[Trophoblastic tumor on the placenta. Diagnosis, prognostic factors, treatments]. / Tumeur trophoblastique du site placentaire. Diagnostic, facteurs pronostiques, traitements.

Previously known under other terms, placenta site trophoblastic tumor (PSTT) is a specific entity among trophoblastic diseases. Outcome is highly variable depending on the clinical course which may range from benign disease to high-grade malignancy. Histology and biology, including mitotic count, the degree of tumor invasion, the process of necrosis within the tumor and plasma beta-hCG level, provide important indications for prognosis. Survival without recurrence can be achieved with wide surgical excision. Complete hysterectomy with or without bilateral salpingooophorectomy is required. Chemotherapy and radiotherapy have no effect. In case of desired pregnancy, the acceptability of conservative treatment must be judged on the basis of hysteroscopy with MRI or endoscopic sonography findings. In cases with good prognosis, conservative management may be proposed with hysteroresection for an endouterine tumor or complete resection of the PSTT, the uterus remaining in situ during the laparostomy. Obstetrical prognosis, still to be determined, depends on the validity, feasability and fertility rate after such procedures. Curettage must be abandoned.

[Uncontrolled retrospective study of 75 pregnancies in women treated for epilepsy]. / Etude rétrospective non contrôlée de 75 grossesses chez des femmes épileptiques traitées.

OBJECTIVE: Our purpose was to study pregnancies and birth outcomes in a population of women treated for epilepsy. STUDY DESIGN: A retrospective uncontrolled study of 75 pregnancies in 55 epileptic women under treatment was conducted in the nursery of CHU Angers. The course of pregnancies and deliveries, the frequency of congenital malformations and the clinical state of the neonates during the first 6 days of life were recorded. RESULTS: There was a high rate of prematurity (15%) especially in patients treated by phenobarbital, a 10.5% rate of intra-utero growth retardation, a 11% rate of major congenital malformations and a 9% rate of isolated minor congenital malformations. Congenital malformations were mainly facial dysmorphia, cardiopahties, urogenital tract abnormalities. The neonatal symptomatology was associated with a high level of antiepileptic drugs in neonates or to a withdrawal syndrome or to hypovitaminosis. CONCLUSION: Overall results justify implementing prevention and detection measures.

[Apert syndrome. Ultrasonic diagnosis, obstetrical management]. / Syndrome d'Apert. Diagnostic échographique, prise en charge obstétricale.

We report two observations of antenatal diagnosis of Apert syndrome. This uncommon genetic disorder suggest an autosomal dominant inheritance, but almost all cases described are sporadic; the responsible gene is yet not located. Ultrasonographic detection is difficult, based on the following signs: brachycephalic skull (unusually detected), flat facial profile with a nasal bridge depression, tall appearance of the forehead (inconstant), total bilateral and symmetrical syndactylies of the hands and feet. At last we present our arguments for medical abortion, when this disorder is detected.

[Serum alkaline phosphatase levels in pregnancy]. / Taux sérique gravidique des phosphatases alcalines.

Serum levels of total alkaline phosphatase increase during pregnancy but the presently available methods are not very precise. We used the CHEM 1 Bayer Diagnostic test in all the consecutive patients admitted to our unit between June 1 and October 16, 1990. Exclusion criteria were twin pregnancies, pruritus, liver disease or parasitosis. A multifactorial analysis was used to discriminate between general, obstetric, pathologic and drug parameters. There were 373 serum samples, 91% were obtained during the last three months of pregnancy. The mean serum alkaline phosphatase level was 68.2 U/l and 75.9 U/l during the first two trimesters respectively and rose to 126.7, 178.8 and 234 U/l during the last three months respectively. The elevation was greater in cases of vomiting during the first trimester, alpha-methyldopa intake. It was less after hypodroxyapatite intake and was positively correlated with weight gain. Age, parity, pregestational weight, neonatal weight, other pathologies and other drug intake did not affect the results. Knowledge of these physiological levels will be useful for evaluating most liver diseases occurring during pregnancy. Assay of the enzyme fractions would be ordered secondarily.

[Rupture of aneurysm of the splenic artery during the first three months of pregnancy]. / Rupture d'un anévrysme de l'artère splénique pendant les trois premiers mois de la grossesse.

A rare but dramatic case of haemoperitoneum of non-gynaecological origin which occurred during pregnancy is reported. Obstetrical causes of shock having been excluded, laparotomy made it possible to discover an aneurysm of the splenic artery and treat it by resection-ligation and splenectomy. In such cases, the uterus is spared before the 6th month of pregnancy, and beyond that data caesarean section is mandatory. The pathogenesis of such arterial ruptures during pregnancy is unknown. The abrupt collapse accounts for the high maternal and foetal mortality. Prevention can only be achieved by surgical treatment of all uncomplicated aneurysm of the splenic artery in young women.

[Hydrops fetalis of non-immunological origin. Study of 24 cases and review of the literature]. / Anasarques foetoplacentaires d'origine non immunologique. Etude de 24 cas et revue de la littérature.

Twenty-four cases of Schriddes' disease of non-immunological origin were observed between 1973 and 1990 in the Gynecology-Obstetrics Service at Angers (France). These cases are analyzed and the results are compared with those published in the literature. This disorder must be diagnosed before birth. Three examinations are currently essential for foetal assessment: obstetrical ultrasound, ultrasonic cardiography and amniocentesis. As a result of improved antenatal diagnosis, the question of the indications for in-utero treatment and medical termination of pregnancy now arises. Despite progress in neonatal resuscitation, the prognosis generally remains very poor.

[Prognostic factors in delivery with breech presentation. Apropos of 357 single-fetus pregnancies at term]. / Facteurs pronostiques de l'accouchement en présentation du siège. A propos de 357 grossesses monofoetales à terme.

For a better definition of the factors which could be at the origin of neonatal distress, 357 cases of mono-fetal term pregnancies with breech presentation were retrospectively studied between January 1st, 1984 and December 31st, 1989. The population is identical to that of all deliveries except for a higher percentage of first pregnancies. The risk of emergency caesarean section mostly concerns large primiparous women, underweight, with normal or large pelvis. Caesarean section is absolutely necessary if the biparietal diameter exceeds 100 mm, if the head is positioned in hyper-deflection and/or if the pelvis is defective. Without being mandatory, the procedure is preferable in case of chronic fetal distress or scarred uterus. On the contrary, neither the age of the mother nor the age of the pregnancy, nor the type of the breech, nor the number of pregnancies have any effect on the prognosis. The current rate of caesarean section is 47.9 per cent with almost complete disappearance of the large breech extraction (0.6 per cent) and the Mauriceau's maneuver (0.3 per cent). The corrected mortality rate is 0.28 per cent. In addition to the parameters considered in our coefficient of risk of breech delivery, it was noted that a pre-pregnancy weight exceeding 70 kg or a weight gain of more than 15 kg represent unfavorable factors. It is desirable to calculate prospectively the severity of the risk in small size cases, when the biparietal diameter ranges between 96 and 100 mm, or when one of the diameters of the bony pelvis is decreased.

[Pseudomyxoma peritonei in females. 13 personal cases. Practical deductions from a review of 420 cases in the literature]. / La maladie gélatineuse du péritoine chez la femme. Treize observations personnelles. Déductions pratiques à partir de la revue de 420 cas de la littérature.

Having considered their 13 cases of pseudomyxoma peritonei where mucin is found in the peritoneum, the authors reviewed 420 cases abstracted from the literature. It is a rare condition (2 out of every 10,000 laparotomies) and is three times more common in women than in men. the mean age is 53 years. The spontaneous evolution of the condition before the diagnosis is made is about 21 months, as the aetiology and histology may be confusing. Diagnosis is made easier by paracentesis, but ultrasound and now tomodensitometry, are very helpful. It is interesting that in 5 out of the 13 cases there was a rise in carcino-embryonic antigen (C.E.A.) both in the gelatinous material and in the serum. Five cases out of the 5 appendix tumours or tumours of the ovary which were benign showed this feature. The level of C.E.A. in the serum was weak (50-150 ng/ml) when the quantity of gelatinous material was large (48,000-70,000 ng/ml). In one case a step-ladder rise in C.E.A. corresponded to clinical changes. Finally, the proof that C.E.A. was secreted by the cells of a cyst adenoma of the ovary could have been brought about by the phenomenon of immuno-competition. The following therapeutic measures are proposed: first surgery and then the use of proteolytic enzymes with, in benign lesions, estimations of C.E.A. and tomodensitometry. This last examination makes it possible, in cases of recurrences, to separate the "young" forms which can still be sensitive to enzyme treatment, from the "old" forms which are resistant to such treatment and may be respond better to chemotherapy.

[Treatment of female stress urinary incontinence. Results and critical analysis based on 78 cases]. / Traitement de l'incontinence urinaire d'effort féminine. Résultats et analyse critique à propos de 78 observations.

This work reviews 78 case histories of urinary incontinence in women treated surgically. There are two series compared with one another: Burch's operation (indirect colpocystopexy) carried out on 37 patients. The placing of an aponevrotic sling under the neck of the bladder by Cukier's method in 41 patients. Urodynamic studies were carried out in each case systematically before and after operation in order to make a diagnosis and indicate the correct treatment to use in each particular patient. The results as far as the incontinence is concerned, clinically and urodynamically, were good, with a cure rate or a great improvement in 94% to 97.5% of cases. The results seem to be better when strips were used; but these increased the numbers of patients who suffered from dysuria. A protocol for treating these cases of stress incontinences in women can be worked out from this study.

[Neonatal ovarian cysts. Apropos of 4 cases]. / Les kystes ovarients néonatals. A propos de quatre cas.

When the authors had seen four cases of ovarian cysts in the newborn during the course of a few months they decided to describe this pathology. All four cases were discovered in utero during the course of ultrasound examination at gestationaL ages between 28 and 36 weeks. Pictures were obtained of round abdominal liquid areas measuring between 45 and 75 mm in diameter, which were separate from the bladder and the kidneys in female fetuses. One of the cysts showed two different ultrasound zones, of which one seemed to be a deposit of blood which was taken to be evidence of torsion of the ovary in utero. The diagnosis was confirmed after birth by clinical examination, straight X-ray of the abdomen, intravenous urography and ultrasound examination of the newborn. The pathological cause of these cysts is still unknown, but suggests that there was probably an abnormal stimulation by the mother's H.C.G. or abnormal enzyme activity of the theca interna. In each case delivery was vaginal. Although in each of these cases the cysts were benign they were treated surgically because all authors agree that there are risks of complications due to torsion or rupture and because one cannot be certain that they are benign.

[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.

[An urethromanometric study using micro-pressures gauges for female urinary incontinence. A definition of the index of continence. Applications (author's transl)]. / Etude urétromanométrique par microcapteurs de l'incontinence urinaire féminine. Définition d'un indice de continence. Applications.

The study has resulted from comparing urethral pressure curves measured with the use of a catheter with two micropressure gauges in 34 continent and 100 incontinent women. Two types of tracing were obtained: first of all at rest and then with the woman coughing repeatedly. Of the different parameters that were measured at rest only one seems to be advantageous over the others. That is the pressure at the maximum closure which becomes less with incontinence and with ageing. The curves that have been produced with effort make it possible to analyse what happens to this pressure when maximum closure is effected. This always rises in patients who are continent and always lessens in patients who are incontinent. The ratio of these two values, Pc with maximum effort over Pc at maximum rest, allows an index of continence (IC) to be drawn; and which conveys the ability of the sphincter apparatus to adapt itself, and which gives a quantitative value to female continence. Its practical application makes if possible to confirm the diagnosis and adapt the therapy to be used in many incontinent patients in whom other tests have been unrevealing, and to unmask incontinences that have been masked by prolapse and to identify possible future incontinent patients.

[Residual slowing of the heart in the first stage of labour. The interpretation and the prognostic value of this sign (author's transl)]. / Les ralentissements résiduels pendant la dilatation. Interprétation et signification pronostique.

117 deliveries in which fetal heart slowing was accompanied by residual bradycardia where at least one measure of the fetal pH was undertaken (212 measures were carried out in the whole series) allowed the authors to analyse the maximum and residual amplitudes, the regular or irregular morphology. The frequency of the slowing and its relationship to uterine contractions (regular or variable) and the number of episodes of slowing were recorded before any measures of the fetal pH in utero were undertaken. The regular morphology and the size of the residual degree of bradycardia beyond 30 Bpm are of great diagnostic importance. In fact, while slowing with residual bradycardia below 30 Bpm is tolerable, beyond this 19% of cases show fetal acidosis when slowing is irregular or variable, and 76% when slowing is regular (53 of these had severe acidosis with a pH of less than 7.20). In this last group, which is by far the most dangerous, acidosis appeared after 5 episodes of slowing and became constant after more than 10 episodes. Because of this, measuring pH in the presence of residual slowing would seem to be only useful in irregular types of slowing.