[Surgical training of trainees, specialists in obstetrics and gynecology: results from a national electronic survey]. / Formation chirurgicale des internes, spécialistes en gynécologie-obstétrique : résultats d'une enquête électronique nationale.

OBJECTIVES: The goal of this dissertation is to assess the current situation of surgical training provided to French trainees in obstetrics and gynecology. MATERIALS AND METHODS: An online survey was made available to all French gynecologists. Within six months, 657 answer forms had been submitted and respondents were sorted out into five subgroups: residents (group 1 [G1]), fellows (group 2 [G2]), public sector surgeons (group 3 [G3]), private sector surgeons (group 4 [G4]) and all surgeons and fellows (group A [GA]). RESULTS: Only 30% of interns (G1) and 78% of surgeons (GA) were satisfied with their training. Most respondents agreed that two general surgery courses as currently offered in the curriculum do not provide enough good basic surgical knowledge. Courses that allow residents to train in other hospitals are generally preferred to those that focus on a particular hospital. Ninety-two percent of respondents consider camaraderie and bonding within a medical unit to be key to a successful course. Theoretical training, including lectures and access to listed references, is thought to be weak. Resources and tools for practical training outside the operating room, including pelvic trainer and anatomical dissection, are scarce. Course evaluation is expected by 83% of all respondents, although it is now virtually nonexistent. CONCLUSION: Surgical training of residents in obstetrics and gynecology can be improved in many ways, such as using synthetic materials and operating on animals or cadavers. Rigorous course evaluation is key to improving surgical training of French residents in obstetrics and gynecology.

[Surgery training of gynecologic residents: master and student in the operating room]. / Formation chirurgicale au bloc opératoire: enquête d'opinion auprès des praticiens et des internes en gynécologie-obstétrique.

OBJECTIVES: Describe the surgical training of gynecologic residents in the operating room, by collecting the opinion of French gynecologists. MATERIALS AND METHODS: A questionnaire investigating this subject was put on a web site. Every French gynecologist could answer the questionnaire from a duration of six months. The data of the inquiry were studied by comparing five groups: residents (group 1), fellows (group 2), seniors of public hospital (group 3), and seniors of private hospitals (group 4), or, groups 2, 3 and 4 together, as Group A. RESULTS: Six hundred and fifty-seven gynecologists answered the inquiry. For the residents, lack of time and senior's weak educational motivation are the explanations most frequently retained in order to explain that residents do not operate. For group A, it is rather the residents' skills which is the most important fact to have residents operate. Residents more often practice surgery in general public hospital that in faculty hospital. For 31% of all the referees, heads of departments do not incite their teams to have residents operate. Nearly 25% of all the investigated believe that a man operates more than a woman in resident curriculum. Besides, by analyzing the answers of groups 1 and 2, we were able to correlate resident seniority at their first practice of 13 surgical operations. For 26% of the group A, residents operate less than they do during their own studies. Finally, all the investigated confirm the lack of surgical assessment in the resident curriculum. DISCUSSION AND CONCLUSION: Decision to let the resident operate remains too dependent on senior personal appreciation and does not seem to join a strategy of training. Opinions of surgical training in the operating room is different between residents and seniors. Operating time increases when residents operate but there is no effect on quality of care. These results show again the necessity of a formal teaching and assessment, in a resident program with objectives, collecting every resident's surgery volume. These educational improvements will contribute certainly to the professionalization of residents.

[Ultrasonography of fetal esophagus: healthy appearance and prenatal diagnosis of a case of esophagus atresia with esotracheal fistula]. / Echographie de l'oesophage foetal: aspect physiologique et application au dépistage anténatal d'une atrésie oesophagienne.

The thoracic part of a fetal esophagus is generally overlooked by usual prenatal ultrasonography. However, screening it might improve the detection rate of esophageal malformations for which prenatal diagnosis remains far from accurate. In this article, we describe the technique which makes it possible to get a precise image of a fetal thoracic esophagus in its more sensitive part: between the trachea and the aorta. After describing the appearance of a healthy thoracic esophagus, we will show how this technique can be used for prenatal detection of esophagus malformations. For this purpose, we provide the case report of a prenatal diagnosis of esophagus atresia with esotracheal fistula.

[Pregnancies occurring during oral contraception: lessons from the GRECO study]. / Grossesses survenant sous contraception orale: les leçons de l'étude GRECO.

OBJECTIVES: The GRECO study has collected data on pregnancies, regardless of their outcome, that occurred in women taking an oral contraceptive. PATIENTS AND METHODS: The analysis concerned 551 women prospectively recruited in services of gynaecology or obstetrics, termination of pregnancy centres, family planning centres or consultations of gynaecology in France throughout 2002 and who were 12 weeks pregnant or less. RESULTS: Contraception used during the cycle of conception was an estroprogestative combination in 88% of cases, a microprogestative in 8.7%, a macroprogestative in 0.9% or another type of pill in 2.4%. Progestatives were levonorgestrel 59.0%, gestoden 17.2%, desogestrel 4.7%, norethisterone acetate 2.9%, norgestimate 1.8%, cyproterone acetate 2.0%, norgestrel 1.6%. When asked about the potential cause of the oral contraceptive failure, 76.9% of women reported events such as missed pills which were the most frequent cause of failure (60.8% of failures and 80.1% of events, 2.7+/-2.7 missed pills), followed by vomiting and diarrhoea. 81.5% of women chose to terminate their pregnancy. DISCUSSION AND CONCLUSION: The GRECO study, despite its limitations (retrospective collection of missed pills data, declaratory data) showed that missed pills, even once, were the most common reason for oral contraceptive failure. The most frequent decision was the termination of pregnancy.

[Preliminary results from the OPNI observatory: long-term follow-up of a cohort of women using the progestagen contraceptive implant Implanon]. / Le suivi à long terme d'une cohorte de femmes porteuses d'un implant contraceptif (Implanon): analyse intermédiaire des données de l'observatoire OPNI.

OBJECTIVE: Describe the initiation and follow-up of Implanon insertion in current office-based practice in France and estimate the rate and causes of early removals. PATIENTS AND METHODS: A prospective cohort study of 1000 women having been inserted with Implanon by a representative national sample of prescribers (gynaecologists and general practitioners) was designed. The follow-up period was 3 years and the enrolment was planned for 2 years starting July 2002 according to a naturalistic design. RESULTS: The results are related to an intermediate analysis describing the situation of the cohort at the date 31 December 2003. 872 women were enrolled, of whom 784 (89.9%) by gynaecologists and 88 (10.1%) by GPs. Implanon was inserted in 691 (79.2%) and 360 (52.1%) had at least one follow-up visit at this date. The mean follow-up period after insertion was 10.5 months. 38 early removals were recorded (actuarial rate at 16 months of 8.8% [CI 95% 5.0-12.7]), integrating the distribution of follow-up duration and the assumption that women with no follow-up visit the still had device. DISCUSSION AND CONCLUSION: The estimated early removal rate was lower than the result of the meta-analysis of international clinical trials but this figure should be confirmed in the final analysis of the study.

[Vaginal dryness]. / La sécheresse vaginale.

Vaginal dryness is one of the "little problems" that are too often, ignored. The disorder essentially manifests at the time of menopause, but can occur at other times, such as with oral contraception, following vaginal infection, after treatment for infection, etc. Screening for the disorder should become routine. Management should have precise objectives: cure of the infection and restablishment of the vaginal flora in order to reconstitute a natural balance. Treatment can be adapted for each patient to obtain effective and lasting results.

Antiphospholipid and antiprotein syndromes in non-thrombotic, non-autoimmune women with unexplained recurrent primary early foetal loss. The Nîmes Obstetricians and Haematologists Study--NOHA.

Various antiphospholipid and/or antiprotein antibodies have been suspected to be associated with recurrent early foetal loss in absence of any habitual aetiology. We conducted a hospital-based case control study on women with no antecedent of thromboembolic or autoimmune disease. We studied 3 groups of 518 women: patients with unexplained primary recurrent early foetal loss, patients with explained episodes and mothers with no previous obstetrical accident. Matching the 3 groups was carried out on the basis of age, number or pregnancies and time elapsed since the end of the last pregnancy. Significant biological markers were then prospectively tested. The various antibodies were shown to be dependent on parity and on the presence of previous foetal loss: cut-off values were thus calculated using data obtained from the group of explained accidents, and adjusted for parity. Only anti-phosphatidylethanolamine IgM [odds ratio: 6.0, 95% confidence interval (2.3-15.7), p = 0.0003], anti-beta2-glycoprotein I IgG [4.4, (1.6-11.7), p = 0.0035] anti-annexin V IgG antibodies [3.2 (1.2-8.1), p = 0.015] and lupus anticoagulant [3.0, (1.3-6.8), p = 0.009], were found to be independent retrospective risk factors for unexplained early foetal loss. These four markers were subsequently found to be, during the following pregnancy, associated with a significant risk of foetal loss despite a low-dose aspirin treatment. In non-thrombotic, non-auto-immune women with unexplained primary recurrent early foetal loss, subgroups of patients with positive anti-phosphatidylethanolamine IgM antibodies, or positive anti-beta2-glycoprotein-I IgG antibodies, or positive anti-annexin V IgG antibodies or lupus anticoagulant must be particularised. This should allow therapeutic trials to be carried in well-defined patients.

[Importance of defecography in the evaluation of genital prolapses]. / Intérêt de la défécographie dans le bilan des prolapsus génitaux.

OBJECTIVE: To determine the interest of defecography for the initial evaluation of genital prolapses. PATIENTS AND METHODS: A retrospective study of 125 patients who had undergone systematically a defecography for the initial evaluation of a genital prolapse. RESULTS: 10% of defecogaphies were normal. On clinical examination a rectocele was found in 94% of patients and an enterocele in 33%. At defecography, these abnormalities were seen only in 39% and 15% respectively. 39% of patients with radiological rectocele had an intussusception at defecography. CONCLUSION: Defecography is appropriate to diagnose and to assess constitutional abnormalities associated with genital prolapse (rectocele, enterocele) and other anomalies which interact with it (intussusception, sphincter and pubo-rectal dyskinesia). Most of women with genital prolapse showed abnormal defecograms. We observed a marked discordance between clinical and radiological evaluation, specially for rectocele. Defecography is of great interest in the evaluation of posterior genital prolapses, specially in women complaining of dyschesia. Defecography may be proposed in case of: posterior vaginal wall prolapse (rectocele, enterocele), dyschesia, post-operative prolapse and before a cervicopexy.

Case-control study of the frequency of thrombophilic disorders in couples with late foetal loss and no thrombotic antecedent--the Nîmes Obstetricians and Haematologists Study5 (NOHA5).

BACKGROUND: Women with familial thrombophilia have an increased risk of still birth. We postulated that the presence of asymptomatic risk factors for venous thrombosis might be a risk factor for late foetal loss. METHODS: We performed a case-control study on the prevalence of heritable thrombophilic defects, of antiphospholipid-related markers and of the C677T mutation in the methylenetetrahydrofolate reductase (MTHFR) gene in patients with at least one episode of late unexplained foetal loss and in control women with successful pregnancies. Partners of cases and controls were also studied. Written conclusions of the pathological examination of the placentas, when available, were also reviewed. RESULTS: We found at least one positive biological risk factor for venous thrombosis in 21.1% of the patients and in 3.9% of the controls (p < 10(-4)). In women, the crude odds ratio for still birth associated with any positive biological risk factor for venous thrombosis was 5.5, 95% confidence interval (95%CI) [3.4-9.0]. No difference was found between partners of cases and controls (5.2% and 4.7%). Using conditional logistic regression analysis, 4 adjusted risk factors for still birth remained: protein S deficiency, positive anti beta2 glycoprotein I IgG antibodies, positive anticardiolipin IgG antibodies and the factor V Leiden mutation. The C677T mutation in the MTHFR gene was not an individual risk factor but an homozygous genotype was strongly associated with the former 4 risk factors (16.8% of patients vs. 0.9% of controls). In women with such associations, still births always occurred in absence of folic acid supplementation during pregnancy. Available conclusions of pathological analysis of placentas were found to have a very high proportion of "maternal vascular disease of the placenta" in patients with at least one positive risk marker for thromboembolism, specially in case of association with the C677T MTHFR homozygous genotype, compared to patients with negative markers (p <10(-4)). CONCLUSIONS: Late foetal loss, through placenta thrombosis, may sometimes be the consequence of a maternal multifactorial prothrombotic state associating traditional heritable or acquired thrombosis risk factors to conditions predisposing to an acute mild hyperhomocysteinaemia (coexistence of a genetic predisposition with late pregnancy-related increased folate needs).

Detection of foetal cells in maternal blood and prenatal sex determination by in situ hybridization. Procedure verification.

We describe an enrichment of foetal cells from maternal blood with a combination of double density gradient and Magnetic Activated Cell Sorting (MACS) of CD71, glycophorin A (GPA), CD34 and CD36 antibodies labeled cells followed by fluorescence in situ hybridization (FISH) with chromosome-specific DNA probes for determination of foetal sex.

Intravenous nicardipine for severe hypertension in pre-eclampsia--effects of an acute treatment on mother and foetus.

OBJECTIVES: To assess the efficacy in lowering blood pressure, and the safety for mother and foetus of an acute nicardipine therapy in severe pre-eclampsia. DESIGN: Prospective clinical study. SETTING: One university hospital obstetric unit. PATIENTS: Twenty consecutive adult pre-eclamptic patients with severe hypertension. INTERVENTION: Nicardipine, 1 microgram/kg per min, was given intravenously to lower the mean arterial pressure (MAP) by at least 15%. Then, the dosage was reduced by 1/3, and the final dosage was determined to maintain MAP at 20-30% below the initial value, by increasing or decreasing the infusion rate by 0.5 mg/h. MEASUREMENTS AND RESULTS: Maternal MAP and heart rate (HR) were assessed every 5 min for 1 h. Foetal HR (FHR) was recorded throughout the study period and assessed for Fischer score. Gestational age, Apgar scores, birth weight, capillary filling time and the duration of stay in the paediatric intensive care unit (ICU) were used to evaluate the short-term perinatal outcome. A 15-30% decrease in MAP occurred within 15-20 min in all patients. An increase in HR was noted, and two patients had severe tachycardia. Maternal side effects included flushing, headache, nausea and dizziness. FHR showed a transient decrease in acceleration episodes and occurrence of decelerations. No nicardipine-related foetal distress occurred. Four infants born during the study period did well at birth and had a good outcome. CONCLUSIONS: Acute nicardipine therapy can induce severe maternal tachycardia. No severe foetal or neonatal adverse effects occurred. This dose scheme requires comparison with alternative therapeutic options.

Pallister-Killian syndrome [i(12p)]: first pre-natal diagnosis using cordocentesis in the second trimester confirmed by in situ hybridization.

Pallister Killian syndrome (PKS) is the most frequent form of partial autosomal tetrasomy 12p in humans. Sufferers have a mosaic of isochromosome 12p [i(12p)]. We report the first pre-natal diagnosis on fetal blood cells after cordocentesis during the second trimester. The extra chromosome was first diagnosed by in situ hybridization. Fluorescence in situ hybridization (FISH) was used to count the interphase and/or metaphase cells containing the isochromosome. A review of the literature identified 27 other reports of PKS diagnosed pre-natally. We showed that the most consistent pre-natal ultrasound findings include hypertelorism, broad neck, shorts limbs, abnormal hands or feet, diaphragmatic hernia and hydramnios. Recognition of this congenital malformation pattern pre-natally may allow utilization of FISH.

A woman with five consecutive fetal deaths: case report and retrospective analysis of hyperhomocysteinemia prevalence in 100 consecutive women with recurrent miscarriages.

OBJECTIVE: To evaluate the medical relevance of hyperhomocysteinemia in women with primary recurrent miscarriages. DESIGN: Case report and retrospective cross-sectional study. SETTING: Hematology outpatient department of a university hospital. PATIENT(S): Case report concerning a woman with five consecutive fetal losses. One hundred consecutive women with primary recurrent unexplained miscarriages (study group) and matched healthy controls (control group) with no antecedent fetal loss. INTERVENTION(S): Venous blood sample collection in resting individuals. MAIN OUTCOME MEASURE(S): Plasma total homocysteine concentrations, plasma folate concentrations, and DNA analysis for the C677T mutation of the 5,10 methylene tetrahydrofolate reductase gene. Normal threshold homocysteine concentration was obtained from values found in the control group (95th percentile). RESULT(S): The case patient was hyperhomocysteinemic, was homozygous for the C677T mutation in the methylene tetrahydrofolate reductase gene, and had plasma folate deficiency. Folic acid and pyridoxine administration normalized the homocysteine concentration and favored a successful pregnancy. In the retrospective study, 12 of 100 patients were hyperhomocysteinemic. Twenty percent had the C677T methylene tetrahydrofolate reductase genotype and 15% had low plasma folate concentrations. The highest values of homocysteine concentration were found in patients with both the C677T genotype and folate deficiency. CONCLUSION(S): Hyperhomocysteinemia should be identified in women with recurrent miscarriages because therapeutic normalization might permit a normal birth.

Respective evaluation of the prevalence of haemostasis abnormalities in unexplained primary early recurrent miscarriages. The Nimes Obstetricians and Haematologists (NOHA) Study.

The prevalence of haemostasis abnormalities was evaluated in 500 consecutive women with unexplained primary recurrent miscarriages. Two matched reference groups with no antecedent of miscarriage were studied: 100 healthy mothers and 50 childless women. In the prospective part of the study, we found 9.4% of the patients (95% C.I.: 6.8-12%) with an isolated factor XII deficiency, 7.4% of the patients (5.0-9.8%) with primary antiphopholipid antibodies, 47% of the patients (42.6-51.4%) with an insufficient response to the venous occlusion test and an isolated hypofibrinolysis was found in 42.6% (38.2-47%) of the patients (reference groups: respectively 0/150, 3/150, 2/150, p < 10(-3)). Willebrand disease, fibrinogen, deficiency, antithrombin, protein C or protein S deficiencies were not more frequent in recurrent aborters than in members of the reference groups. In the retrospective part of the study, cases of plasma resistance to activated protein C were not abnormally frequent. Patients had higher Willebrand factor antigen (vWF), tissue-type plasminogen activator antigen (t-PA), plasminogen activator inhibitor activity (PAI) and D-dimers (D-Di) than the reference women. Values of vWF, t-PA, PAI and D-Di were altogether correlated but were not related to C-reactive protein concentrations. Among patients, those with an antiphospholipid syndrome and those with an insufficient response to the venous occlusion test had higher vWF, t-PA, PAI and D-Di values than the patients with none of the haemostasis-related abnormalities. Thus, factor XII deficiency and hypofibrinolysis (mainly high PAI) are the most frequent haemostasis-related abnormalities found in unexplained primary recurrent aborters. In patients with antiphospholipid antibodies or hypofibrinolysis, there is a non-inflammatory ongoing chronic elevation of markers of endothelial stimulation associated with coagulation activation. This should allow to define subgroups of patients for future therapeutic trials.

[Trends in therapeutic abortion management from 1986 to 1994]. / Prise en charge des interruptions médicales de grossesse. Evolution de 1986 à 1994.

OBJECTIVE: This study was performed in order to evaluate indications, techniques and maternal risks of medical abortions, and technical difficulties encountered in these procedures. TYPE OF THE STUDY: A monocentric, descriptive and retrospective study. MATERIALS AND METHODS: Four hundred seventeen medical abortions (MA) were performed in our fetal medicine Unit between 1986 and 1994, including 117 (28%) performed for maternal reasons and 300 (72%) for fetal reasons. Each indication was discussed in a collegial system and varied protocols of labor induction were used, mainly prostaglandins, RU 486, or feticide. MAIN PARAMETERS MEASURED: They were duration of the labor, maternal accidents, number of the fetal post-mortem examinations, counselling given to the couples. We considered that a MA is correctly managed when the intervention corresponded to the following criteria: expulsion by natural route without uterine damage, an examinable fetus and examination by a foetopathologist. MAIN RESULTS: Mean rate of MA satisfying our definition was about 45% in 1988 and reached to 74% in 1994. Our results show that the procedure is rarely complicated and that vaginal expulsion can be obtained. The foetopathologist examination rate increased regularly over the period. The mean gestational age of MA due to maternal indications was 14.5 weeks vs 23.9 weeks when dealing with fetal indications. The infection rate is about 6.2%, hemorrhage rate following expulsion was about 5.9% and the rate of uterine rupture was about 0.48%. CONCLUSIONS: These data suggest that medical abortion need to be evaluated regularly.

Severe preeclampsia superimposed on polyarteritis nodosa.

A patient with a history of drug abuse and histologically diagnosed hepatitis B-related polyarteritis nodosa was admitted for severe hypertension. After a cesarean section because of worsening of her clinical status with severe proteinuria and edema, she improved dramatically. No sign of acute polyarteritis nodosa occurred.

Late vaginal induced abortion after a previous cesarean birth: potential for uterine rupture.

This descriptive study was conducted to evaluate the risk of uterine rupture in cases of late vaginal induced abortions among women with previous cesarean sections. 23 women were referred at a mean gestational age of 23.9 (SD 6.9) weeks of gestation after one or two cesarean sections. Indications for terminating the pregnancy were maternal diseases in 4 cases and fetal anomalies in 19 cases. RU 486 and/or prostaglandins were used for cervical ripening and to induce labor. Vaginal birth was obtained in 20 cases (86.9%) with an average duration of 72 (SD 52) h. Cesarean section was performed in the remaining 3 women because no cervical dilation could be obtained. One uterine rupture occurred and was treated with conservation of the uterus. Late termination of pregnancy in such cases can be achieved without cesarean section with a high success rate.