[A myocardial infarction during pregnancy treated by percutaneous transluminal coronary angioplasty and stent implantation. Case report]. / Infarctus myocardique durant la grossesse: à propos d'un cas traité par angioplastie transluminale percutanée et implantation d'un stent coronarien.

Acute myocardial infarction is an un-frequent event during pregnancy. It clearly causes an increase in both maternal and fetal mortality. We describe a case of pregnancy complicated during the second trimester by an acute myocardial infarction witch was treated by percutaneous transluminal coronary angioplasty combined with stenting. The challenge involved in managing this condition during pregnancy is briefly discussed.

[Chronic pelvic pain: a psychoclinical approach]. / La douleur pelvienne chronique: cheminement psychoclinique.

To take care of a patient presenting with chronic pelvic pain requires a long-term approach considering all the organic, psychological and sexological aspects of the problem. To relieve the patient, it could be very useful to analyse the doctor-patient relationship. Most probably a multidisciplinary team with all the colleagues caring for the patient is the best place to discuss these items.

The immunocytochemical versus cytosol measurement of the oestrogen receptor in invasive breast cancer tissue.

To compare two methods of measurement of oestrogen receptor (ER)-expression in invasive breast cancer tissue. Sections from 299 breast cancer cases were stained for the ER by immunocytochemical assay (ICA), using mouse monoclonal antibody (MAb) NCL-ER-6SF11, and by the dextran-coated charcoal assay (DCC). Concordant results were observed in 230 of the 299 cases (77%), 69 patients had discordant results (kappa=0.537). We found a moderate concordance between ICA and DCC for ER measurement in breast cancer tissue. If we change the golden standard from DCC to ICA, 23% of patients would receive a different therapeutic approach.

[Benign endometrial lesions induced by tamoxifen]. / Lésions endométriales bénignes induites par le tamoxifène.

Tamoxifen is a nonsteroidal antiestrogen drug which has some estrogen agonist activity on the female genital tract. This influence could generate endometrial modifications. The most important lesion is adenocarcinoma but it remains very rare and most lesions are benign. Among them, glandulo-cystic atrophy seems to be the most typical effect of this drug upon the uterine cavity. Development of polyps or hyperplasia is also more frequent among Tamoxifen users than same patients not receiving this treatment. Uterine follow-up could be done by means of endovaginal ultrasonography or hysteroscopy.

Pregnancy and dialysis.

The outcome of pregnancy in patients with end-stage renal failure has long been considered to be extremely poor, and the literature concerning pregnancy while on dialysis is rather scarce. We reviewed the records of five pregnancies in dialysis patients and performed a national survey on this topic. The dialysis technique and dialysis dose, the effects of erythropoietin (EPO), and the evolution of blood pressure levels in our patients are presented. The dose of EPO had to be increased to maintain the hemoglobin level at 10 to 11 g/dL. There was no case of EPO-related hypertension and no need for transfusion. The obstetric data of the national survey, including our own patients, were analyzed. The incidence of pregnancy going beyond the first trimester was 0.3 per 100 patient-years (15 cases in 1,472 females of childbearing age treated, for a total of 4,545 patient-years). In all but one patient initiating pregnancy while already on dialysis, the frequency and dose of dialysis were increased (to a weekly Kt/V of six to eight in our personal cases). The outcome was successful in 50% of pregnancies occurring in hemodialyzed patients and in 80% of patients who started dialysis after initiation of pregnancy. Polyhydramnios was found in eight of 13 cases and growth retardation in two of nine cases. The incidence of low birth weight and prematurity was 100%, and cesarean section was performed in 66% of successful pregnancies. In successful pregnancies, we found a correlation between birth weight and dose of dialysis. Our findings confirm the remarkable improvement in the prognosis of pregnancy in dialysis patients in recent years.

[Role of hysterosalpingography in the evaluation of infertility in Black Africa]. / Place de l'hystérosalpingographie dans l'évaluation d'une infertilité en Afrique noire.

Infertility affects a great number of women in Black Africa and tubal obstruction seems to be common. Because of this high incidence, an accurate test for tubal patency is needed and several examinations have been proposed. Recent reports indicate that the method of choice is hysterosalpingography since it is simple, quick, and reliable. Concordance with laparoscopy, the gold standard, is 85% for assessment of tubal patency and 75% for detection of tubal abnormalities. Due to the lack of radiological facilities in most hospitals in Black Africa, a simplified examination is proposed and seems to be useful as an initial screening test. This simplified test consists of obtaining a delayed anteroposterior image after a brief walk. The most severe complication of hysterosalpingography is pelvic infection which occurs in 2 to 4% of cases and requires prophylactic antibiotic therapy. Interestingly an increase in pregnancy rate has been observed in the months after hysterosalpingography. Recent reports concerning infertility workups in developing countries confirm that the method of choice for assessment of tubal function is hysterosalpingography provided that the risk of infection can be controlled.

Heterotopic ovarian pregnancy after clomiphene ovulation induction.

Heterotopic pregnancy is a life threatening condition which seems to occur more frequently than previously estimated. We report a case of combined ovarian and intrauterine pregnancy after clomiphene treatment. Diagnosis was delayed because clinical presentation was atypical and ultrasound was falsely reassuring. The neonate was healthy but presented with a single umbilical artery. When an ectopic gestation is suspected after induction of ovulation or assisted reproductive technologies the presence of an intrauterine pregnancy can no longer be considered reassuring and an heterotopic pregnancy has to be ruled out.

Hysteroscopic findings in patients with a cervical polyp.

OBJECTIVE: Our objective was to determine the presence of intrauterine lesions in patients with a cervical polyp. STUDY DESIGN: We performed a retrospective analysis to determine the influence of hormonal treatment and age on 165 patients with a cervical polyp and bleeding on admission. All 165 patients underwent a diagnostic hysteroscopy to rule out intrauterine lesions, including polyps, fibroids, hyperplasia, and adenocarcinoma. RESULTS: Endometrial polyps were found in up to 26.7% of patients who had a cervical polyp. In patients undergoing a combined pill treatment this incidence was much lower (8.3%). Menopausal patients had a 56.8% incidence of cervix-related endometrial polyps, and hormone replacement therapy did not significantly increase (45.7% vs 28.6%) the incidence of coexisting polyps. All cervical polyps present during tamoxifen treatment were associated with endometrial polyps. Abnormal vaginal bleeding was of no clinical significance in excluding concomitant endometrial polyps. CONCLUSIONS: All menopausal patients with a cervical polyp could benefit from a diagnostic hysteroscopy. Premenopausal patients receiving a combined pill treatment are the least likely to have coexistent endometrial polyps.

Caesarean section rates in an African country.

The use of caesarean section (C.S.) has been analysed in the 12 hospitals of the Midlands Province of Zimbabwe during a 2-year period. Maternal mortality rate, perinatal mortality rate, low birthweight rate, percentage of high risk pregnancy, C.S. rate and instrumental delivery rate have been extracted for each hospital. The rate of C.S. delivery varied between 2.2 and 16.8 per 100 deliveries but was not correlated with the number of high-risk pregnancies. Increased use of C.S. was not linked to better perinatal results. An important determinant of the C.S. rate appears to be the physician and the ratio between the rate of instrumental deliveries (ID) and C.S. differentiated the 12 hospitals into two groups. Although there was no difference in the number of high risk patients in these two groups, outcomes were much better in the hospitals with a high ID rate than in the hospitals with a high C.S. rate, suggesting that attitudes of medical staff can influence both the mode of delivery and the perinatal outcome in a developing country.

PIP: All deliveries recorded during the years 1985 and 1986 in the 12 hospitals in Midlands Province were analyzed. For each hospital, the number of high-risk pregnancies was defined according to risk list together with the number of primigravidas. Maternal mortality, perinatal mortality, and low birth weight (LBW; with cut-off value set of 2000 g) were recorded. There was a good correlation between the number of high-risk pregnancies and the perinatal mortality rate or LBW rate. The frequency of Cesarean section (CS) rate varied between 2.2% in Hospital 8 and 16.8% in Hospital 1. However, there was no relationship between the CS rate and the number of high-risk pregnancies for a given hospital. In contrast, there was a positive correlation between the rate of CS and the perinatal mortality rate. A hospital with a higher rate of CS resorted to abdominal delivery more frequency for the ill-chosen indications of unknown presentation, retained second twin, or delivery of a stillborn child. Hospitals with a higher number of instrumental deliveries (ID) (vacuum extraction, forceps, symphysiotomy, embryotomy) tended to have a reduced number of CS and vice versa. The use of ID was inversely proportional to the CS rate, leading to an ID/CS ratio varying between 0.03 and 1.24. The number of LBW infants and high-risk pregnancies were comparable in the 6 institutions with an ID/CS ratio higher than 0.2 as opposed to the 6 hospitals with a ratio of less than 0.2, but both the perinatal and the maternal mortality rates were statistically higher to the hospitals with ID/CS ratio below 0.2. Hospitals recorded very dissimilar CS rates not related to the obstetric risk, and hospital with a higher CS rate had not better obstetric results than the other hospitals. Similarly, the CS rate for breech presentation varied between 5 and 30%. Hospitals with a higher ID/CS ratio had lower maternal and perinatal mortality rates. CS should be the last resort.