Vascular endothelial growth factor antagonist reduces the early onset and the severity of ovarian hyperstimulation syndrome.

BACKGROUND: Ovarian hyperstimulation syndrome (OHSS) is the most serious complication of controlled ovarian stimulation (COH) during assisted reproductive technology (ART) protocols. This syndrome is a result of ovarian expression of vascular endothelial growth factor (VEGF), which increases vascular permeability. OBJECTIVES: To evaluate the efficiency of prophylactic and therapeutic use of cabergoline in women with higher risk of developing OHSS. MATERIALS AND METHODS: In this prospective randomized study, 146 women undergoing in vitro fertilization (IVF) cycles with GnRH agonist protocols with a higher risk of OHSS diagnosed during the HCG day administration (more than 18 follicles observed larger than 12mm in diameter during COH and/or estradiol levels of 3000-3500pg/ml, previous episodes of OHSS). Women were randomly divided in two groups. The first group included 78 women who received 0.5mg per day of cabergoline (Dostinex®) orally for 7 days starting from hCG administration day. The second group included 68 women who received no medication treatment. Overall, in each group 25 patients have developed OHSS. This defines subgroup 1 that includes 25 cases of OHSS obtained in group 1 and subgroup 2 where 25 cases of OHSS obtained in group 2. Early OHSS was defined as being when the onset of the syndrome was initiated during the first 9 days after hCG administration and late OHSS was defined as being when the onset of the syndrome was initiated from 10 days after hCG administration. Outcome measures of this study were the incidence of moderate and severe OHSS, early or late OHSS and pregnancy rates. RESULTS: There was no evidence of a statistically significant reduction in the incidence of OHSS in cabergoline group (32.05% vs. 36.76%; P>0.05). Late OHSS was observed in 60.6% of cases in cabergoline group while 39.4% of cases in the other group (P=0.036). Early OHSS decreased significantly (P<0.05) in the cabergoline group. Severe OHSS cases were more common within subgroup 2 than subgroup 1 (32% vs. 8%, P=0.000). There was no difference in clinical pregnancy rates (PR) and miscarriages rates between the two subgroups. CONCLUSIONS: The cabergoline administration (Dostinex®) for patients with high-risk of OHSS can reduce the rate of early OHSS and its severity in GnRH agonist IVF cycles, but cannot prevent the incidence of OHSS.

PP169. Management of fetal and maternal prognosis during severe toxemia.

INTRODUCTION: Severe gravidic toxemia gives heavy maternal and fetal morbidity and mortality. OBJECTIVES: The purpose of our data is to identify bad maternal and fetal factors during severe toxemia and the outcome of pregnancy. METHODS: It is a retrospective and comparative study about 200 cases of severe toxemia reported during 8 years 2004-2011 among 25,000 deliveries (control group). Toxemia is considered severe when blood pressure⩾160/100mHg, proteinuria ⩾2g/l, bad neurosensorial signs, hemostasis disorders, kidney and liver failure, some fetal tests: delay intra-uterine growth acute fetal suffering, fetal death. RESULTS: Frequency of severe toxemia 8‰, primiparous 58% vs. 35% control, gestational diabetes 12% vs. 10% control, oedema 87% vs. 45% control. Maternal morbidity is dominated by hemostasis disorders: low platelet count<80,000 23% vs. 8%, hypofibrinogenemia <4g/l 13% vs. 2%, HELLP syndrome eight cases vs. 0. We raised eight cases of eclampsia crises, 22 cases of retroplacental hematoma vs. 10 control. Blood transfusion 15% vs. 10% control, inhibitors of VII factor administered in two cases vs. 0. We do not deplore any maternal mortality. Fetal prognosis is very compromised ,the delay intra uterine growth 44% vs. 18% control, prematurity 66% vs. 15% control, perinatal mortality 60‰ vs 12‰ control CONCLUSION: More toxemia appears early during pregnancy more maternal and especially fetal prognosis is compromised. New drugs, predictive tests and preventives measurements improve maternal outcome better than fetals' one.

[Cerebral venous thrombosis during pregnancy: about 7 cases]. / Thrombophlebite cerebrale survenant lors de la grossesse: a propos de 7 cas.

BACKGROUND: cerebral venous thrombophlebitis (CVT) is a rare but serious pathology. The pregnancy and especially the postpartum constitute supporting circumstances occured of the CVT. AIM: the aim of our study is to remember the symptomatology of CVT, the importance of the IRM and the angio IRM in the diagnosis of CVT, and its treatment. OBSERVATIONS: We present a retrospective study relating to 7 cases of CVT during gravidopuerperality over 7 years (1996 to 2002). The average age of our patients is 32.1 years. The CVT occured during the first trimester of the pregnancy in one case and in the postpartum in 6 cases. The symptomatology was dominated by cephalgia and the signs of intracranian hypertension. Convulsions occured in 3 cases. The diagnosis of CVT was confirmed by IRM coupled with the Angio-IRM in all cases. The treatment by heparinotherapy was instaured immediately and relayed by the Anti-Vit K as the evolution was favorable in all cases. CONCLUSION: cerebral venous thrombophebitis (CVT) is a serious pathology (especially in pregnancy and post partum). The diagnosis is performed by the magnetic resonance imaging (IRM) and the early introduction of the heparinotherapy.

[Endometrectomy. Analytical study of 20 cases]. / Endométrectomie. Etude analytique de 20 cas.

UNLABELLED: Endometrial removal represents a therapeutic alternative to hysterectomy. AIMS: Through a retrospective study of 20 cases of endometrial removal colleted over a period of 4 years, the authors try to determine the indications of this therapeutic method, its efficiency, its advantages as well as its contra indications. RESULTS: Average age of the patients was 44 years. Average parity was 4. Functional menstrual disorders were found in 90% of cases. Gynaecological examination revealed a uterus of normal size in 85% of cases, and increased in size in 15% of cases. All the women had a preoperative diagnostic hysteroscopy. A simple endometrectomy was performed in 70% of the cases, an endometrectomy with a polypectomy in 25% of the cases and an endométrectomy with a myomectomy in 5% of the cases. The rate of success was 90%. We had a case of uterine perforation, because of uncontrollable bleeding a hysterectomyhad to be carried out in 2 cases. CONCLUSION: Endometrectomy is an alternative to hysterectomy in cases of menorrhagia due to mild functional disorders resistant to medical treatment.

[Intra-uterine growth retardation: etiologic factors and management]. / Retard de croissance intra-utérin: etiologie et prise en charge obstetricale.

OBJECTIVE: The aim of this study is to define the etiologic factors, the diagnostic proceduresand obstetrical rules to be observed during a pregnancy in relation with low birth weight. PATIENTS AND METHODS: This is a retrospective study of 124 cases, carried out at the military hospital of Tunis, between January 1st 1999 and December 31 st 2001. RESULTS: The frequency of intra-uterine growth retardation (IVGR) was 2.1%. 46.8% of the patients were primiparous. The mean age of the patients was 30 years. 25.8% of the patients developed toxemia. The etiology was predominantly renovascular-syndromes, urinary infections, and idiopathic hypotrophy. The positive diagnosis was suggesred by the measure of the uterine height in 96% and was confirmed by sonogaphy in all cases. The ombilical Doppler was pathological in 17.76% of the cases. A corticosteroid administration for pulmonary maturation was prescribed in 28% of the cases. Obstetrical common rule was fetal extraction: 42.7% of the patients were delivered by cesarean. CONCLUSION: There is a real need to insist on the importance of early detection of fetal hypotrophy and of better management of the women at risk.

[Maternal mortality: epidemiology, risk factors and evitability. About ten cases]. / La mortalité maternelle : épidémiologie, facteurs de risque et évitabilité. A propos de dix cas.

OBJECTIVES: To determine maternal mortality rate during the last decade as revealing the quality of obstetrical follow-up and the necessary measures to be taken. PATIENTS AND METHODS: A retrospective study conducted in the department of gynaecology in the military hospital in Tunis between 1990 and 2001, permitted to count 10 cases of maternal death. RESULTS: Maternal mortality rate was about 33.72/100,000 live births. Mean age of patients was 31.2 years. Primiparity, multiparity, poor socio-economic conditions, high-risk pregnancies and bad follow-up were responsible in 5, 1, 6 and 3 cases and represent the risk factors of mortality. All deaths occurred after delivery, with 60% before 24 h. Causes of death were haemorrhage in 40%, gravidic hypertension in 20%, anesthetic accidents in 10%, acute hepatic failure in 10%, and infection in 10%. Indirect causes are responsible for 20% of cases. DISCUSSION AND CONCLUSION: Deaths were judged evitable in 66.6% of cases, which confirms, although maternal mortality has diminished in the recent past, the necessity of pursuing study of risk factors together with study of remedies to them.

[Urinary incontinence with effort: surgical management in the maternity ward of a Tunisian military hospital (91 case reports)]. / Incontinence urinaire à l'effort: prise en charge chirurgicale à la maternité de l'hôpital militaire de Tunis (à propos de 91 cas).

We bring back a retrospective study on the surgical treatment of the incontinence in the effort about 91 cases. Our objective is to estimate the results of our surgical techniques. Three procedures were used: plicatures under urethrales; intervention of bologna; intervention of Burch. The incontinence in the effort was associated to a genital prolapse in every cases; prolapse was of third degree in 70% of cases. We obtained a good functional result in 94% of cases and a good anatomical result in 96% of cases on an average recession of 60 months. The complications per and postoperating are marked especially by the urinary infections. Our study shows that classical technics are still available.

[Management of uterine fibromas. Report of 219 cases]. / Prise en charge des fibromes uterins. A propos de 219 cas.

This study is about 219 uterine fibroma treated surgically between 1994 and 1998. The surgical operation represent 19.1% of the gynecological interventions. The average age of our patients was of 41.7 years with 30.6% of nulliparous. The main motives of consultation were: the confusion of the menstrual cycle in 56.6%, the pelvic pains in 32%, the increase of the volume of the belly in 10% and the infertility in 10% of cases. The surgical indications were dominated by the big size of the womb in 68% of cases and hemorrhagic complications in 57.7% of cases. The myomectomy indicated for women young and avid for pregnancy was realized in 94 cases; 80.8% by abdominal way, 13.8% by hysteroscopic way and 5.3% by coelioscopy. Hysterectomy proposed for women near menopauses was realized in 125 cases: 70.4% by abdominal way and 29.6% by vaginal way. The complications per- and post-operating are rare, represented essentially by the bleeding and the urinary infections.

[Uterine ruptures. 32 cases]. / Les ruptures utérines. A propos de trente-deux cas.

On the basis of qqq 32 cases of rupture of the uterus observed over a 5-year period at the Monastir University hospital (Tunisia), the authors recall the high incidence of this obstetrical emergency: 1 incident per 548 deliveries. The usual aetiological factors were present: multiparity, caesarean scar, mechanical dystocia, oxytocic dystocia and obstetric manoeuvres. The foeto-maternal prognosis is poor with a maternal mortality rate of 3.13% and a perinatal mortality rate of 46.9%. Treatment should be conservative whenever possible. The authors attempt to define a prophylactic approach on the basis of the aetiological context.

[HELLP syndrome. Epidemiological, nosological and prognostic aspects]. / HELLP syndrome. Apports épidémiologique, nosologique et pronostique.

The authors report a prospective and controlled study of hellp syndrome in two groups of patients: normal and preeclamptic. Hellp syndrome was seen only in the pre-eclamptic group (19.3 per cent). Maternal prognosis was poor when Hellp syndrome was confirmed. Several maternal complications were seen: severe hypertension, subarachnoid hemorrhage, coagulation disorders and renal failure. Maternal mortality was high (16.7 per cent). Hellp syndrome does not worsen fetal prognosis, which is already compromised by pre-eclampsia.

[Fetal prognosis in breech delivery. Statistical study of 543 cases]. / Le pronostic foetal de l'accouchement par le siège. Etude statistique à propos de 543 observations.

The authors report a retrospective study of 543 breech deliveries during a 4-year period (1987-90). The cesarean section rate was 18.4 per cent, and perinatal mortality 3.68 per cent. Poor prognostic factors were: multiparity, large fetus, cord prolapse, second stage of labour lasting more than 30 mins and obstetric manoeuvres. Prenatal care and obstetric evaluation before labour may improve fetal prognosis.

[Evaluation of the method of delivery in breech presentation]. / Evaluation du mode d'accouchement dans la présentation du siège.

The authors report a retrospective study based upon 543 breech deliveries at term, collected between 1987 and 1990. The cesarean section rate was 18.4 per cent. It was prophylactic in 56 cases. When the possibility of vaginal delivery was accepted, cesarean section was performed in 9 per cent of cases. Fetal mortality and morbidity were higher with vaginal delivery. However, maternal morbidity was greater in the cesarean section group. Study of the literature shows that the increase in cesarean section rate in recent years is not the only factor responsible for improved fetal prognosis. It is therefore important to restrain this increase and find the optimum percentage rate.

[Characteristics of pregnancy and delivery in women with heart diseases]. / Caractéristiques de la grossesse et de l'accouchement chez la femme cardiaque.

The authors report 78 cases of pregnancy in women with heart disease during a 4 year period (1985-1988). Heart disease involved a rheumatic valve lesion in 90 per cent of cases. Heart disease was properly monitored in these patients (74.5 per cent) but the pregnancy in only 50 per cent of cases. These patients gave birth to 78 newborn infants. Labour was premature in 15.38 per cent of cases. Labour was of short duration: less than 6 hours (73 per cent of cases). There was only delivery by cesarean section. Bleeding at the time of delivery was common (12.4 per cent of cases). There were two maternal deaths during the post-partum period (2.56 per cent). Essential risks to the newborn included low birth weight (17.5 per cent) and prematurity (15.38 per cent). Neonatal mortality was 2.5 per cent.

[Problems posed by the delivery of twin pregnancies]. / Problèmes posés par l'accouchement de la grossesse gémellaire.

The authors present a retrospective study of 249 deliveries of twin pregnancies collected between 1987 and 1990. The incidence of twin pregnancies is 1.6%. Delivery is premature in 28.1% of cases and that of low birth weight is 51.7%. In 13.2% of cases, delivery was Cesarean and the Apgar score was significantly higher for the first twin than for second. Perinatal mortality was 7.2 percent. The authors compare these findings with those reported elsewhere in the literature.

[Early echographic diagnosis of omphalocele. 2 case reports and review of the literature]. / Le diagnostic échographique précoce de l'omphalocèle. A propos de deux cas et revue de la littérature.

The authors report two cases of early diagnosis of omphalocele. The first, suspected by ultrasonography at 11 weeks amenorrhea, was associated with a cystic lymphangioma of the neck. In the second case, bearing in mind the past history of interrupted pregnancy and of fetal malformation, the early indication for ultrasonography enabled the diagnosis of an omphalocele associated with anencephaly and abnormal closure of the neural tube. The ultrasonographic discovery of these malformations during the first part of pregnancy enabled vaginal fetal extraction.