Transvaginal cervicoisthmic cerclage as an alternative to the transabdominal technique.

OBJECTIVES: To analyse the foetal outcome after transvaginal cervicoisthmic cerclage, to determine whether it is a valid alternative to the reference transabdominal technique. STUDY DESIGN: Description of the vaginal operative technique, retrospective review of 20 cervicoisthmic cerclage patients from 1990 to 2000. RESULTS: In the curative group of women with a history of late pregnancy losses or premature deliveries and usually previous failed classical cervical cerclage, the foetal survival rate improved from 18% before cerclage to 79% after cerclage. No operative complications were reported. In the prophylactic group, typically characterised by the absence of the cervix as a consequence of surgery for invasive cervical cancers, the foetal survival rate was 83% after cerclage. CONCLUSIONS: The transvaginal cervicoisthmic cerclage allows a high foetal survival rate without complications in highly selected patients with poor obstetrical history. Because of its simplicity, this technique should replace the transabdominal route for surgeons experienced in vaginal surgery.

[Using ultrasound imaging in implantation]. / Einsatz der Sonographie bei der Implantation.

Sonography represents one of the best methods of clinical investigation which might give information about the preimplantation prognosis by evaluation of the following parameters:--morphological parameters (with bidimensional sonography): thickness and structure of the endometrium;--functional parameters (with doppler): evaluation of uterine vascularisation. The prognostic value of the morphological parameters appears to be controversial:--thickness of endometrium: a linear correlation between endometrial thickness and implantationsuccess may not exist. However no pregnancy occurs without a minimum threshold value of 6 to 8 mm endometrial thickness;--structure of the endometrium: concerning the role of the endometrial structure, controversial studies are available. According to some authors, endometrial hyperechogenicity is incompatible with a pregnancy. However hypoechogenic endometrium with 5 well delimited layers is an excellent prognostic factor. The coloured pulsed Doppler allows a functional assessment of the uterus and represents a technical progress in sonography investigations since the early nineties. The evaluation of uterine vascularisation can take place at different levels of the uterine vessels.--The pregnancy rate is inversely proportional to the uterine pulsatility index (PI). There is a consensus concerning a threshold value of PI. With values above 3, the pregnancy rate drops significantly.--The presence of a protodiastolic notch and the absence of end diastolic blood flow have bad prognosis. The presence or not of a sub-endometrialen vascular flow may be the most important prognostic parameter. No pregnancy may occur by absence of these flows. The sonography gives not only important morphological informations about endometrium but also allows a study of the uterine vascularisation by coloured doppler. This allows a real assessment of endometrial potentials for implantation. Optimal conditions of implantation could be:--endometrium > 7 mm,--hypoechogenic endometrium with 5 well delimited layers,--uterine PI < 3,--presence of sub-endometrial vascular flow.

[Towards simplified cesarean section?]. / Vers une simplification de l'opération césarienne?

In the past few years, many international publications have reported important improvements in the cesarean section procedure. Considering these improvements, M STARK suggests a new technique for the cesarean section which is called <> (=ML). To assess feasibility and efficiency of this technique the authors conducted a prospective randomised study for 4 months including all cesarean sections and compared the ML technique with the classical Pfannenstiel are. The following criteria were noted for each woman. Results showed the superiority of the M.L. technique especially with regard to the length of duration of the post-operative fever and the parietal blood collection, where difference is significant. Regarding the blood loss rate, the post-operation pain, the delay before gas and the duration of the hospitalisation period the M.L. technique seems to be better although the difference is not very significant statistically. Following this study and the international literature survey, authors conclude that the M. L technique is so much better than the pfannenstiel technique that it must be used throughout daily obstetrical practice.