[Induced abortion: Guidelines for clinical practice - Text of the Guidelines (short text)]. / L'interruption volontaire de grossesse : recommandations pour la pratique clinique ­ Texte des recommandations (texte court).

OBJECTIVE: Develop recommendations for the practice of induced abortion. MATERIALS AND METHODS: The Pubmed database, the Cochrane Library and the recommendations from the French and foreign Gyn-Obs societies or colleges have been consulted. RESULTS: The number of induced abortions (IA) has been stable for several decades. There are a lot of factors explaining the choice of abortion when there is an unplanned pregnancy (UPP). Early initiation and choice of contraception in connection to the woman's life are associated with lower NSP. Reversible contraceptives of long duration of action should be positioned fist in line for the teenager because of its efficiency (grade C). Ultrasound before induced abortion must be encouraged but should not be obligatory before performing IA (Professional consensus). As soon as the sonographic apparition of the embryo, the estimated date of pregnancy is done by measuring the crown-rump length (CRL) or by measuring the biparietal diameter (BIP) from 11 weeks on (grade B). Reliability of these parameters being±5 days, IA could be done if measurements are respectively less than 90mm for CRL and less than 30mm for BIP (Professional consensus). A medical IA performed with a dose of 200mg mifepristone combined with misoprostol is effective at any gestational age (EL1). Before 7 weeks, mifepristone followed between 24 and 48hours by taking misoprostol orally, buccally sublingually or eventually vaginally at a dose of 400 ug possibly renewed after 3hours (EL1, grade A). Beyond 7 weeks, misoprostol given vaginally, sublingually or buccally are better tolerated with fewer side effects than oral route (EL1). It is recommended to always use a cervical preparation during an instrumental abortion (Professional consensus). Misoprostol is a first-line agent for cervical preparation at a dose of 400 mcg (grade A). Aspiration evacuation is preferable to curettage (grade B). A perforated uterus during an instrumental suction should not be considered as a scarred uterus (Professional consensus). IA is not associated with increased subsequent risk of infertility or ectopic pregnancy (EL2). The pre-abortion medical consultations does not affect, most of the time, the decision to request an IA. Indeed, a majority of women is quite sure of her choice during these consultations. Acceptability of the method of IA and satisfaction appears to be larger when they are able to choose the abortion method (grade B). There is no relationship between an increase in psychiatric disorders and IA (EL2). Women with psychiatric histories are at increased risk of mental disorders after the occurrence of an UPP (EL2). In case of instrumental abortion, oral estrogen-progestogen contraceptives and the patch should be started from the day of the abortion, the vaginal ring inserted within 5 days of IA (grade B). In case of medical abortion, the vaginal ring should be inserted within a week of taking mifepristone, oral estrogen-progestogen contraceptives and the patch should be initiated on the same day or the day after taking prostaglandins (grade C). In case of instrumental abortion, the contraceptive implant may be inserted on the day of the abortion (grade B). In case of medical abortion, the implant can be inserted on the day of mifepristone (grade C). The copper Intrauterine Device (IUD) and levonorgestrel should be inserted preferably on the day of instrumental abortion (grade A). In case of medical abortion, an IUD can be inserted within 10 days following mifepristone after ensuring by ultrasound of the absence of intrauterine pregnancy (grade C). CONCLUSION: The implementation of these guidelines may promote a better and more homogenous care for women requesting IA in our country.

[Cholesteatoma of the middle ear. Choice of technique and results in the adult and child]. / Le cholestéatome de l'oreille moyenne. Choix des techniques et résultats chez l'adulte et chez l'enfant.

On the basis of a series of 577 tympanoplasties performed between January 1968 and December 1978 for 424 cholsteatomas and 153 epidermisations involving 464 adults and 113 children aged less than 15 years, the authors describe techniques, results and indications. An open technique was used in only 28 cases. Since 1973, the authors have preferred the closed technique in two stages (227 cases) to a, closed technique in 1 stage (113 cases). The open technique with obliteration was used in 68 cases in one stage and in 141 cases in 2 stages. This latter group included 17% of patients referred from elsewhere and already operated upon. Rates of tympanic closure varied between 93% for open techniques and 97% for closed techniques and open techniques with obliteration. The presence of silastic caused a fall in this closure rate of a little more than 2% both in the closed technique (94,8%) as well as in the open technique with obliteration (94,4%). An appreciably difference between the adult and child was seen only with the open technique with obliteration in two stages: 96% in the adult, 83% in the child. Residual cholesteatoma pearls extirpated during the 2nd stage were found in 28% of cases in the adult and in 36% of cases in the child in closed techniques and in 21% of cases in the adult and 33% of cases in the child in open techniques with obliteration. Retraction pockets were fairly common after the closed technique in one stage (6 out of 35 at 5 years). They were nevertheless also seen after closed techniques in two stages (5 out of 81 at one year and 3 out of 29 at 3 years). The best functional results were obtained with closed techniques in 2 stages. The air-bone gap was 10 dB or less in 44% of cases and 20 dB or less in 63% of cases when the stapes was intact. It was 10 dB or less in 31% of cases and 20 dB or less in 45% of cases when the stapes was destroyed. There was no appreciable difference between adults and children for a given technique. The closed technique in two stages is preferable, in particular when the mastoid is pneumatised and/or if the cholesteatoma is large or papillary, which is customary in the child. The open technique with obliteration is preferable if the wall of the mastoid antrum is destroyed if the mastoid is severely retracted and if the eustachian tube functions poorly. It is also the method indicated in the presence of a large retraction pocket.