Fetal electrocardiogram ST-segment analysis and prediction of neonatal acidosis.

OBJECTIVE: To determine the diagnostic value of fetal ST-segment analysis (STAN) in predicting neonatal acidosis. METHODS: The STAN S21 was used to monitor singleton fetuses in labor with abnormal FHR. Physicians later reviewed tracings to identify any ST events dictating intervention. Outcome measures were umbilical artery pH< or =7.15 and pH< or =7.05 at birth. The sensitivity, specificity, PPV, and NPV of a significant ST event to predict both outcomes were calculated. RESULTS: Analysis included 411 women. Sensitivity of a significant ST event for screening pH< or =7.15 (21.9%) was 38% (41/108), specificity 83% (252/303), PPV 45% (41/92) and NPV 79% (252/319), and for pH< or =7.05, it was (3.4%), 62.5% (10/16), 79% (313/395), 11% (10/92), and 98% (313/319), respectively. CONCLUSION: In a population with abnormal FHR in labor, STAN sensitivity is moderate (almost 40%) for predicting pH< or =7.15 and better (almost 60%) for more severe acidosis (pH< or =7.05).

[Left colon necrosis after endoscopic para-aortic lymph node exploration in a cervical carcinoma stage IIB]. / Nécrose colique gauche après un curage lomboaortique coelioscopique pour cancer du col utérin de stade IIB.

Authors report a left colon ischemia six days after laparoscopic para-aortic lymphadenectomy in the staging of advanced cervical carcinoma. Before surgery, positron emission tomography scanning was performed: there were no para-aortic nodal metastasis. The histologic examination confirmed the radiological staging. Positron emission tomography scanning could avoid surgery in the case of patients with high risks morbidity factors.

Anal localization as first manifestation of metastatic ductal breast carcinoma.

The incidence of extrahepatic gastrointestinal metastases from breast cancer is reported in the literature only as necroscopy studies (6-18%); they usually originate from lobular or a mixed ductal-lobular subtype. Nonspecific presenting symptoms, death of the patients caused by other more frequent metastases, and variable radiographic features mimicking primary neoplasms cause a clinical underestimation of this pathology. We report here a case of rectal metastasis from an invasive ductal carcinoma (IDC). This is to our knowledge, the first recorded instance of an anal metastasis from IDC.

[Obstetrical management in the event of persistent or worsening postpartum hemorrhage despite initial measures]. / Prise en charge obstétricale en cas d'hémorragie du post-partum qui persiste malgré les mesures initiales ou qui est grave d'emblée.

Sulprostone infusion must be started without further delay if the first treatment (oxytocin, manual removal of the placenta, uterine revision, vaginal and cervical examinations) has been unsuccessful in the first 30 minutes after delivery. In France, the use of this treatment has been officially authorized in this indication (marketing approval, AMM). Intramuscular and intramyometrial injections being contraindicated, sulprostone is administered through continuous intravenous infusion. Dosage is 500 microg (one vial) per hour. Starting dose is 1.7 microg/min (10 ml/h), and can be increased if necessary in steps of 1.7 microg/min (but not exceeding 8.3 microg./min). The success rate of this treatment is linked to the rapidity of its commencement (within 30 min of the diagnosis of postpartum hemorrhage). In case of contraindications, since postpartum hemorrhage is life-threatening, the benefit-risk ratio needs to be estimated. A strict monitoring of cardiovascular parameters is compulsory before and after its administration. There is no time limit after which this treatment can be considered as ineffective: it depends on the amount of blood lost, the patient's clinical state, and on means that have already been used to stop the bleeding. However, if after 30 min of sulprostone infusion, there is no improvement or if the situation is worse, other therapeutic strategies must be considered (e.g., embolization, surgery). The use of intra-rectal misoprostol is still under assessment. To date, we have been unable to find studies that justify this treatment. Intra-uterine balloon, tube, or mesh packing has been studied in a few small series, where it was successful. Use of these strategies must not delay the treatment by sulprostone.

[Routine use of ST-segment of fetal electrocardiogram for monitoring labor. A year's experience (preliminary results)]. / Utilisation en routine de l'analyse du segment ST de l'électrocardiogramme foetal pour la surveillance du travail. Une année d'expérience (résultats préliminaires).

OBJECTIVES: Two randomized trials found that monitoring labor by analyzing the fetal electrocardiogram (STAN) appears to offer better sensitivity and specificity in screening for metabolic acidosis than cardiotocography (CTG) does. We report here the results of a descriptive study of 173 cases between 1 June 2001 and 31 May 2002, the objectives of which were twofold: to determine the number of possible false negatives (defined by neonatal metabolic acidosis with a pH less than 7.05 and base deficit (BD) greater than 12 mmol/l, in the absence of a STAN decisions event more than 30 min before birth), and to assess whether STAN indicated the need for operative intervention too late in cases of fetal distress. PATIENTS AND METHODS: Our study was conducted on an at-risk population with CTG changes. STAN was used with a scalp electrode to monitor labor according to a protocol based upon the FIGO CTG classification and the clinical instructions used in the Swedish trial. Accordingly, we compared two groups: in group 1, a STAN decision event required a rapid conclusion to labor, while in group 2, the absence of any STAN decision event meant that labor continued, despite the changes in the tracing. RESULTS: We found seven cases with a neonatal pH less than 7.05, but only one may involve a false negative by this method. The mean arterial pH and the number of fetuses born with an arterial pH less than 7.10 did not differ significantly between the two groups, nor were there any significant differences in the mean BD at birth, or the number of children with a BD greater than 12 mmol/l. CONCLUSION: The results appear to indicate that use of STAN with the usual CTG enables an appropriate response to cases of fetal distress, but it remains difficult to determine the real benefits that can be expected from this method in France. Longer assessment in our population is required before we can assess its actual advantages.

[Multidisciplinary management of aortic dissection complicating pregnancy]. / Prise en charge multidisciplinaire d'une grossesse compliquée de dissection aortique.

BACKGROUND: Most cases of aortic dissection observed in women under 40 years of age occur as a complication of pregnancy in patients with other risk factors. Case report. We report a case of dissection of the ascending aorta in a young primigravida at 35 weeks gestation. The risk factor was aortic regurgitation. Multidisciplinary management enabled fetal extraction followed by repair of the aorta. Outcome was favorable for both mother and child. DISCUSSION: A review of the literature shows a variety of etiological factors leading to this disease. Emergency diagnosis and management is mandatory. Obstetricians should be aware that pregnancy can be a triggering factor in patients with a predisposition, e.g. connective tissue disease. A complete cardiovascular evaluation should be conducted before conception and a suitable surveillance planned for the entire pregnancy. The aim of this careful follow-up it to avoid surgery in an emergency setting that could compromise prognosis for both mother and child.