Avortements spontanés répétés chez une patiente présentant une intervillite chronique histiocytaire placentaire

L'Intervillite Chronique Histiocytaire Placentaire (IVCH) est une affection rare de la grossesse, d'étiologie inconnue. Elle est généralement responsable d'avortement spontané ayant tendance à la répétition. Nous rapportons le cas d'une patiente suivie au Centre Hospitalier de Montélimar (France), pour avortement spontané à répétition. A sa première grossesse, cette patiente a eu une interruption médicale de grossesse à 21 SA pour Retard de Croissance Intra Utérin (RCIU) sévère. L'étiologie a été retrouvée à l'examen histologique du placenta par la découverte de lésions décrites comme une intervillite chronique histiocytaire placentaire (IVCH). Ses 2 grossesses suivantes ont abouti à des morts fœtales spontanées à 16 et 13 SA dans le même tableau malgré les traitements entrepris. Cette observation avait pour objectif de discuter des difficultés de la prise en charge de cette affection responsable d'avortement spontané à répétition

Occlusion intestinale pendant la grossesse au Centre Hospitalier et Universitaire de Treichville (Abidjan - Côte d'Ivoire)

Introduction : La survenue d'une occlusion intestinale pendant la grossesse est une situation rare qui met en jeu rapidement le pronostic materno-fœtal.Observation : Nous rapportons un cas d'occlusion intestinale diagnostiquée à la 33ème semaine de grossesse chez une patiente de 23 ans, ayant un antécédent de salpingectomie. Le diagnostic a été posé tardivement, sur des arguments cliniques. Le traitement qui a consisté à réaliser en urgence une césarienne première suivi d'une iléostomie proximale, a permis de sauver l'enfant et la mère.Discussion : Cette observation nous permet de discuter les mécanismes physiopathologiques, et les difficultés de la prise en charge de l'occlusion intestinale aiguë au cours de la grossesse dans nos pays tropicaux à plateau technique limité

Prise en charge d'un prolapsus génital extériorisé pendant la grossesse

La survenue d'un prolapsus génital pendant la grossesse est une situation rare qui pose le problème du pronostic materno-fœtal. Nous rapportons ici un cas de prolapsus du col au stade 3, survenu brutalement à la 34ème d'une grossesse mono-fœtale chez une nullipare de 24 ans. Nous avons réduit le prolapsus sans difficultés mais à terme, en début de travail, le col s'est extériorisé à nouveau. Nous l'avons réduit une nouvelle fois afin de tenter un accouchement par les voies naturelles. A 5 cm il s'est installé une dilatation stationnaire suivie d'une récidive de l'extériorisation du col. Une césarienne a donc été réalisée permettant la naissance d'un enfant bien portant pesant 3200gr. A la fin de la césarienne le col a été manuellement réduit et l'évolution a été favorable avec la constatation de la régression totale du prolapsus à la visite post-natale à 6 semaines. Cette observation nous permet de discuter les mécanismes physiopathologiques, et les possibilités de la prise en charge du prolapsus au cours de la grossesse

[Functional symptoms and associations of women with genital prolapse]. / Prévalence des troubles fonctionnels et associations anatomo-fonctionnelles chez les femmes présentant un prolapsus génital.

OBJECTIVE: To assess functional symptoms related to genital prolapse and to test anatomo-functional associations. PATIENTS AND METHODS: Observational study, performed between January 2005 and June 2012, on all patients operated for prolapse in a French tertiary referral centre. Data were collected from standardized patients' notes, including baseline characteristics, complete interview on urinary and colo-rectal functional symptoms, MHU score, and POP-Q (Pelvic Organ Prolapse Quantification) clinical evaluation. RESULTS: Three hundred and seventy-four patients, with a mean age of 65.1 years old, mean parity of 2.5, and mean BMI of 25.4, were included. These patients were post-menopausal in 92.5% of cases. Urinary symptoms were: SUI in 30.5%, urgencies in 44.4%, and voiding difficulties in 38.8%. Colo-rectal symptoms, such as defecatory dysfunction and anal incontinence, occurred in 25.1% and 18.5%, respectively. On clinical examination, anterior vaginal wall prolapses were the most common (74.1%). Patients with stage 3-4 cystocele suffered significantly more frequently of nocturia (P=0.04), voiding difficulties (P=0.04), and occult stress urinary incontinence (P<0.001). Patients with stage 3-4 rectocele suffered significantly more frequently of defecatory dysfunction (P=0.005) and performed more often maneuver for defecation (P<0.001). CONCLUSION: Urinary and colo-rectal symptoms are commonly associated with genital prolapse. Anatomo-functional associations were shown regarding different prolapse types and stages. LEVEL OF PROOF: 4.

[Should we perform intra-operative endometrial biopsy during pelvic reconstructive surgery with uterine preservation?]. / Doit-on faire une biopsie d'endomètre peropératoire dans les cures de prolapsus avec conservation utérine?

OBJECTIVE: To evaluate the interest of systematic endometrial biopsy at the time of vaginal reconstructive surgery with uterine preservation. METHODS: We performed a retrospective monocentric study on all women who had vaginal reconstructive surgery with uterine preservation from 2005 to 2012. All following parameters have been studied: baseline characteristics (age, parity, BMI, hormonal status, medical history), prolapse stage using the POP-Q, preoperative pelvic ultrasound (endometrial thickness), and type of surgery. Women with previous hysterectomy were excluded. RESULTS: Four hundred and fourteen patients were operated during this period, and 268 have uterine preservation (64.7%). Baseline characteristics were mean age 64.7±10.7 (39 to 92), mean parity 2.6±1.5, mean BMI 25.5±4.2, menopause 238 (88.8%), HRT 32 (12%), previous breast cancer 16 (6%), diabetes mellitus 31 (11.6%), and hypertension 87 (32.5%). Prolapse were at stage II in 127 (47.3%), stage III in 99 (36.9%) and stage IV in 17 (6.3%). Preoperative pelvic ultrasound has been done in 255 patients (95.2%), and mean endometrial thickness was 5.1mm (range 1.6-16). Overall, 152 intra-operative endometrial biopsies were assessable (56.7%). In 24 cases (15.8%), samples were too small to be interpretable. Finally, the 128 interpretable biopsies (82.2%) have shown one carcinoma (0.8%), four hyperplasia (3.2%), two endometrial polyps (1.6%), and 121 normal endometria (94.5%). The only cancer was discovered on a 77 year old patient, with a history of previous breast cancer, and with a preoperative endometrial thickness of 7 mm. No patient with normal preoperative ultrasound endometrial screening had abnormal endometrial biopsy. CONCLUSION: Vaginal reconstructive surgery with uterine preservation implicates a preoperative endometrial evaluation by ultrasound. Intra-operative endometrial biopsy does not seem to be justified.

Aspects epidemiologiques et etiologiques des couples infertiles a Abidjan

Objectif : Ce travail avait pour objectifs d'identifier les caracteristiques sociodemographiques des couples infertiles et de preciser les principales etiologies. Methode : Nous avons mene une etude retrospective descriptive portant sur 210 couples consultant pour infertilite dans les services de gynecologie du CHU de Treichville et d'une clinique privee de la place durant la periode 1er fevrier 2013 au 30 septembre 2014 (20 mois). Resultats. La prevalence de l'infertilite etait de 14;03%. L'age moyen etait de 34;31 ans chez les femmes et de 43;2 ans chez les hommes. La majorite des patientes avait atteint au moins le niveau d'etude secondaire (77;1%). Les couples residant hors d'Abidjan etaient de 15%; et les differentes couches socio-economiques etaient touchees par l'infertilite. La duree moyenne de vie commune des couples etait de 6;9 ans avec une duree moyenne d'infertilite de 6;3 ans. L'infertilite etait en general de type secondaire; touchant aussi bien les femmes (41%) que les hommes (30%). Les etiologies chez les femmes etaient d'origine uterine (47;06%); hormonale (22;79%) et tubo peritoneale (17;65%). Chez l'homme les troubles du sperme etaient domines par l'oligoasthenospermie (69;91%) d'etiologie generalement infectieuse. Conclusion. l'infertilite etait frequente dans nos services; touchant aussi bien les femmes que les hommes

Can the PFDI (Pelvic Floor Distress Inventory) or PFIQ (Pelvic Floor Impact Questionnaires) be used to predict outcome in pelvic reconstructive surgery?

OBJECTIVE: To determine a syndrome score threshold on PFDI or PFIQ predictive of a significant improvement in post-operative functional results. DESIGN: A retrospective case review (Canadian Task Force Classification II-2). SETTING: University and research hospital. POPULATION: Women diagnosed with pelvic organ prolapse and repaired with synthetic vaginal mesh. METHODS: Quality of life was arbitrarily considered to have improved significantly if the score decreases by more than 50% between pre-operatively and 36 months post-operatively. We investigated the pre-operative cut-off score predictive of no quality of life improvement at M36 from a prospective trial for surgical pelvic organ prolapse treatment. RESULTS: The most accurate pre-operative cut-off score predicting a failure to improve quality of life at 36 months post-operatively was 62/300 (PFDI Score). This cut-off value had a positive predictive value of 83.6% and specificity of 62.1%. No significant threshold was obtained from the PFIQ score. CONCLUSION: The intensity of symptoms before surgery may interfere as a predictive factor for outcome.

[An uncommon complication of unsafe induced abortion: bowel prolapse through uterine perforation]. / Une complication rare mais grave des avortements provoqués clandestins : l'évisceration iléale per vaginum.

The authors report one case of bowel prolapse through uterus following induced abortion. The eviscerated bowel was completely gangrenous, devoided from its mesentery and entrapped in the uterus wall. The treatment was a bowel resection and ileo-ileum anastomosis; the uterus was evacuated of retained products of conception and then sutured. The patient recovered uneventfully; fertility prognosis is expected to be poor because of abortion sequelae. If the abortion law still remains in Ivory Coast, more effort should be directed at reducing the incidence of unwanted pregnancy. This could be best archived by a better information on contraception and better health education programs.

Les hemorragies de la delivrance : a propos de 134 cas referees a la maternite du CHU de Treichville

Objectifs : Determiner la frequence des patientes referees pour hemorragie du post partum immediat (HPPI); decrire les caracteristiques socio-demographiques des patientes et identifier les dysfonctionnements pouvant aggraver le pronostic maternel. Population et methode : Etude descriptive et retrospective menee de janvier 2005 a juin 200 incluant toutes les patientes referees a la maternite du CHU de Treichville pour HPPI. Resultats : 134 patientes ont ete referees pour HPPI soit une incidence de 1;27. L'age moyen des patientes etait de 28;5 ans. La parite moyenne etait de 3;5. La majorite des patientes etaient sans activite remuneratrices et sans niveau d'instruction. La decision de transfert etait decidee dans 85;82 des cas par la sage femme. Le transfert avait ete assure par de vehicules non medicalises (86;58). La duree moyenne d'evacuation etait de 62;7min. A l'admission; 47;76 etaient en etat de choc hypovolemique avec dans 16;42 une coagulation intravasculaire disseminee. Trente et six patientes sont decedees soit un taux de letalite de 26;90. Les principales causes de deces etaient la coagulopathie (55;6) et le choc hypovolemique (36;1). Conclusion : Le taux de letalite par hemorragie de la delivrance chez les patientes referees est eleve. Sa reduction passe par l'amelioration des dysfonctionnements identifies dans l'itineraire therapeutique des patientes

[Appendicitis and pregnancy: 21 cases]. / Appendicite aiguë et grossesse. A propos de 21 cas.

OBJECTIVE: Describe the epidemiological, diagnostic and therapeutic features of acute appendicitis in pregnant women. MATERIAL AND METHODS: Retrospective analysis of a series of 21 cases of appendicitis in pregnant women who underwent surgery between January 1997 and June 2001. RESULTS: The association of acute appendicitis with pregnancy was noted in 0.2% of the pregnant women. Ten patients were in the first trimester of pregnancy, ten in the second and one in the third. Abdominal pain was noted in all patients. The localization varied with gestational age. Abdominal ultrasound contributed to the diagnosis in twenty patients who underwent the examination. Diagnoses retained were: acute uncomplicated appendicitis (n=18), acute appendicitis with focal induration (n=1) and acute diffuse peritonitis (n=2). Appendectomy was performed in all cases. Intensive care, peritoneal cleaning and drainage were associated in cases with appendicitis. In cases with focal induration, medical treatment was followed by appendectomy performed after delivery. Tocolysis was instituted in all cases. Twelve pregnancies continued to delivery: one fetal death, one premature delivery and ten term deliveries of live infants. CONCLUSION: Pregnancy makes it difficult to confirm the diagnosis of appendicitis. Appendectomy should be performed in patients presenting a highly suggestive clinical and ultrasonographic picture, preferably by laparoscopy in order to avoid more severe complications which could be life-threatening for the mother or infant.

Uterine torsion with maternal death: our experience and literature review.

Torsion of the gravid uterus around its cervical junction is a rare event especially in humans. In 1992, a literature review by Jensen, mentioned by Carbonne, showed 212 cases with different etiologies. Uterine torsion is more frequently dextrorotatory (2/3 of cases). The diagnosis is difficult and generally done during cesarean section because it is frequently not symptomatic. Uterine torsion signs, when present, are not specifics. Pain, nausea and vomiting may present without any sign of shock, as in our patient. Sometimes ultrasonography can lead to a correct diagnosis, showing a modification of the placenta site during pregnancy, or an abnormal positioning of the ovarian vessels which pass in front of the lower uterine segment. Some authors report cardiotocographic abnormalities probably due to the reduction of blood flow caused by the torsion. Quickness of surgical treatment is fundamental for the reduction of fetal mortality which is very frequent in a large number of cases, while maternal mortality is not so frequent but possible. A diligent anamnesis and ultrasonographic examination are surely useful to single out the rare cases of uterine torsion in pregnancy.