La consultation préconceptionnelle : nouveau concept ? Effet de mode ? Besoin de santé publique ?

The preconception consultation is the keystone of primary and secondary prevention in obstetrics. It allows one to take stock of the situation either before a first pregnancy or a repeat pregnancy. It is appropriate to arrange that the odds are in favour of the best outcome for the couple and the child. It constitutes a complete medical consultation, either standing alone or incorporated in the woman’s gynaecological follow-up. A pregnancy that is wanted and planned is an achievable dream. The factors that help the couple to provide the best environment for the child include: ensuring vaccinations are up to date, control of a chronic illness, improvement in life style, and assessment of the socioeconomic conditions. Individual and family obstetric and surgical past history may have foreseeable effects on the progress of a pregnancy and delivery. It would be so easy to screen for them before the pregnancy, whereas too often they come to light when a complication arises. The key word in prevention is anticipation.     

Hysterography in the diagnosis of dead and retained human ovum

Hysterography is of great value when there is a presumptive diagnosis of a dead and retained ovum. It is a useful diagnostic procedure up to the fourth or fifth month of pregnancy. It has no complications. The radiopaque image is characteristic: the outer limits in contact with the uterine wall are incomplete and festooned; the inner limits of the shadow resulting from contact of the medium with the dead ovum are irregular in outline. The x-ray examination should not be made unless we are sure that fetal death has taken place because, in cases of gestation with a live embryo, it can easily lead to an abortion.     

Chronic inflammation of the peritoneum and vagina: review of its significance, immunologic pathogenesis, investigation and rationale for treatment

Chronic inflammation is not an infrequent histologic finding in symptomatic gynecologic patients. It is present in 14.6% of peritoneal biopsies in women with chronic pelvic pain in whom no other cause of pain is evident. It is found in almost all vaginal biopsies in noninfected women with dyspareunia and discharge of vaginal mucosal origin. It represents a local immunologically activated inflammatory disorder. When investigations are car ried out as to whether it is a local representation of a systemic disorder, numerous systemic inflammatory and autoimmune disorders are discovered. A study of chronic pain reveals that the immune system is intimately involved in the production, conduction and exacerbation of pain and of its clinicalfeatures, such as hyperalgesia and allodynia. Immune modification using local steroids and disease-modifying antirheumatic drugs, such as hydroxychloroquine, are known to inhibit inflammatory cells and cytokines, such as interleukin-1, interleukin-6 and tumor necrosis factor, which are responsible for pain and tissue damage. These drugs are found to be effective in the treatment of chronic pelvic pain when of an inflammatory nature and for symptomatic chronic inflammation of the vagina.     

Nonerythropoietic roles of erythropoietin in the fetus and neonate

Epo was once regarded as a cytokine with only hematopoietic effects. It is now clear that the distributions of Epo and Epo-R are more widespread in the developing human. Epo-R is widely distributed during early fetal development, leading to speculation that Epo acts in concert with other growth factors to optimize growth and development. Areas in which Epo has important recognized effects are on endothelial cells, and in the developing heart, gastrointestinal tract, and brain. It may also be important in the regulation of vascular growth during the menstrual cycle, and in the stimulation of testosterone production in men. Epo and Epo-R are prominent in the brain during fetal development, leading to speculation that they play an important role in neurodevelopment. There are also promising data regarding rEpo as a possible neuroprotective agent in such conditions as hypoxia, because it decreases programmed cell death induced during such adverse conditions. It is unlikely, however, that rEpo crosses the blood-brain barrier in normal premature infants, and it is not clear whether the CNS effects of rEpo, should it cross the blood-brain barrier, are harmful or beneficial in the setting of a developing brain.     

Magnetic resonance imaging of normal levator ani anatomy and function

OBJECTIVE: To evaluate the anatomy and function of the levator ani in normal women by dynamic magnetic resonance imaging. METHODS: Twelve asymptomatic, nulliparous, premenopausal women with no previous pelvic surgery underwent a dynamic magnetic resonance imaging scan of their pelvis. The origin, orientation, thickness, and function of the two components of the levator ani were studied. RESULTS: The ileococcygeus is a thin muscle with an upward convexity. It slopes forward and medially. It is of variable thickness (mean thickness 2.9 mm, standard deviation 0.8 mm). There are apparent gaps in the muscle diaphragm and at its site of origin from the obturator fascia. The puborectalis is a thicker muscle. It is shaped like a belt encasing the pelvic organs. It is taller posteriorly than anteriorly. It is not attached to the bladder neck, but the midurethra and lower urethra lie in close proximity to it. The puborectalis moves dorsoventrally, whereas the ileococcygeus moves craniocaudally. CONCLUSION: The levator ani is not a single muscle but has two functional components that vary in thickness, origin, and function. The ileococcygeus has a mainly supportive function, whereas the puborectalis has a sphincteric function. Gaps in the diaphragmatic portion of the ileococcygeus are a normal finding. Individual components of the levator ani may be prone to different types of childbirth trauma and should therefore be assessed separately when planning rehabilitation.     

An adaptive on-line method for the extraction of the complete fetal electrocardiogram from cutaneous multilead recordings

The detection of a fetal electrocardiogram (FECG) is described to be a so-called inverse problem. A geometric interpretation of such a problem is presented. It can be solved by determining the weights to be used in one or more weighted sums of measurement signals. A novel method is presented to determine these weights. Theoretical and experimental evidence is given that this method has the following attractive properties. Application of the method results in one or more FECG signals, free of maternal ECG (MECG) which are at the same time maximal with respect to noise. It is shown that one FECG signal does not always suffice to describe the observed electrical heart activity in a set of cutaneous electrodes, equivalently to the adult ECG (see figure 7). It is explained and experimentally verified that the application of three thoracic signals is useful to guarantee the suppression of the MECG. The positions of the abdominal electrodes then determine the obtained FECG to noise ratio, and will have no influence on the degree of MECG suppression (see figure 6). It is expected that a total of about eight measurement signals are sufficient in most cases. The method is simple to apply by medical personnel, and after a transient of about 1 s the signals with the mentioned properties are obtained (see figure 5). Further on, the weights are allowed to change in order to adapt automatically to sudden changes in the measurement signal properties (see figure 6). These may occur e. g. due to fetal movement. Application of the method requires no human interpretation or decision in order to obtain the claimed properties.     

Immunological aspects of preeclampsia

Pre-eclampsia is a common obstetric syndrome affecting about 7-10% of pregnant women. Symptoms of this syndrome: hypertension and impaired renal function appear during the second or third trimester of pregnancy. Despite intensive efforts to find mechanisms and markers induced pre-eclampsia, no specific etiological factor has been identified until now. It is known that pre-eclampsia is a placental disorder developing in two stages. The first lies in the poor placentation with acute atheroma. It seems that abnormal cell adhesion molecule (integrin) expression can contribute to inappropriate invasion of trophoblasts. Furthermore, T helper 1 type cytokines which are present in decidua of patients with pre-eclampsia can alter the trophoblast invasion. Lower expression level of HLA-G molecule in pre-eclamptic placenta can influence on the profile of cytokines which are produced in pre-eclampsia. The second stage of the disease development comprises the consequences of placental ischemia. It has been suggested that TNF-alpha is produced by ischemic placenta and causes endothelial activation. It seems that some types of pre-eclampsia can be autoimmune origin, with the autoantibodies directed against phospholipids, laminin and endothelium. The events leading to pre-eclampsia are not known, but it seems that abnormal activation of the immune system may play a role in the etiology of this disorder.     

Fetal renal anomalies and genetic syndromes.

Renal abnormalities are some of the commonest and most easily detectable anomalies on ultrasound. Many are an isolated finding but the prognosis may be altered considerably by the detection of other anomalies which could indicate a genetic disorder or syndrome. It is often easier to detect presupposed anomalies and the purpose of this article is to introduce and discuss those syndromes that may present with a renal abnormality on ultrasound. Common renal findings are presented with the range of additional anomalies that should be sought and suggested diagnostic tests. It should be remembered that although for many genetic conditions specific mutation analysis is now available, this usually requires pre-pregnancy investigations. Furthermore, in some cases the definitive diagnosis may not be suspected until post mortem. By this time it may be too late to establish a cell line to confirm the suspicion using laboratory methods. It is therefore important to take tissue samples antenatally where possible, or at delivery, as postnatal samples may have a high culture failure rate.     

Embryocidal action of a bis(dichloroacetyl)-diamine: an oral abortifacient for rats

It is demonstrated that for rats N,N'-bis(dischloroacetyl)-1,8-octamethylenediamine (Win 18,446) is a highly efficient embryocidal N,N'-bis(dichloroacetyl)-1,8-octamethylenediamine It was previously used to supress spermatogenesis in man and other mammals. In the initial rat studies, a fixed dosage of Win 18,446 was administered daily from Day 3 to Day 21. With dosages equal to or greater than 100 mg per day all the implants are resorbed although the implantation sites are clearly visible. At a dose of 50 mg per day 90% of the embryos are resorbed; the remainder being alive but deformed. It was determined that although the drug is most effective when administered at Days 10 through 11, a longer schedule that includes these 2 days is not harmful to the mother. The optimal dosage is 200 mg. A mechanism is proposed involving mitochondrial function and replication to explain the action of this drug in the inhibition of embryonic development as well as the suppression of spermatogenesis.     

Female sterilization: an update.

Female sterilization is the most popular form of birth control in the world. It is performed laparoscopically or through a minilap, depending on the timing (postpartum) and where the patient lives. It is a safe and efficacious procedure with few complications that can be performed under local or general anaesthesia. The techniques presently in use are all adequate and the choice should evolve from a discussion between the doctor and the patient.     

Sexual differentiation of the human midtrimester brain

It is firmly believed that sexual differentiation of the brain is linked with external genital differentiation in timing as an in utero event in the human. An extensive search for oestrogen, androgen and progestin receptors failed to show their presence despite adequate controls in cytosols from human fetal brain of gestational ages 14-20 weeks. It is possible that the receptors are present in levels so low that they are undetectable by present-day methods. Our results would indicate that hormonally influenced in utero brain sexual differentiation is most unlikely to occur as a mid-trimester event.     

Experiences with tocolysis

The results of tocolysis applied for delaying premature delivery and abortion is reported as well as its side effects in the mother. 168 patients were included in the study. It is stated that fenoterol can be successfully administered for stopping early contractions. The side effects of the drug are relatively mild and avoidable. It is also stated that fenoterol treatment is not superfluous even in case of a ruptured membrane when the fetal lungs are not ripe yet. Looking for combined possibilities should be the subject of future studies.     

Hémodynamique fœtale. Physiologie et mécanisme d’adaptation

The cardiovascular system is functional since eight weeks gestational age. The fetal circulation is very particular by some anatomic and hemodynamic elements. It is marked by an immaturity, particularly for myocardium. An in-depth knowledge of this circulation allows a better understanding when there are anatomic or functional anomalies. The capacities of adaptation are possible, but limited. It is particularly vascular redistribution. The fundamental studies are already old with animal’s model, but the progress of ultrasonic method allows today a veritable clinical approach.     

子宫颈小细胞癌10例临床与预后分析

目的 :研究子宫颈小细胞癌 (SCCC)的临床病理、生物学行为特征及预后 ,探讨其治疗方法。方法 :回顾性分析 10例SCCC患者的临床病理资料及随访记录。结果 :SCCCⅠb期 2例、Ⅱa期 4例、Ⅲb期 4例 ,SCCC早期即可发生盆腔淋巴结转移 ,并很容易转移至肺、肝等器官 ;对 10例患者采用手术 +放疗 +化疗或放疗 +化疗的综合治疗 ,5例分别已存活 37、2 7、16、10、9个月 ,另 5例分别存活 10、10、11、13、14个月后死亡。结论 :SCCC与肺小细胞癌的组织病理学和生物学行为特征相似 ,早期容易发生盆腔淋巴结转移和远处转移 ,对化学治疗比较敏感 ,早期患者应行子宫广泛性切除术 +盆腔淋巴结清扫术 ,术后给予辅助性放疗和化疗 ;晚期患者应采用放疗 +化疗。化疗目的在于预防或治疗远处转移性病变     

Catamenial pneumothorax

Catamenial pneumothorax (CP) is a specific type of secondary spontaneous pneumothorax. It is characterized by a temporal relationship with menses. CP is considered to be the most frequent symptom of thoracic endometriosis. It occurs mainly in women above 30 years of age and is typically right sided. The authors reviewed the current literature on this entity. The hypotheses on its pathogenesis and the diagnostic possibilities and therapeutic options are discussed.     

Spare embryos: 3000 reasons to rethink the significance of genetic relatedness

IVF laws in Victoria, Australia provide that human embryos must not remain in storage in excess of 5 years. Studies reviewing the fate of surplus human embryos reveal that close to 90% of couples choose to discard their excess embryos and that hundreds of embryos are disposed of annually. It has been argued that human embryos are a valuable resource and that there is a need to consider educational programmes to encourage couples to donate spare embryos to other infertile couples, rather than discard them. Surveys show that one reason that so few embryos are donated is that couples attach great significance to genetic parenthood. Advances in reproductive technology may necessitate a review of biological definitions of family and the importance of genetic relatedness. It can be argued that it is unreasonable to conclude that genetic ties are so significant that embryos should be discarded rather than donated and raised by non-genetically related parents. It is suggested that education programmes should encourage reflection on people's beliefs about the importance of genetic relatedness with regard to what makes a family. Open embryo donation or directed embryo donation programmes might cause couples to change their minds, or alleviate their anxiety about donating embryos to others.     

Prevention and treatment of preterm labor in twins

It is well established that mothers with twin gestations are at a significant risk of giving birth to a premature infant and, compared to singletons, the perinatal mortality and morbidity are significantly increased. Unfortunately, it is clear that little progress has been made over the past two decades in either the prevention or the treatment of premature labor in twins. The clinician is left with more questions than answers. This latter aspect needs to be recognized by the legal profession. Obviously, more studies regarding the possible beneficial effect of either bedrest or prophylactic beta-sympathomimetics are needed before meaningful recommendations can be made on a universal basis. It is also obvious that more potent tocolytic agents are needed to actually treat premature labor once it occurs. Taking all of these facts into consideration, the authors would recommend the protocol outlined in Table 3 for the general management of twins with regard to premature labor.     

Histamine receptors in the female reproductive system. Part I. Role of the mast cells and histamine in female reproductive system

Histamine isolated from many different tissues, acts via three types of histamine receptors: H1, H2 and H3. In peripheral tissues histamine is mainly stored in mast cells (MC). Presence of mast cells was proved also in mammals' uteri. In human uterus the majority of mast cells are located close to smooth muscle cells. It might indicate that MC plays a role in tissue remodelling during the menstrual cycle. The quantity and activity of mast cells is in connection with hormonal status of the organism. Although there are some differences, human uterine mast cells are similar to the mast cells isolated from other tissues. It is suggested that histamine is important for normal ovulation, blastocyst implantation, placental blood flow regulation, lactation and contractile activity of uterus. Histamine may also play a role in pathological processes such as pre-eclampsia or preterm delivery. The participation of mast cells and histamine in blastocyst implantation is very controversial. In W/Wv mice (without mast cells) normal implantation was observed. It denies the main role of mast cells in this process but dos not exclude histamine action. In mice the major source of histamine are uterine epithelial cells during early pregnancy. The influence of cytokines on blastocyst implantation and the role of histamine in cytokines release from the uterine mast cells are also very unclear.     

PCOS: diagnosis and management of related infertility

Polycystic ovarian syndrome (PCOS) is one of the most common endocrine disorders in women of reproductive age. It is characterised by a combination of hyperandrogenism (either clinical or biochemical), chronic oligo/anovulation, and polycystic ovaries. It is frequently associated with insulin resistance and obesity. PCOS receives considerable attention because of its high prevalence and possible reproductive, metabolic, and cardiovascular consequences. It is the most common cause of anovulatory infertility. Ovulation induction with an aromatase inhibitor or anti-oestrogen is the first-line medical treatment. The aim of ovulation induction is monofollicular growth to avoid multiple pregnancy. The second-line treatments include gonadotrophins and laparoscopic ovarian drilling. The role and benefit of metformin in ovulation induction is uncertain. Woman with PCOS undergoing IVF are at significant risk of ovarian hyperstimulation syndrome. Women with PCOS are also at an increased risk of developing gestational diabetes, pregnancy-induced hypertension, and pre-eclampsia.     

A simple geometric flap for the closure of skin defects.

The Limberg flap is a useful method of closing defects anywhere on the body which are too large for simple closure but where skin grafting is not desirable. It is an easy flap to perform, and it is reliable and safe to use. It must not, however, be used indiscriminately or by rote. Care must be taken in planning both the excision and the flap so that the points which must move farthest are placed where the skin is maximally extensible. With such planning, accurate and precise designing and careful surgical technique, the Limberg flap can be used successfully to solve a number of otherwise extremely difficult problems.