[The HELLP syndrome. 13 cases]. / Le HELLP syndrome. A propos de 13 observations.

The Hellp syndrome is a complication of raised blood pressure in pregnancy, haemolysis, a rise in liver enzymes and thrombopenia. In this retrospective study we report 12 cases of Hellp syndrome which occurred in the University Hospital Centre of Poitiers between 1982 and 1990 and we discuss causes, the progress, the prognosis and the management. Six patients were helped by prophylactic Caesarean operation. Two patients had eclamptic fits. Fortunately there was no maternal death. There were seven cases of intrauterine growth retardation, two of in utero fetal death and one of early neonatal death. When clinical and biological parameters of the Hellp syndrome come right following delivery, the outlook for the mother is quickly favourable, but the syndrome can continue and sometimes become worse after delivery. Stopping the pregnancy is the basic treatment and conservative treatment has only a very limited success. Finally, the prognosis for the future is usually good and it is unlikely to recur.

[Indications and results of autotransfusion. Normovolemic hemodilution in gynecology-obstetrics]. / Indication et résultats de l'auto-transfusion. Hémodilution normovolémique en gynécologie-obstétrique.

Considering the importance of haemorrhagic complications in gynaecology-obstetrics and the increasing fear of accidents during blood transfusion, the authors propose, from the literature and the study of 13 cases, a reflection on the indications of deferred autotransfusion (DAT) and of normovolemic haemodilution (NVH). In obstetrics, even if DAT has undoubtedly certain advantages (besides viral contaminations, appearance of allo-antibodies...), it can be indicated at present only for pregnant women exposed to a predictable risk of haemorrhage or for women with a rare blood group. In gynaecology, the authors have not found any significant advantages in our study as regards NVH associated with DAT. However, as in obstetrics, the technique is harmless, and no thrombo-embolic complications have been observed, even in women at high thrombotic risk. These methods are expensive and require qualified personnel. Their exact modalities and indications, as well as their medico-legal aspects, are yet to be defined.

[The value of antibiotic prophylaxis during intrauterine procedures during vaginal delivery. A comparative study of 500 patients]. / Intérêt de l'antibioprophylaxie lors de gestes intra-utérins au cours d'un accouchement par voie basse. Etude comparative à partir de 550 patientes.

This comparative study carried out on 550 patients has made it possible for us to show how valuable prophylactic antibiotic therapy is when certain intra-uterine manipulations (such as forceps delivery, manual removal of the placenta or exploration of the cavity of the uterus) are carried out during vaginal delivery. Furthermore, we have been able to show that there are certain risk factors of which the most important are premature rupture of the membranes, infected liquor, birth weight of the infant less than 2,500 g and epidural analgesia. The financial study has shown that it is cheaper to use prophylactic antibiotics when the comparison is made with the cost of treating complications of infection associated with these intra-uterine procedures.

[Pre-eclampsia and the nephrotic syndrome. Prognosis and management; apropos of a series of 23 cases]. / Pré-éclampsie et syndrome néphrotique. Pronostic et conduite à tenir; à propos d'une série de 23 cas.

In pregnancy pre-eclampsia can be complicated by the nephrotic syndrome. We report on the clinical findings in 23 patients who had the nephrotic syndrome in pregnancy with hypertension. None of these patients had any previous sign of nephropathy. In most patients clinical signs first showed up in the 3rd trimester. The prognosis for the fetus was poor. This was because of the degree of proteinuria and of uraemia (5 fetuses died). After delivery all signs cleared up, as they would have done in moderately severe pre-eclampsia. All patients were considered to be cured by six months. In spite of this the longterm prognosis is difficult to assess. It is necessary to find out whether the nephrotic syndrome was evidence of an underlying nephropathy or just was due to the pre-eclampsia. Treatment consists mainly of rest, control of hypertension, correction of low blood volume and delivery of the fetus with regard to the degree of maturity and the viability of the fetus.

[Marfan's disease and pregnancy. Apropos of a case]. / Maladie de Marfan et grossesse. A propos d'un cas.

Marfan's syndrome is a dominant autosome transmitted disease with different degrees of seriousness. When it is associated with pregnancy there is a considerable increase in the rate of cardio-vascular complications which are responsible for a serious rate of maternal mortality due to aortic dissection. It is therefore very important that the patient, before starting a pregnancy, should be examined very carefully clinically and with ultrasound. A woman with dilatation of the aorta less then 40 mm as measured ultrasonically and who has no major clinical signs can start a pregnancy but even then she should be considered as a high risk case. In other cases therapeutic termination of pregnancy or prophylactic surgical treatment of the condition should be considered. Apart from the serious genetic risks (50%) the risks for the fetus are dominated by prematurity and by fetal death resulting from maternal death.

[Ripening of the cervix and induction of labor at term with prostaglandin F2 alpha gel in increasing doses]. / Mûrissement cervical et induction du travail à terme par le gel de prostaglandine F2 alpha à dose croissante.

The induction of labour at term has a place of choice amongst the numerous obstetric applications of prostaglandins. The present clinical trial (50 cases) showed that F2 alpha prostaglandin, after incorporation in a high-viscosity gel and following insertion into the extra-amniotic space, is capable of accelerating cervical ripening and of inducing myometrial activity close to spontaneous physiological conditions. The use of increasing doses of prostaglandin avoids the development of acute foetal distress. Our experience confirmed the efficacy (8% true failures), the rapidity and the good maternal and foetal tolerance of the induction of labour at term by prostaglandins.

[Cesarean section preceding the 34th week of amenorrhea: maternal and fetal repercussions at the western university hospitals. Regional survey or 383 cesarean sections and 436 newborn infants out of 86,116 births in 5 years]. / Césarienne avant 34 semaines d'aménorrhée: retentissement maternel et foetal dans les C.H.U. de l'Ouest. Enquête régionale sur 383 césariennes et 436 nouveau-nés à partir de 86 116 naissances en 5 ans.

This statistical enquiry carried out in a region of France by the University Hospital Services in Obstetrics and voluntarily devoid of bibliographical references, deals with a group that are particularly pathological and thus probably explains the seriousness of the prognosis for the newborn and the frequency of maternal morbidity following these early operations. 15% of serious maternal complications with severe neonatal pathology which was often heavy and responsible for the death of the fetus in 22.4% of the cases and the late sequelae in the newborn in more than 10% of cases, mad it important to seek for the inevitable link between the pathology and the length of gestation at the time of the operation. Only one in three children were alive without any sequelae after Caesarean carried out between 28 and 31 weeks, but more than 80% were alive when the operation was performed at 34 weeks. In view of these findings the authors suggest that each case should be considered very carefully before early Caesarean section is carried out, both from the advantages and disadvantages of this means of delivery for the baby as well as for the mother. Caesarean section before 30 weeks of amenorrhoea on an infant with an estimated weight of less than 1 000 grams is seldom to be recommended in view of the poor results for the newborn and in the absence of severe maternal pathology which requires immediate evacuation of the uterus. In view of the poor statistical results that have been analysed, early Caesarean section for fetal pathology and particularly for fetal distress when there is no adequate sophisticated means of resuscitating the baby should be lowered to the minimum possible figure. The comparative study of the notes shows that pathological conditions apparently similar to one another lead to occasions for carrying out very early Caesarean section, and also show that the outlook is different from the point of view of the immediate prognosis and a late prognosis for the newborn infant in view of the delay that has occurred before extracting the baby and of the facilities available to resuscitate the baby.

[Intravenous urography in pregnancy and the risks of fetal hypothyroidism]. / Urographie intraveineuse pendant la grossesse et risques d'hypothyroïdie foetale.

The authors approach the question of the risk of fetal and neonatal hypothyroidism when intravenous pyelography is carried out in the pregnant woman. They looked at a continuous series of 15 cases in 7 years, of which 8 were studied retrospectively and 7 prospectively. They did not find any clinical or biological signs of hypothyroidism when the children were from 10 months to 9 years of age at review. The authors approached the reaction of the fetal thyroid to this excess dose of iodine considering what is known about the physiology of this gland in utero and the publications concerning hypothyroidism occurring after prolonged administration of iodine or amniofetography. They conclude that there is probably a temporary disturbance of fetal thyroid function but it does not continue into the neonatal period. All the same, caution is advocated because intravenous urography during pregnancy should be carried out only for very tight indications and the newborn should be carefully examined.

[The teratogenic risks of anti-epileptic treatment]. / Risques tératogènes des traitements anti-épileptiques.

Janz and Fuchs, in 1964, started the question of the teratogenicity of anti-epileptic drugs by their publications. In Poitiers we have carried out a retrospective study on 56 epileptic women who gave birth to 85 children. We found that 12 of these children (14.4%) had malformations. These results confirm that there is a risk of malformation in the use of anti-epileptic measures, a conclusion which corresponds with those of the majority of authors. The hydantoins and the barbiturates seem to have an equal role to play but they do so by different mechanisms. The most common malformations are hare-lips or cleft palates and cardiopathies. The most obvious ones are the facial deformities and skeletal abnormalities; none of these are lethal. In spite of this risk all authors state that it is important to carry on with anti-epileptic treatment for the mothers' sake.

[Antispasmodic agents (author's transl)]. / Les tocolytiques.

The authors summarize current knowledge of the anatomical and physiological basis of uterine contractions and their inhibition, and review the different antispasmodics used at the present time in France. For each product they describe the pharmacological effects, the mode of administration, maternal and fetal tolerance, indications, contra-indications and efficacy. The choice of product and their association are then discussed. The authors emphasize the value of treatment by these products, and stress the need for careful prescribing, because of the severity of the accidents provoked by overdosage or when their contra-indications are not respected.

[Reflections on four cases of uterine perforation after pregnancy termination by aspiration]. / Reflexions sur quatre cas de perforation uterine apres interruption de grossesse par aspiration.

PIP: The article reports on 4 cases of uterine perforation during abortion by vacuum aspiration; for 2 patients the lesions were so severe that hysterectomy was necessary. Factors conducive to uterine perforation during abortion are the inexperience of the operator, and the fragility of the uterus, depending on gestational age and parity. Diagnosis of uterine perforation is sometimes done immediately, but often too late, when complications have already set in; at this point treatment with antibiotics is usually not sufficient, making hysterectomy necessary.^ieng

[Fossae, recesses and culs-de-sac in the pelvic peritoneum of women (author's transl)]. / Fosses, récessus et culs-de-sac du péritoine pelvien chez la femme.

The pelvic peritoneum in women is peculiarly irregular because of the numerous folds, fossae, recesses and culs-de-sac that exist in it. Blood and purulent serous fluids occur in the abdomino-pelvic cavity and stagnate in these sites. Since they are particularly to be found around the adnexae they can give rise to secondary infection occurring as a result of primary adnexal infection. Furthermore, when serous fluid is regurgitated into the tubo-ovarian hollow through the abdominal os of the tube and into the pertoneum around the ovary, adhesions and endometrial deposits occurring in this area can be explained. Each one of these structures should be systematically explored, particularly when hystero-salpingographies and laparoscopies are being carried out. Furthermore, they should be cleaned out very meticulously after all conservative surgery to prevent the formation of adhesions.