopa and dopamine agonists. They had more dysmenorrhea and PMS when compared with women with PD onset after menopause and controls.

Climacteric complaints, female identity, and sexual dysfunctions.

Forty early menopausal women seeking relief from sexual symptoms within a long-term marital relationship and 40 matched women seeking relief of climacteric complaints completed questionnaires concerning three subject: vasomotor and psychosocial symptoms, sexual dysfunctions, and female identity. Results showed that women with sexual dysfunctions were more likely to suffer from vasomotor and psychosocial complaints and their feminine identity was based mainly on ideals of motherhood and beauty. In addition, sexual desire disorders were present significantly in those women with higher psychosocial symptoms, while sexual arousal disorders were particularly evident in women suffering more vasomotor symptoms.

[Borderline tumors of the ovary: a multicenter study in 137 patients]. / Tumeurs borderline de l'ovaire: Etude multicentrique a propos de 137 patientes.

OBJECTIVES: Evaluate management of patients with a borderline ovarian tumor. MATERIALS AND METHODS: A multicentric retrospective survey was conducted in 137 patients with borderline ovarian tumor diagnosed between January 1, 19975 and December 31, 1995. RESULTS: Mean follow-up was 6.5 years, mean age was 50 years. Initial surgery was cystectomy, unilateral salpingo-oophorectomy and total hysterectomy with bilateral salpingo-oophorectomy in 22, 40 and 75 cases respectively. Eleven patients had residual disease. Serous, mucinous and Brenner tumors were observed in 67, 69 and 1 cases respectively. Staging was I, II, III in 117, 3, and 17 cases respectively with two pseudomyxomas. Adjuvant therapy was given in 15 patients. There was a recurrence in 15 patients and 14 died. The 5-year survival rate was 89.3%. Prognosis factors with an impact on survival rate were age, recurrence and type of surgery. Factors with a negative impact on recurrence were adjuvant therapy and residual disease after surgery. CONCLUSION: Careful staging followed by complete and radical surgery is essential. Unilateral salpingo-oophorectomy with omentectomy and multiple peritoneal biopsies may be indicated in younger patients undergoing radical surgery after pregnancy. Aduvant therapy is necessary for invasive implants.

[External cephalic version as a possible treatment of breech presentation]. / Il rivolgimento cefalico per manovre esterne come possibile trattamento della presentazione podalica del feto.

BACKGROUND: Breech presentation shows 3-4% incidence on every foetal presentation at the time of delivery and is more correlated than vertex presentation to a foetal risk of perinatal mortality (with a frequency from 2 to 5 times higher) and to foetal malformations, low weight at birth and prematurity. On the other hand, without a careful case selection, breech delivery has a higher risk of perinatal morbidity and mortality in comparison to cephalic presentation. It is estimated that perinatal mortality for breech presentation at term is about 4-5% for vaginal delivery and about 2-4% for caesarean section. In addition caesarean section has a higher maternal morbidity and a small but significant risk of perinatal mortality, therefore, external cephalic version (ECV) can be a good choice to increase physiological deliveries. The aim of the present study is to evaluate the real efficacy of this obstetric manoeuvre to decrease the frequency of breech presentation at delivery. METHODS: The study group included 67 patients (age 29.5 +/- 3.8) with foetal breech presentation at gestational age 35.8 +/- 1.9 weeks, recruited at the Department of Obstetrics and Gynaecology of the Pavia University. Every patient underwent ECV. The same physician has performed every ECV attempt using the forward roll technique, with previous tocolysis in 50 cases (rithodrine vs isoxsuprine). The following variables have been taken into consideration: amount of amniotic fluid, gestational age, kind of tocolysis, placental location, foetal back position, parity, breech variety and foetal adnexial complication at birth. RESULTS: ECV succeeded in 77.6% (n = 52) and failed in 22.4% (n = 15) of cases. No maternal or foetal complications, side effects and spontaneous breech version occurred and in 74.6% of cases (n = 50) a vaginal delivery was performed. In 25.4% of cases (n = 17) a caesarean section was performed (15 breech presentation, 1 foetal distress in labour and 1 cervical dystocia). Among variables examined related to successful ECV, it has been observed that the amount of amniotic fluid (chi 2 = 15.33; p < 0.0000), the kind of tocolysis (chi 2 = 10.04; p < 0.007) and the umbilical cord rounds (chi 2 = 3.98; p < 0.045) were distributed in a significantly different way, whereas gestational age (p < 0.045) was significantly higher in unsuccessful ECV. CONCLUSIONS: The results obtained suggest that ECV may be a good therapeutic approach for decreasing the percentage of breech presentation at delivery.

The DopFet system: a new ultrasonic Doppler system for monitoring and characterization of fetal movement.

To enable the investigation of fetal movement in a manner similar to fetal heart rate (FHR) monitoring we have developed an apparatus (the DopFet system) that consists of a pair of miniature sensors, a 2-MHz continuous-wave directional Doppler electronic module and a laptop personal computer. One of the sensors is aimed at the fetal limbs and the other at the thorax to detect heart and upper body movements. The signals are analyzed, presented in real-time and postprocessed by software developed by us. The postprocessing software computes a number of parameters (the DopFet parameters) describing fetal movement. These parameters can be divided into two categories: parameters that describe the quantity of fetal movement (i.e., number of movements) and parameters that describe qualitative aspects of fetal movement (i.e., average movement duration). Future studies using the DopFet system will be aimed at discovering which of these parameters or combination of parameters is the best indicator of fetal well-being. We present an example of a 0.5 h recording and the results of testing on 23 volunteer mothers. These results show good sensitivity of the system compared to real-time ultrasound (US). The system detects 96% of rolling movements, 100% of flexion movements and 97% of leg movements.

Low alpha-linolenic acid content of adipose breast tissue is associated with an increased risk of breast cancer.

Data derived from experimental studies suggest that alpha-linolenic acid may have a protective effect in breast cancer. Observations obtained from epidemiological studies have not allowed conclusions to be drawn about a potential protective effect of dietary alpha-linolenic acid on breast cancer, possibly because of methodological issues. This case-control study conducted in an homogeneous population from a central area in France was designed to explore the hypothesis that alpha-linolenic acid inhibits breast cancer, using fatty acid levels in adipose breast tissue as a biomarker of past qualitative dietary intake of fatty acids. Biopsies of adipose breast tissue at the time of diagnosis were obtained from 123 women with invasive non-metastatic breast carcinoma. 59 women with benign breast disease served as controls. Individual fatty acids were analysed by capillary gas chromatography. An unconditional logistic regression model was used to obtain odds ratio estimates whilst adjusting for age, menopausal status and body mass index (BMI). No association was found between fatty acids (saturates, monounsaturates, long-chain polyunsaturates n-6 or n-3) and the disease, except for alpha-linolenic acid which showed an inverse association with the risk of breast cancer. The relative risk of breast cancer for women in the highest quartile of adipose breast tissue alpha-linolenic acid level was 0.36 (95% confidence interval=0.12-1.02) compared with those in the lowest quartile (P trend=0.026), suggesting a protective effect of alpha-linolenic acid in the risk of breast cancer. The effects of dietary alpha-linolenic on the risk of breast cancer warrant further study.

[Scarred uterus: is routine exploration of the cesarean scar after vaginal birth always necessary?]. / Utérus cicatriciel: la révision systématique de la cicatrice de césarienne après accouchement par voie vaginale est-elle toujours utile?

OBJECTIVE OF THE STUDY: To determine the risks and benefits of routine transcervical revision of previous cesarean uterine scar in patients with successful vaginal delivery. MATERIAL AND METHODS: Retrospective study, over a 10-year period, of a routine palpation practice in the two units of our Obstetric department. Then, a 30-month prospective study comparing, in each unit, two different attitudes toward uterine revision (routine exploration vs symptomatic patients exploration) was conducted. RESULTS: The retrospective part of our study led us to report 3 uterine ruptures (0.43% of all scarred uterus) and 14 dehiscences (2%) during the ten years. All uterine ruptures were sufficiently symptomatic in order to be suspected prior to scar exploration. No dehiscence needed surgical treatment. Some patients with bloodless dehiscence and no repair had subsequent vaginal deliveries with no scar separation found on uterine exploration. In the prospective part of our study, we found a significative difference in the occurrence of fever (18.9% vs 9.9%; p < 0.05) and antibiotic treatment (22.8% vs 12.7%; p < 0.05) between the two groups based on attitude toward uterine revision. CONCLUSION: These data suggest that transcervical revision of previous cesarean uterine scar should be performed only in symptomatic patients (persistent suprapubic pain, placental retention, excessive bleeding during labor or delivery) or when risk factors are present (prolonged labor, prolonged expulsive efforts, instrumental extraction).

Bilateral ovarian removal during hysterectomy: what is done and what should be done.

OBJECTIVE: Discussion of the indications for bilateral removal of the ovaries at hysterectomy after the age of forty. DESIGN: A multicenter survey involving 50 university centres and regional hospitals was carried out. RESULTS: The majority of French Obs-Gyn carry out bilateral removal of adnexa when the patient is over fifty years old, rather than after forty years of age. DISCUSSION: Reducing mortality due to ovarian cancer is commendable, as is the reduction of morbidity due to ovarian cysts and pathology after hysterectomy, but it is necessary to evaluate the cost of prematurely induced menopause. CONCLUSION: The authors believe that an age limit of forty years is too low. A consensus has emerged for performing bilateral removal of the ovaries after the age of fifty in the absence of a history of pelvic adhesions and/or endometriosis. It is necessary to explore the condition of the ovaries during the laparotomy.

[Management of premature rupture of membranes in a monofetal pregnancy before 28 weeks gestation]. / Conduite à tenir devant une rupture prématurée des membranes sur une grossesse monofoetale avant 28 semaines d'aménorrhée.

To establish appropriate management of premature rupture of the membranes before 28 weeks, we examined maternal and fetal risks in pregnancies complicated by this rare problem (1-7/1000). Three main factors were identified in such circumstances: prematurity, infection and oligohydramnios. Prematurity is inevitable and depends on three factors: gestational age at rupture of the membranes which is an independent predictor of poor prognosis before 22 weeks; gestational age at delivery as neonates born before 26 weeks gestation have an overall perinatal survival < 50%, and latency period between preterm rupture of the membranes and delivery which ranged from 1 to 161 days with a mean 7.8 days. Infection is the second factor with a high incidence (> 30%) of chorioamnionitis. The third factor is skeletal deformations and pulmonary hypoplasia predicted by severe and prolonged (> 14 days) oligohydramnios. Only about 40% of such women will take home a live baby. Successful outcome can be achieved in about 60% of these survivors. Termination of pregnancy is warranted at 22 weeks gestation or less and may be proposed. Beyond 22 weeks gestation, management is based on a wait-and-see attitude with ultrasonographic and bacteriological surveillance. After 25 weeks gestation, management becomes more active with use of antibiotics, tocolytics and steroids which can help prolong the latency period and improve fetal outcome. Ongoing counselling and psychological support are essential in the management of this morbid complication of pregnancy.

Urethral cytology and diagnosis of the pregnancy term. About some observations on the use of this method in an hospital setting.

A retrospective study of routine urethrocytograms performed over a 10-year period in 3,478 pregnant women for the diagnosis of pregnancy term was carried out to determine the reliability of urethral cytology when two, three, or four successive urethral smears were performed at 2- or 3-day intervals, and to investigate the correlations between the cytological results and the neurological ages of newborns. Microscopical examination of the 3,478 routine smears demonstrated the existence of a before-term aspect, a near-term aspect, or an at-term aspect in 7.4%, 66.7%, and 22.1% of cases, respectively. The diagnosis of post-term was noted only in 1 smear. Repeated urethrocytograms (1, 2, or 3 smears after the firstone) in women with a previously diagnosed before-term aspect or a near-term aspect revealed the occurence of the at-term aspect over time. Concordant correlations between cytological results and the neurological ages of the newborns were noted in 98.1% of cases. Three developmental stages (beginning, middle, end) of the near-term aspect and three stages of the at-term aspect were described. Due to its interest, the urethral-smear method should be worth generalizing as the other laboratory examinations that are routinely used to determine the term of pregnancy.

Intrahepatic cholestasis of pregnancy: a French prospective study.

The aim of this prospective study was to analyze the characteristics of intrahepatic cholestasis of pregnancy (ICP) in a French population. From 1989 to 1995 we studied 50 consecutive pregnant women with ICP (41 single, 7 twin, and 2 triplet pregnancies) referred for hepatologic consultation. All patients suffered from pruritus and/or jaundice associated with elevated fasting serum levels of total bile acids (mean 49 micromol/L, range 7-290). No patients had concomitant liver disease and all recovered normal liver function after delivery. Overall prematurity rate was 60%: 100% in multiple pregnancies and 41% in single pregnancies. Three of 61 babies died. Systematic clinical interviews revealed that 34 patients had been treated with oral micronized natural progesterone (200-1,000 mg/d) during the current pregnancy for risk of premature delivery, including at least 32 (64%) before the onset of pruritus. Onset of pruritus was statistically earlier in patients previously receiving progesterone than in patients not receiving progesterone (217 +/- 21 vs. 240 +/- 26 days, P < .01). This was also found in the single pregnancy subgroup of patients (222 +/- 19 vs. 240 +/- 26 days, P < .05). Pruritus disappeared before delivery in 10 of 50 patients, i.e., after withdrawal of progesterone in 7 patients (only one concurrently treated with cholestyramine), after decrease in dose of progesterone in 1 patient, and spontaneously in 2 patients. During the same period, the percentage of pregnant women without ICP who had been treated with progesterone during pregnancy was statistically lower than the percentage of patients treated with progesterone before the onset of pruritus in our group of patients with ICP (36% vs. 64%, P < .01, odds ratio 3.16, 95% CI:1.29-7.80). These results suggest that orally administered progesterone might be an exogenous factor which triggers ICP in predisposed women.

The effect of male factors in repeated spontaneous abortion: lesson from in-vitro fertilization and intracytoplasmic sperm injection.

Between 6.5 and 21% of pregnancies result in spontaneous abortion. The incidence of repeated spontaneous abortion (RSA) is, however, lower: 0.05-1.0% of pregnancies. These values vary, not only according to the populations studied and the means of diagnosing the miscarriages, but also to the age and the parity of the patient: 4% at 20 years of age versus 16% after 35 years. These differences are greater if biochemical pregnancies are taken into account. The aetiologies of RSA are multiple and at times even multifactorial. While certain aetiologies, such as chromosomal, anatomic, hormonal, immunological or unexplained anomalies, have been extensively explored, the sperm characteristics likely to influence the quality of the conceptus have rarely been examined. This review examines the male factor's contribution in RSA.

[Retroperitoneal malignant fibrous histiocytoma]. / Histiocytome fibreux malin rétropéritonéal.

Malignant fibrous histiocytoma is the commonest soft tissue sarcoma of adults. The soft tissue of the extremities is the commonest primary site of malignant fibrous histiocytoma. It is much less common in the female retroperitoneum, leading to diagnostic errors. The clinical, radiographic and CT signs are non-specific. This tumor can only be diagnosed by histology. An initial complete resection is essential for successful treatment of the primary tumor. Radiation therapy is limited and chemotherapy has only been successful in a limited number of cases. This tumor has a poor prognosis. These lesions are relatively rare and consequently difficult to study. The authors report three cases and review the literature.

Twenty-day cerebral and umbilical Doppler monitoring on a growth retarded and hypoxic fetus.

In one growth retarded and hypoxic fetus, the cerebral and umbilical hemodynamic changes were assessed (by Doppler), daily over 20 days. The fetal brain was investigated by magnetic resonance imaging (MRI) close to the delivery, and because the fetus died at delivery we performed an anatomical study of the fetal brain. The evolution of the fetal hemodynamics (day by day) was interpreted according to the MRI findings and the clinical findings. During the period of observation (under sustained hypoxia) the fetal deterioration was characterized by: (a) the progressive development of the oligohydramnios (190d), (b) the disappearance of the vascular reactivity (eight successive cerebral resistance index (RI) constant at 194d), (c) the occurrence of fetal heart rate decelerations (199d), and finally (d) the increase of the cerebral vascular resistances with reduction of the brain perfusion (204d). The anatomical study of the brain showed a periventricular congestion however the histology revealed hypoxic lesions like gliosis and a marked vasodilation of the anterior and middle cerebral arteries. Finally in addition to single Doppler measurements performed 1 week before delivery (for prediction of fetal outcome), one can suggest to use the 'loss of fluctuation of the cerebral RI' to identify the beginning of the period of very high risk for the fetus. Such hypothesis may have to be confirmed on a larger number of pathological pregnancies.