Malformations fœtales congénitales à Brazzaville : A propos de cinq cas

Les auteurs rapportent des cas de malformations fœtales congénitales colligés au laboratoire d'histologie­embryologie de la faculté des sciences de la santé de Brazzaville. L'objectif de cette étude est de rapporter tous les cas colligés. L'impact des malformations fœtales congénitales(MFC) au Congo Brazzaville a déjà été souligné dans des publications précédentes et sont ici rappelés. Les MFC représentent environ 5,09% des hospitalisations dans le service de néonatologie du CHU de Brazzaville. Le taux de létalité y est de 59,3%. Ces malformations graves n'ont pu être dépistées au stade anténatal par manque de diagnostic prénatal comme cela se fait actuellement en occident dans les centres pluridisciplinaires de diagnostic anténatal. Le dépistage anténatal est possible, en associant l'échographie an;ténatale systématique à respectivement 12, 22 et 32 semaines d'aménorrhées (SA) à d'autres paramètres : marqueurs sériques, âge des parents, caryotype fœtal et bilan infectieux. Les principales causes des MFC sont variables : génétiques (anomalies chromosomiques, syndromes polymalformatifs), infectieuses (toxoplasmose, rubéole, CMV), médicamenteuses (nitrofurantoïne, sulfonamides), environnementales (radioactivité, exposition à un toxique, pesticide), carences alimentaires (déficit en acide folique, avitaminose). Matériels et méthode : des fœtus dont les malformations ont été découvertes à la naissance dans diverses maternités de Brazzaville, ont été colligés dans cette étude rétrospective observationnelle descriptive. Ils ont été mesurés et pesés. Résultats : 1 cas de jumeaux conjoints dicéphales sysomiens thoracodymes, 4 cas de fœtus simples : arhinencephalie (ectrorhinie). + Omphalocèle, pleurosomie, cyclocéphalie, sirénomélie. Leur poids moyen à la naissance était de 2,650 Kg. Conclusion : Les malformations fœtales congénitales sont des pathologies qui présentent un intérêt aussi bien par leur fréquence, que par leur lourdeur médicale et le devenir de l'enfant. La majorité d'entre elles sont diagnosticables au 2ème trimestre de grossesses et sont souvent en rapport avec des anomalies chromosomiques. Le pourcentage non négligeable des MFC

[Preterm births at Brazzaville University Hospital]. / Naissances avant terme au CHU de Brazzaville.

The objectives of our study were to assess the frequency, causes and outcomes of preterm births in Brazzaville University Hospital and to improve our obstetric and pediatric management. We retrospectively studied all births during 1994: 5109 in all. We collected information about the circumstances of preterm birth and all available information about its causes, mode of delivery, and immediate 24-h outcome. There were 852 preterm births (16.7% of all births). Mothers aged 14-20 years accounted for 27% of these births, while those 35 years or older accounted for only 9%. The 24-h survival rate was 73.7% (n=628). Those born at a gestational age of 28-30 weeks accounted for 40.7% of the deaths. The principal causes in order of frequency were: premature rupture of membranes (48%, caused by infection in 68% of cases), complications of high blood pressure (23.9%, including eclampsia, abruptio placentae and HELLP syndrome), twin pregnancies (14%), and previa placenta and hemorrhage (7%). The average time until the baby's transfer to neonatal intensive care was 12 hours, often because of an absence of beds. The principal causes of such transfer were: neonatal infection (48%), respiratory distress (27%) and gestational age less than 33 weeks (22%). Prognosis for preterm births is better at Brazzaville University Hospital at and after 33 weeks; extreme prudence is required before this term, especially for cesarean deliveries.

alpha-thalassemia in Bantu population from Congo-Brazzaville: its interaction with sickle cell anemia.

Deletional alpha(+)-thalassemia (-alpha(3.7)) was investigated in four groups of unrelated individuals from the Bantu population (newborns, normal adults, sickle cells trait carriers, sickle cell anemia patients) of Brazzaville, Congo. The frequency of the (-alpha(3.7)) chromosome was similar between newborns (f = 0.40) and adult subjects (f = 0.36), and between sicklers and nonsickler subjects. The frequency of the (-alpha(3.7)) chromosome in sickle cell anemia patients (SS patients) did not change when age was stratified. The hematological characteristics of SS patients with (-alpha/alphaalpha, -alpha/-alpha) and without (alphaalpha/alphaalpha) alpha(+)-thalassemia were similar to those reported in Jamaican and US sickle cell anemia patients. alpha(+)-Thalassemia had an effect on the percentage of hemoglobin S in sickle cell trait carriers. Thus, the high frequency of alpha(+)-thalassemia in the Congolese population presumably results from this disorder having a selective advantage favoring survival. However, the frequency of alpha(+)-thalassemia was not affected by age. Although in this selective tropical environment, alpha(+)-thalassemia as elsewhere markedly affects the hematological characteristics of sickle cell anemia patients, however our data provide no evidence that alpha(+)-thalassemia increases survival of SS patients.

Large-Loop Excision Using a New Probe: Variloop for the Treatment of CIN.

BACKGROUND: Our objective was to evaluate the efficiency of using a diathermic loop with an adjustable diameter (Variloop for the treatment of cervical intraepithelial neoplasia (CIN) in outpatient surgery. MATERIALS AND METHODS: Loop electrosurgical excision was performed on 185 patients, including 21 (11.3%) with low-grade lesions and an endocervical squamocolumnar junction, 44 (23.7%) with CIN2, 118 (63.7%) with CIN3, and 2 (1%) with discrepancies between cytological and histological findings. The procedure was performed in an average of 10 minutes. For 177 patients, local anesthetic was used. In all cases, the specimen was removed in one piece. RESULTS: We observed minimal epithelial distortion with mild coagulation necrosis at the edge of the specimens in 2 of 185 (1%) cases, but this did not interfere with the histological evaluation. Correlation between the biopsy and the conization diagnosis was the best for CIN3, found in 70% of the cases. However, two cases of microinvasion and three cases of adenocarcinoma in situ that were diagnosed were not suspected preoperatively in any of these patients. In 171 of 185 cases (92.4%), there was no endocervical margin involvement. At the 1-year follow-up, two patients had a moderate stenosis with a squamocolumnar junction not visualized, and two others had a severe stenosis with a marked cervical narrowing. CONCLUSIONS: The use of the diathermic loop with adjustable diameter (Variloop) allows efficient treatment of CIN, wherein endocervical development does not exceed 15 mm from the external os without causing significant thermic alterations.

[Multiple pregnancies prevention in in vitro fertilization: limiting the number of transferred embryos to two maximum?]. / Prevention des grossesses multiples en FIV: vers une limitation a deux embryons replaces au maximum?

The success of an IVF-programme is mainly linked to the number and quality of embryos transferred as well as women's age, but the incidence of obstetrics complications rises significantly with the number of fetuses. Reducing the number of embryos transferred is therefore recommended in order to avoid the medical, social and financial problems associated with multiple births. Present data suggest that, when at least three embryos of good quality are available, the pregnancy rate already reaches its maximum value when two embryos are transferred. A third one merely increases the number of triple pregnancies. Further studies are needed to conclude, especially in the cases of poor quality embryos.

L'accouchement des Noires Africaines a la Maternite GUY le Lorier de l'Hopital Tenon : etude retrospective de 781 accouchements de 1989 a 1991

781 patientes Noires Africaines sur 5503 femmes ont accouche entre le 1er janvier 1989 et le 31 decembre 1991; a la maternite Guy Le Lorier de l'Hopital Tenon a Paris; representant 14 pour cent des accouchements du service. Geographiquement ce sont essentiellement des parturientes originaires d'Afrique Francophone; celle de l'Afrique de l'Ouest representent 79 pour cent des accouhees. Les Maliennes au nombre de 309 viennent au premier rang soit 40 pour cent des accouchees africaines et 5 pour cent des accouchements viennent ensuite les Senegalaises (195) puis les Guineennes (38). Les ressortissantes d'Afrique Centrale sont au nombre de 164 soit 2;5 pour cent des accouchees du service. Les Zairoises sont les plus nombreuses 849). L'age moyen des parturientes de cette communaute africaine est de 20 a 23 ans; generalement nullipares. Depuis 1990; il y a une dimunition progressive de la parite a partir de la cinquieme naissance. Le suivi de la grossesse et l'accouchement ne posent pas de problemes majeurs; il n'y a pas non plus une surmortalite par rapport a la population temoin. La mortalite maternelle est nulle. Cependant; les Africaines representent 40 pour cent des seropositives (VIH +) du service; 33 sur 81 recensees; particulierement les Zairoises; 17 sur 31; qui a elles seules atteignent 51 pour cent de seropositives de la communaute obstetricale africaine et 20 pour cent de la maternite. Depuis quelques annees; il y a une tendance a la baisse du taux de cesarienne chez la femme africaine; de 18;8 pour cent en 1981 et 1984 a 5;6 pour cent en 1990 a Corbeil (region parisienne); sans augmentation de la morbidite maternelle ou neonatale; par la reduction des cesariennes systematiques pour bassin retreci ou uterus cicatriciel. Actuellement; le management de la grossesse et de l'accouchement chez la femme africaine pose moins de problemes qu'au debut des annees 1980; du fait de la conjonction des facteurs positifs; entre autre l'integration progressive des populations mais aussi l'effort d'adaptation des equipes obstetricales

[Hysteroscopic cure under ultrasonic control of complex and/or recurrent uterine synechiae]. / Cure hystéroscopique sous contrôle échographique des synéchies utérines complexes et/ou récidivées.

Hysteroscopy now plays a major role in the rapidly changing therapeutic approach to the diagnosis and treatment of uterine synechiae. The fibrous nature of the lesion and its precise localization can be determined. Operative hysteroscopy has greatly benefited from technological progress in optic fibers and instrumentation. It is now possible to control the endocavitary operation with a video-endoscope. In this report, we present preliminary results obtained in 11 patients who underwent echo-controlled hysteroscopic surgical cure of complex and/or recurrent uterine synechiae. The intra-operative echographic control was validated in the operating theatre radiographically. Intra-operative echography allowed hysteroscopic lysis of intrauterine adhesions at a controlled and equivalent distance from the uterine walls. It is thus possible to better treat the uterine cornua since the operator is informed when to limit progression to avoid massive fluid infusion into the abdominal cavity and perforation of the uterus. With this technique we obtained 8 normal cavities with bilateral tube permeability. Normal cycles were achieved in 10 patients. The effect of this newly developed technique on improving fertility cannot yet be established.

[HIV seropositive pregnant women from black Africa seen at the Guy de Lorier maternity unit of Tenon hospital. Report of 33 cases]. / Les femmes enceintes séropositives (VIH+) d'Afrique noire à la maternité Guy le Lorier de l'hôpital Tenon. A propos de 33 dossiers.

There were 5503 deliveries between 1989 and 1991 in the Guy de Lorier Maternity Unit (Pr Salat-Baroux) of Tenon Hospital, Paris. These included 81 women testing HIV+ in the department with 33 asymptomatic black African women among 781 deliveries. Africans account for 14% of women delivered in the department but for 40% of seropositives in the unit, with a predilection for women from Zaïre (central Africa), accounting for 17 seropositives. They only represent 50% of all cases of African HIV+ and 20% of the unit, while they account for only 6% of the black African community and 0.8% of the maternity unit. Women from west Africa accounted for 45.5% of African seropositive cases, with Ivory Coast in first place with 24.3% while only 9% of women from Mali, accounting for 40% of African patients and 5% the units, tested positive (3 cases out of 309 patients). The mean age of seropositive patients was 23 +/- 4, pregnancies proceeded normally and there were 4 therapeutic abortions. There were 9 births by cesarean section, with no evidence of neonatal contamination, the same applying in the other 20 vaginal deliveries. Routine testing (informed consent) for HIV in these high-risk (endemic zone, drug addiction) or unrecognised seropositive patients is important whenever the opportunity presents itself (prenuptial examinations, prenatal visits, family planning, preoperative assessment) in order to attempt to lower infection rates and ensure the best possible care for mother and child when there is a wish to continue the pregnancy, but also to protect hospital staff from the risks to which they may be exposed.

[Endoscopic gynecologic surgery in Africa. Luxury of necessity?]. / Chirurgie endoscopique gynécologique en Afrique. Luxe ou nécessité?

Per- and postoperative mortality remain high in black Africa, with rates of the order of 30 to 40% according to teams. Three essential causes are generally reported: infection, hemorrhage and anesthetic complications. There can be no doubt as to the advantages of celiosurgery over open surgery: low postoperative morbidity, less than 1% serious complications, real savings in treatment costs by shortening of average hospital stay and time off work. Celio-surgery is technology-dependent and operator-dependent. The cost of equipment remains prohibitive and its maintenance delicate and expensive, potentially hampering the implantation and spread of this new technique in Africa, which also lacks specifically trained staff as well as an appropriate technical infrastructure. Nevertheless, the experience of teams in Cameroon and Gabon are encouraging with 110 and 220 patients respectively treated by celio-surgery without complications. A veritable journeyman-apprentice approach is necessary for the learning of these new techniques by teams in developing countries, in several possible ways (locally or abroad), in order that the population as a whole can enjoy the benefits of the reproducible therapeutic and diagnostic advances of new techniques (celio-surgery, MAP, antenatal diagnosis, medical imaging).

[Electro-conization with the diathermic loop. Indications and results]. / L'électroconisation à l'anse diathermique (ECAD). Indications et résultats.

The experiment of electro-conization with diathermic loop was effected on 185 patients. The indications are represented by: a) low grade lesions: 21 cases (11.3%) only when the squamo-columnar junction was into the endocervix; b) CIN 2: 44 cases (23.7%): c) CIN 3: 118 cases (63.7%); d) cyto-histologic discordance: 2 cases. After one year, the following results could be noted: 94.1% of the patients were cured, only 11 out of the 185 presented a recurrence (or persistence). It seemed interesting to us to study the factors which could influence the "in sano" (Free margin)/or not character of the resection. It appeared that the surface of the lesion did not seem to influence its histological result since we got: 83%, 96%, 94.5% and 92.3% of "in sano" conizations to be correlated with a lesion surface equal to 1/4, 2/4, 3/4, 4/4 of the cervical area. The second factor to be studied was the patients' age. So from 15 to 25 years (96%) of the resections were "in sano". There from 26 to 35 (92%), and from 36 to 45 (91.9%). Among post-menopausal women from 46 to 55 years old only 86.4% of electro-conizations were "in sano". Histologic alterations of the histologic specimen were noted in two cases (1%), the interpretation was easy and clear in the other cases. What about the complications? In 2 cases a moderate stenosis was to be noted; in 2 other cases: post-operative hemorragiae which were treated by a selective electro-coagulation.(ABSTRACT TRUNCATED AT 250 WORDS)

The unopened colostomy: a procedure to protect colonic anastomosis.

The results of an alternative to the classic diverting lateral colostomy when used to protect a high risk anastomosis are reported. Fourteen out of 122 patients undergoing colonic or colorectal resection had a restoration of intestinal continuity with a proximal closed loop colostomy--of these 11 did not require opening in the immediate post-operative period. These had an uneventful early post-operative course, and the return of the colostomy to the abdominal cavity was performed within 10 days post-operatively, without having been opened. In three cases where local or general complications occurred, the opening of the colonic loop led to the creation of a conventional temporary protective colostomy. This procedure allowed a reduction of the originally planned number of colostomies by 50%.

[A fetal extraction device used in under-equipped countries: the obstetrical vacuum extractor. Results of 393 vacuum extractions in the Maternity Hospital in Sélestat. (Reflections on the use of this device in African practice)]. / Instrument d'extraction foetale adapté dans les pays sous-équipés: la ventouse obstétricale. Résultats de 393 ventouses à la Maternité de Sélestat (Réflexions sur l'usage de cet instrument en pratique africaine).

The level of mortality and feto-maternal morbidity in under-equipped countries is frightening. It is important to find answers. Among these: the obstetrical Ventouse is an instrument that can be used for extracting the fetus without too much difficulty. It is relatively easy to learn and to apply as compared with forceps (so long as the mechanism by which it is used is understood). The conditions under which it can be used are well defined at present: term pregnancy, the woman must be in labour, fetal membranes must be ruptured, the cervix must be completely dilated, presentation must be cephalic and the head must be engaged. 393 Ventouse extractions were carried out between 1982 and 1988 at the Maternity Hospital of Selastat and this resulted in delivery of 393 infants in good health. No maternal or fetal mortality occurred in the series. The maternal morbidity was low at 0.76% and the fetal morbidity was only 4.7%. In view of our experience, we believe that the tendency for black women to have android pelves makes it preferable to use the Ventouse as against the forceps because it has several advantages. In view of the literature and of their practice, the authors advise that the obstetric Ventouse should be used in under-equipped countries where conditions of practice are often precarious and the team poorly qualified. This will reduce the mortality and morbidity due to delivery. Pregnant women are insufficiently educated. The quality of health personnel is inadequate. The health services are inadequate for the needs of the population.(ABSTRACT TRUNCATED AT 250 WORDS)

[Testicular feminization syndrome. Prenatal diagnosis: observations apropos of 2 sisters]. / Contribution à l'étude du syndrome du testicule féminisant. Diagnostic anténatal: observations à propos de deux soeurs.

The anatomo-clinical aspects and the physiopathology of the feminizing testicle syndrome, are now better known. The prenatal diagnosis of this familial genetic ailment through the determination of the fetal sex by ultrasonography and the study of fetal karyotypes by amniotic fluid analysis or biopsy of trophoblast, is currently possible. Risk groups must be defined in order to ensure a better care for these children.