[Current surgical practice of prophylactic and opportunistic salpingectomy in France]. / État des lieux de la salpingectomie prophylatique en France.

OBJECTIVES: Since the recent evidence of a tubal origin of most ovarian cancers, opportunistic salpingectomy could be discussed as a prophylactic strategy in the general population and with hereditary predisposition. We aimed to survey French gynecological surgeons about their current surgical practice of prophylactic salpingectomy. METHODS: An anonymous online survey was sent to French obstetrician-gynaecologists and gynecological surgeons. There were 13 questions about their current clinical practice and techniques of salpingectomy during a benign hysterectomy or as a tubal sterilization method, salpingectomy versus salpingo-oophorectomy in the population with genetic risk, salpingectomy in relationship with endometriosis and questions including histopathological considerations. RESULTS: Among the 569 respondents, opportunistic salpingectomy was always performed between 42.48% and 43.44% during laparoscopic, laparoscopic-assisted vaginal or laparotomic hysterectomy and only 12.26% in case of vaginal route. In the genetic population, salpingo-oophorectomy was mainly performed. Tubal sterilization was often practiced by the hysteroscopic route. More than 90% of respondents didn't perform salpingectomy in case of endometriosis. There was not any specific tubal histopathological protocol in 71.54% of cases. CONCLUSIONS: Salpingectomy may be a preventing strategy in the low- and high-risk population. The survey's responses show that salpingectomy seems to be a current practice during benign hysterectomy for more than 40% doctors. However, there is not any change with no more salpingectomy in the population with genetic risk, or in case of endometriosis or tubal sterilization.

[Bowel injuries after port insertion in laparoscopy. Gynerisq's database analysis]. / Plaies digestives à l'insertion des trocarts en cœlioscopie. Analyse de la base de données de retour d'expérience de Gynerisq.

INTRODUCTION: Port insertion is a high-risk period during laparoscopy. The French Gynecologist and Obstetricians College (CNGOF) published recommendations in 2010 to minimize those risks. The aim of our analysis was to establish the accidents' circumstances and consequences and to determine if those incidents could have been depending on whether recommendations had been respected or not. MATERIAL AND METHODS: Gynerisq is an approved organism by the Haute Autorité de santé (HAS). Its mission is to evaluate and improve practices by a risk management centered approach. We analysed incidents reported by Gynerisq's adherents in an experience report database. RESULTS: Above 114 incidents analysed in the Gynerisq's database, we reported 31 bowel injuries. Those injuries occurred for 77.4% (24/31) during planned interventions. For 32.3% of the cases (10/31), interventions were judged complex by the surgeons. A total of 54.8% (17/31) of the patients had a history of laparotomy. Above 27 injuries occurred during Veress needle or open laparoscopy, 17 could have been avoided regarding to the surgeon. The causes reported were in 10 cases that the recommendations had not been respected, in 2 cases another cause and in 5 cases no causes were given to explain the incident. CONCLUSION: Our analysis shows that bowel injuries after port insertion, in open laparoscopy or Veress needle use, do not seem to occur only in an emergency context or during complicated interventions. However, most of the incidents occurred for patients with risk factors.

[Hysterectomy for benign pathology: Guidelines for clinical practice]. / Hystérectomie pour pathologie bénigne: recommandations pour la pratique clinique.

OBJECTIVE: The objective of the study was to provide guidelines for clinical practice from the French college of obstetrics and gynecology (CNGOF), based on the best evidence available, concerning hysterectomy for benign pathology. METHODS: Each recommendation for practice was allocated a grade which depends on the level of evidence (guidelines for clinical practice method). RESULTS: Hysterectomy should be performed by a high volume surgeon (>10 procedures of hysterectomy per year) (grade C). Rectal enema stimulant laxatives are not recommended prior to hysterectomy (grade C). It is recommended to carry out vaginal disinfection using povidone iodine solution prior to an hysterectomy (grade B). Antibioprophylaxis is recommended during a hysterectomy, regardless of the surgical route (grade B). The vaginal or the laparoscopic routes are recommended for hysterectomy for benign pathology (grade B), even if the uterus is large and/or the patient is obese (grade C). The choice between these two surgical approaches depends on others parameters, such as the surgeon's experience, the mode of anesthesia and organizational constraints (operative duration and medico economic factors). Hysterectomy by vaginal route is not contraindicated in nulliparous women (grade C) or in women with previous c-section (grade C). No specific technique to achieve hemostasis is recommended with a view to avoid urinary tract injuries (grade C). In the absence of ovarian pathology and personal or family history of breast/ovarian carcinoma, it is recommended to conserve ovaries in pre-menopausal women (grade B). Subtotal hysterectomy is not recommended in order to diminish the risk of per- or postoperative complications (grade B). CONCLUSION: The application of these recommendations should minimize risks associated with hysterectomy.

[Struma ovarii or malignant ovarian goiter. A case]. / Les struma ovarii ou goitres ovariens malins. Une observation.

BACKGROUND: We report a case of follicular struma ovarii observed in an ovary teratoma without metastatic dissemination. CASE REPORT: A right ovarian tumor was discovered at ultrasound examination in a 31-year-old woman complaining of low abdominal pain. The patient underwent laparoscopic exploration and a 4-cm cystic mass of the right ovary was removed. Microscopic examination showed a malignant struma ovarii of the follicular type with vascular space invasion; other teratomous elements were identified. Immunohistochemical staining for thyroglobulin confirmed the nature of the tumor. The patient was treated by complete right ovariectomy followed by total thyroidectomy and administration of radioactive iodine (99 mCi I-131). Repeat I-131 body scan performed at 6 months was normal. DISCUSSION: Struma ovarii is a rare type of ovarian teratoma, consisting mainly of thyroid tissue. The incidence of malignant struma ovarii is below 1% and fewer than two dozen cases with distant metastases have been reported. The major problem associated with struma ovarii has been the establishment of criteria for malignancy.

Maternal hyperoxygenation: a fetal blood flow velocity prognosis test in small-for-gestational-age fetuses?

Maternal hyperoxygenation tests were performed in 20 small-for-gestational age fetuses using 8 l/min of 70% humidified oxygen given for 20 min through a face mask. Assessments were made of the fetal blood flow velocity, and the placental resistance index, cerebral resistance index and cerebroplacental ratio were calculated in 78 normal pregnancies and in the 20 small-for-gestational-age fetuses during the hyperoxygenation test. The test was positive when the velocity indices increased by more than 10%. The reference ranges for placental and cerebral resistance indices were derived from the data measured in the 78 normal pregnancies. Of the 20 small-for-gestational-age fetuses, three had a normal placental resistance index with a negative oxygen test response and a good fetal outcome. Seven had a mild increase in placental resistance index (> +2SD) and a brain-sparing effect was observed (cerebral resistance index < -2SD or cerebroplacental ratio < l). In these seven fetuses, the fetal outcome was not poor, whether the oxygen test response was negative or positive. Ten of the 20 small-for-gestational-age fetuses had no umbilical diastolic flow (placental resistance index = 1) and a brain-sparing effect. Their outcome was strongly dependent on the oxygen test response: a positive response indicated a good prognosis, a negative one a poor fetal outcome.

[Umbilical Doppler velocimetry in prolonged pregnancies]. / La vélocimétrie Döppler ombilicale dans les grossesses prolongées.

One-hundred and eighty-seven single pregnancies, at full term determined accurately and confirmed by ultrasound before 17 weeks of amenorrhea and which were proceeding normally were monitored every 2 days after the expected end of term. This was done by conventional methods and in 132 cases by determining a placental resistance index (R = D/S). All the deliveries were carried out under monitoring and the infants examined by a pediatrician. The umbilical index at 280 to 300 days of gestation was found to be constant and equal to R = 0.52 +/- 0.041 (n +/- D) and the signs of fetal distress and post-maturity increased beyond term. In the first 80 pregnancies studies in this way, the determination of the value of the index R was not included in the decision-making process. Twelve of the 14 cases of fetal heart rate arrhythmia during delivery and all recorded cases of post-mature clinical signs and neonatal acidosis occurred when the index was above RI = 0.54. The next 107 pregnancies were randomly divided into two groups. In the 52 pregnancies in which the Doppler revealed an index at two consecutive determinations in excess of 0.54, this was taken to be a criterion for the induction of childbirth. In this group, some of the women gave birth earlier, without any increase in the number of Caesareans and this resulted in fewer post-mature infants.(ABSTRACT TRUNCATED AT 250 WORDS)

[Cerebral hemorrhage in utero. Diagnosis and management. A case report]. / Hémorragie cérébrale in utero. Diagnostic et conduite à tenir. A propos d'un cas.

The authors report a case of massive intracerebral haemorrhage which was diagnosed in utero by ultrasound. The ultrasound of the brain showed a total disorganisation of all known structures with the appearance of unhomogeneous zones spread across both hemispheres and including a large dilatation of the ventricles. Transcervical puncture of the fontanelle allowed the delivery of a stillborn child without other congenital abnormalities. CMV infection was thought to be the cause. A review of the literature shows that there are different ways of treating this conditions depending on the ultrasound appearances. The prognosis must be very guarded and depends on the aetiology.

[Contribution of cerebral doppler in the evaluation of fetal well being]. / Apport du Döppler cérébral dans l'évaluation du bien-être foetal.

Foetal well being is assumed in normally proceeding pregnancies. In pregnancies with a risk of foetal distress, the obstetrician now has the possibility of carrying out foetal cerebral hemodynamic exploration in order to reach a short-term prognosis. The brain of the foetus is a hemodynamically privileged site in cases of hypoxic foetal distress; this brain-sparing effect gives rise to Doppler velocimetric signs which are seen in animal and human foetuses. Cerebral resistance, measured in Doppler velocimetry from the resistance index R = (S.D)/S falls at the beginning of the last third of pregnancy, but remains higher than placental resistance. This is due to the considerable development of foetal brain vascularization from this time forward. Inversion of the ratio between the cerebral index (CRI) and the umbilical index (PRI) and a marked reduction of the cerebral index below the normal range demonstrates the brainsparing effect during hypoxic distress. In cases of delayed intra-uterine growth, this signs is linked to a high probability of forthcoming acute foetal distress (AFD). In hypertension of pregnancy, the fall in CRI is closely correlated with a high Caesarian rate due to AFD and a higher morbidity level and neo-natal sequelae. The prognosis for these foetuses therefore depends on their gestational age: it is good after 34 weeks of amenorrhea, but remains doubtful between 28 and 34 weeks of amenorrhea. In these cases, the administration of oxygen to the mother for 20 minutes (FLO2 = 70%, 8 l/min) constitutes a prognostic test. The foetuses whose CRI is corrected have a better prognosis than the others, if the pregnancy continues up to the change in foetal cardiac rhythm.(ABSTRACT TRUNCATED AT 250 WORDS)

[Umbilical and cerebral Doppler velocimetry hypertension in pregnancy]. / Vélocimétrie Doppler ombilicale et cérébrale au cours des états hypertensifs de la grossesse.

The authors carried out a combined study using Doppler Flow Studies of the umbilical and fetal anterior cerebral arteries in 26 pregnancies which were complicated by maternal hypertension. Using the ratio between the cerebral and the umbilical blood flow it may be possible to diagnose intra-uterine growth retardation more accurately than using classical measurements. An inversion of the ratio between the cerebral and the umbilical flows has a great prognostic value with a sensibility of 91.6%, a specificity of 87.5% and a positive predictive value of 84.6% with a negative predictive value of 93.13%. There may however quite often be a lengthy interval of time between the appearance of change in the ratio and the appearance of fetal distress, so that this sign can only be one indication for delivery of the fetus.

[Doppler umbilical artery velocimetry during labor in normal pregnancies]. / Vélocimétrie Doppler ombilicale au cours du travail dans les grossesses normales.

A prospective study using umbilical artery velocimetry was carried out with continuous Doppler wave forms coupled to a spectral analyser (D.F.P.C. Slous) with placement of Pourcelot's placental resistance index in 94 deliveries at term of singleton normal pregnancies. Neither the position of the patient, rupture of the membranes, epidural anaesthesia, oxytocics, Dextrofemine, nor the length of labour, change the placental resistance levels during the delivery. These remain constant and equal R = 0.51 +/- 0.10 (M +/- 2 DS) whatever the appearance of the RCF at the start of labour, during dilatation and during the delivery. We considered term as being between the 38th and the 42nd week of amenorrhea. Our results show that changes in the index of resistance in the umbilical artery do not help in assessing deliveries in normal pregnancies.

[The contribution of umbilical Doppler velocimetry in suspected echographic IUGR]. / Apport de la vélocimétrie Doppler ombilicale dans les suspicions échographiques de R.C.I.U.

Doppler pulses or continuous flow in the umbilical artery is a technique recently used in practical obstetrics and of value particularly in screening at risk pregnancies. The authors wish to study its value as a diagnostic and prognostic tool in the special cases where ultrasound has given rise to a suggestion that there may be intra-uterine growth retardation (I.U.G.R.). In a preliminary publication they report their experience in 100 normal pregnancies so that they have obtained a control diagram. Then, working on a population of 117 pregnancies with ultrasonically diagnosed I.U.G.R. they studied the birth-weight, the early neonatal morbidity and the neonatal mortality as a function of the Pourcelot S - D/S index. They were able to separate out 63 cases of I.U.G.R. without any hypertension and 54 cases associated with hypertension. They analyse the same parameters. They then discuss first the value of the diagram they have made in comparison with other known curves, also the diagnostic and prognostic performance of the method. They conclude that there is a moderate diagnostic value in Doppler velocimetry. The prognostic value is much better because the Doppler can differentiate those case of slow growth that are going to do well against those that are going to do badly.

[Ectopia cordis: early echographic diagnosis in utero]. / Ectopie cardiaque: dépistage échographique précoce in utero.

Having had a case of ectopia cordis which was diagnosed early in utero, the authors have analysed the information they have obtained and they have suggested what steps to take according to the features revealed by the ultrasound pictures and taking into account the different anatomical forms. They have also considered the lesions that are associated with this condition and the principal prognostic features.