[Is vaginal hysterectomy important for large uterus of more than 500 g? Comparison with laparotomy]. / L'hystérectomie vaginale a-t-elle un intérêt pour les gros utérus de plus de 500 g? Comparaison avec la laparotomie.

OBJECTIVE: Vaginal hysterectomy is an advantageous surgical technique as compared with abdominal hysterectomy: operating time is shorter, it is safer and hospitalization stay and recovery time are shorter. However in France, 2/3 of all hysterectomies are still performed by laparotomy. Would the vaginal approach be reasonable if a difficult hysterectomy is expected? The purpose of our study was to compare the per- and postoperative complications and the period following vaginal hysterectomy versus the abdominal route in patients with a large uterus. PATIENTS AND METHODS: Forty-nine vaginal hysterectomies were compared retrospectively with 22 abdominal hysterectomies for fibroma during the period from 01.01.91 to 31.12.95. Uterine weight in all cases was between 500 to 1,000 g. RESULTS: The average uterine weight was significantly different between the vaginal and the abdominal groups (644 g vs 747 g, p = 0.02). Operating time, pre- and postoperative complications and analgesic use were not significantly different between the two groups. Operative bleeding was significantly higher in the abdominal group than in the vaginal group (659 ml vs. 359 ml, p = 0.006), as well as hemoglobin loss (2.49 vs. 1.82, p = 0.04). There was also a statistical difference between the vaginal group and the abdominal groups in terms of hospital stay (4 d vs. 6 d respectively, p = 0.0002). CONCLUSION: Vaginal hysterectomy with morcellation is advantageous in comparison with abdominal hysterectomy even when the uterine weight is over 500 g, since it offers better post-operative comfort than laparotomy without endangering the patients. The main contraindications for the vaginal route are uterus beyond the ombilicus and vaginal atresia. Excepting these cases, the indication for the vaginal approach depends on the patient's past surgical history, uterine mobility and vaginal access. In more difficult cases, these factors are assessed under anesthesia.

[Maternal and congenital syphilis]. / Syphilis maternelle et congénitale.

Testing for syphilis during pregnancy reveals a positive serologic status in 0.02% of cases. However, a 66% rate of stillbirths is noted in women who are infected and who have not benefited from any treatment. Routine screening is at present performed during the early stages of pregnancy but a second serologic test during the third trimester is useful in the diagnosis of a late infection especially in drug users or HIV (human immunodeficiency virus) positive patients. Congenital syphilis is diagnosed in utero when a positive maternal serologic status is associated with ultrasound images showing fetal abnormalities; these include hepatosplenomegaly, hyperechogenic bowel, signs of bowel obstruction or fetal hydrops. Maternal syphilis is treated by delayed action penicillin and is indicated even for patients allergic to the antibiotic which in this particular case is delivered after desensitization. First line therapy by intravenous penicillin is indicated when confronted with the following high risk factors of congenital syphilis: an elevated titre of VDRL (venereal disease research laboratory) at the time of diagnosis or delivery, unknown date of the precise onset of the infection, the appearance of a rash or of a chancre during pregnancy, ultrasound fetal abnormalities or late therapy during the third trimester. Treatment of the new-born child will depend on the results of clinical, serologic and X-ray evaluation. Long term follow-up for at least a year is mandatory.

The feasibility of vaginal hysterectomy.

OBJECTIVE: To assess the feasibility of vaginal hysterectomy for benign uterine disease and to assess how frequently laparoscopic assistance is necessary. METHODS: A prospective series of 806 hysterectomies for benign disease of the uterus without prolapse which were performed in our institution from 1 March 1991 to 28 February 1994 is discussed. The report is an evaluation of a planned approach for hysterectomy. Vaginal hysterectomy was performed whenever possible-laparoscopic hysterectomy was indicated for adnexal pathology, known or anticipated significant pelvic adhesions and for a narrow vaginal access with a moderately enlarged uterus-abdominal hysterectomy was chosen when both laparoscopic and vaginal surgery were judged to be impossible. RESULTS: Vaginal hysterectomy was performed in 80.6% of patients. Laparoscopic assistance was needed in 9.4% of cases. The need for laparotomy was reduced to 10% with an acceptable pre- or postoperative complications rate.

[Breast feeding: which contraceptive method?]. / Allaitement maternel: quelle contraception?

Contraception during breast feeding must take two points into account: the first physiological contraception due to anovulation which disappears at around the 9th week of lactation); the second pharmacological: any substance ingested by the mother during breast feeding is excreted in milk, chiefly by passive diffusion. All pharmacokinetic studies have shown that the transfer of progesterone or of estrogen when taking a contraceptive pill is extremely slight, being of the same order as that of natural hormones. When it is decided to use hormonal contraception, this should be started after the 6th week of lactation, when lipid profile has returned to normal and thromboembolic risk is identical to that of the population in general. As with all prescription during lactation, the drug should be taken as far as possible from the next feed. Barrier techniques (combining condoms and spermicides) are an elegant alternative to drug methods.

PIP: When breast feeding is the only and unique form of infant feeding, it is an excellent contraceptive method. By the ninth week of lactation, ovulation may begin. For example, among women who practice exclusive breast feeding, none ovulate at six weeks; but by nine weeks, 1% do. This proportion increases to 17% at 12 weeks and 36% at 18 weeks. In France, breast feeding is no longer the only form of infant feeding and lactating women often ask for effective and safe contraception. Barrier methods (spermicides or condoms) are safe and effective contraceptives. They are a great method for women who have contraindications to oral contraceptives (OCs). If lactating women choose to use hormonal contraception, they should begin after the sixth week postpartum when their lipid profile has normalized and the risk of developing thromboembolism is the same as the general population. They should take each pill as far as possible from the next feeding. During OC use, progesterone and estrogen pass into breast milk in only very small quantities. Some obstetrician-gynecologists recommend that lactating women use an OC with a third-generation progestin and a low-dose estrogen. Third-generation OCs have a very weak androgenic effect.

[Medullary aplasia during treatment for congenital toxoplasmosis in a twin pregnancy]. / Aplasie médullaire au cours du traitement d'une toxoplasmose congénitale lors d'une grossesse gémellaire.

The authors report a case of a patient who in the 24th week of a twin pregnancy became sero-positive for toxoplasmosis. This was diagnosed by cordocentesis as being infected, and the treatment was therefore started with pyrimethamine and sulfadiazine and folic acid at the 28th week of pregnancy. At 35 weeks, the patient had an acute medullary aplasia due to the absence of the folates. The mother's state was improved rapidly by giving her folinic acid and the twins were normal haematologically. In this case, the authors point out how important the folates are in a pregnancy, especially in twin pregnancies, and point out the precautions that have to be taken when treatment with pyrimethamine and sulfadiazine is started for congenital toxoplasmosis.