[Uterine necrosis following pelvic arterial embolisation for postpartum haemorrhage: case report]. / Nécrose utérine après embolisation pelvienne pour hémorragie du postpartum : à propos d'un cas.

We report a case of uterine necrosis in a 38 year-old patient, who underwent a caesarean section for placenta praevia and an embolisation of the uterine arteries for postpartum haemorrhage. The pelvic embolisation was performed with absorbable gelatine sponge pledgets. This woman presented with abdominal pain and fever three weeks after delivery and a computed tomography scan revealed the presence of gas in the myometrium and endometrium and allowed the diagnosis of uterine necrosis. A total abdominal hysterectomy was performed with adnexal conservation and the diagnosis of uterine necrosis was confirmed histologically. The complications of pelvic embolization and the risks of surgical procedures for the management of intractable obstetric hemorrhage are described.

[Single-shot ropivacaine wound infiltration during cesarean section for postoperative pain relief]. / Intérêt de l'instillation pariétale unique de ropivacaïne dans la prévention des douleurs après césarienne.

OBJECTIVE: To assess the efficiency of single-shot ropivacaine wound infiltration during cesarean section for postoperative pain relief, using a prospective, randomized, double-blinded study. PATIENTS AND METHODS: One hundred consecutive patients with planned cesarean section were enrolled between September 2007 and May 2008 and randomized into two groups: single-shot wound infiltration of 20mL of ropivacaine 7.5mg/mL (Group R; n=56) or single-shot wound infiltration of 20mL of saline solution (group T; n=44). The primary goal of this study was the double-blinded evaluation of the postoperative pain after coughing and leg raise using the 100-mm visual analog scales (VAS) during the first 48 postoperative hours after cesarean delivery. The secondary goals were the occurrence of nausea and vomiting and the morphine consumption. RESULTS: Numerical pain rating scale for pain evaluation was significantly lower (P<0.05) in the ropivacaine group than in the control group at M0, M20, M40, M60, H2 and H4. But, at H8, H12 and H24, no significant difference for VAS was noted between the two groups. The occurrence of nausea and vomiting and the total morphine consumption were not significantly different between the two groups during the first 48 postoperative hours. DISCUSSION AND CONCLUSION: Single-shot ropivacaine wound infiltration during planned cesarean section is a simple and safe procedure that provides effective reduction of post-partum pain within the first 4hours.

[Continuous medical evaluation in a gynaecological and obstetrical unit: Our experience about scheduled caesarean]. / Evaluation des pratiques professionnelles dans le cadre de la certification d'un établissement public de santé à propos des césariennes programmées.

Continuous medical evaluation (CME) is compulsory which aims to ameliorate and guarantee quality of care. This paper describes the experience of our unit during the different stages of evaluation that permit us to obtain our accreditation. Our evaluation dealt with the "amelioration of women's and newborn's care after scheduled caesarean section". A first retrospective study of files of scheduled caesareans allowed to update possible points of improvement, after application of adapted corrective actions, both at the medical and paramedical level. The second study, made after application of these actions, allowed to appreciate the results of our initiative of CME, to update new possible points of improvement, but also to notice certain limits in the achievement of the objectives.

[Surgical management of peripartum hemorrhage: a retrospective study]. / Prise en charge chirurgicale des hémorragies de la délivrance: étude rétrospective.

OBJECTIVE: Peripartum haemorrhage is an obstetrical emergency and requests a life saving procedure. The purpose of this study is to describe our experience with the surgical management of peripartum haemorrhage. PATIENTS AND METHODS: We performed a retrospective study including 16 patients who necessitated a surgical management of peripartum haemorrhage (artery ligations, uterine compression and/or emergency peripartum hysterectomy) between 1985 and 2007. RESULTS: The incidence of surgical management of peripartum haemorrhage was 0.047%. Conservative surgical management consisted in uterine compression sutures in three cases. Artery ligations were performed without success in seven patients; only one case of isolated utero-ovarian artery ligations was effective. An emergency peripartum hysterectomy was necessary in 12 cases. Uterine atony was the principal etiologic factor (43.8% of cases). There were no significant perioperative complications. No maternal death was reported. DISCUSSION AND CONCLUSION: In cases of non life-saving procedure, medical treatment and uterine arteries embolisation are often sufficient. Uterine compression suturing techniques are interesting alternatives and uterine arteries ligations can always be performed before hysterectomy. In cases of failure of conservative treatment, the emergency peripartum hysterectomy must be performed. Then, the choice concerning the surgical technique for the management of peripartum haemorrhage may be adapted to the patient, the centre and the obstetrical team.

Cardiovascular responses to manual dissection associated with transhiatal esophageal resection.

Marked cardiovascular responses to esophageal manipulation are commonly observed during transhiatal esophagectomy without thoracotomy. To delineate the mechanism and the time course of these hemodynamic changes, 10 patients undergoing this surgical procedure were studied. Heart rate (HR), mean arterial blood pressure (MAP), pulmonary capillary wedge pressure (PCWP), cardiac output (CO), cardiac index (CI), systemic vascular resistance (SVR), and arteriovenous oxygen content difference (C[a-v]O2) were measured or calculated each time the surgeon's hand entered the thorax to dissect the esophagus. Significant and simultaneous decreases in both MAP and CI were observed in all cases during manipulations (-46% from the baseline value). A significant increase in PCWP also occurred, whereas HR and SVR were unchanged. All parameters returned to control values once manipulation was stopped. The simultaneous decreases in MAP and CI were clearly related to impaired venous return and/or ventricular ejection from manual compression. From these findings, it can be assumed that long-lasting alterations in hemodynamic status could be detrimental to patients with cardiac disease; therefore, careful intraoperative hemodynamic monitoring is advisable. In addition, some patients with advanced cardiac dysfunction may not tolerate these manipulations and may require an open thoracic surgical procedure.