Qui faut-il vacciner contre la coqueluche ?

Whooping-cough is one of the rare diseases for which vaccine prevention has been available for many years. However, in spite of good vaccine coverage in the infant, the pertussis infection remains a frequent disease in the teenagers and adults partially immunized. The missing diagnosis of the infection, added to its often clinical banal expression, contributes to support the circulation of Bordetella pertussis and explains the contamination of the young infants in whom the disease remains a true danger as the few declared deaths show it every year. Control of the disease must go through reinforcement of vaccination as a practitioner of booster vaccine in preadolescents, teenagers and adults. Instituted since 1998 in the French vaccine calendar, the 2nd booster in preadolescence between 11-13 years olds or 5th dose of vaccine is not enough carried out and must be encouraged like the installation of another additional vaccine dose for adults and certain professional categories. The protection of infants too young to have received the 3 doses goes through the vaccination of their entourage, family and socio-professional alike. The new recommendations thus preach to begin vaccination in children from the age of 2 months, a reinforcement of the vaccine boosters in preadolescents, in adults likely to become parents and in the medical and paramedical personnel in contact with very young infants.     

La primiparité est-elle le seul facteur de risque des lésions du sphincter anal en cours d'accouchement ?

OBJECTIVE: Primiparity has been identified as the main risk factor of type 3 and 4 perineal injuries The purpose of our study, according to a population-based observational study, was to identify other clinical risk factors for lesions during vaginal delivery. PATIENTS AND METHODS: Two groups have been compared. Group A or study group (n=63) was defined as parturients with three or four-degree perineal tears. Group B or control group (n=67) included women who delivered vaginally without any perineal lesion during the same period. Characteristics of the population were compared: maternal age, race, maternal weight, BMI (Body Mass Index), parity, mode of anaesthesia, gestational age, post maturity, length of labor, fetal weight, mode of delivery (assisted or not). Specific characteristics were also compared, obesity, shoulder dystocia, type of presentation, episiotomy and dose of ocytocin. RESULTS: Primiparity was significantly associated with higher frequency of sphincter lacerations (71 vs 43%, p=0.001). The patients of group A were with significantly higher weight than the patients of control group (67 vs 63 kg, p=0.036). Futhermore the BMI was different in the two groups (25,6 vs 23,4, p=0.003). There was a significant difference according to the length of the second part of labor (68 vs 48 min, p=0.037) and the posterior variety (32 vs 4%, p<0.001). The occurrence of shoulder dystocia was only just significant (6 vs 0%, p=0.052). Assisted-extraction is highly associated with perineal injuries (44 vs 1%, p<0.001). Futhermore the instrument has been concerned by the difference: Tarnier's forceps-assisted extraction (14 vs 1%, p=0.003), Suzor's forceps-assisted extraction (16 vs 0%, p=0.0005), Thierry's spatula-assisted extraction (14 vs 0%, p=0,0005). The association forceps and episiotomy has been found with higher frequency of perineal injury (43 vs 1%, p<0,0001). There were no difference between the 2 groups according fetal characteristics, type of analgesia, maternal age, gestational age, post-maturity or dose of ocytocin. DISCUSSION AND CONCLUSION: Primiparity is not the only risk factor of perineal injuries. Other risk factors have been found: assisted-extraction, occiput posterior fetal head position, and association episiotomy and assisted-extraction. Black origin seems to be protective.     

Comment informer une patiente qui désire une grossesse après cancer du sein ?

When a former breast cancer patient asks for pregnancy, several questions have to be considered. The physician has to answer and counsel clearly and honestly his/her patient regarding the possibilities, risks and specificities associated with a pregnancy in this case. The individual risk of relapse should be considered, together with individual predictive factors and theoretical benefits of specific prolonged treatments such as hormone therapy. Both risks associated with the pregnancy itself and with the modification of treatment schemes have to be evaluated. Risks related to Assisted reproductive techniques when indicated, should also be considered and explained. Potential foetal risks should be explained too. The aim of this review is to summarize the current knowledge and then available tools that the physician can use to help the couple making decision regarding subsequent pregnancy.     

Anonymat du don de gamètes : protection d'un modèle social ou atteinte aux droits de l'homme ?

The French legislation about gamete donation imposes anonymity between the donor and the demanders, in reference to the principles of protection of the human dignity that are applied in other fields of biomedicine. We are here wondering about this choice: does this obligation really protect the human rights that are one of the ethical bases of law? At the time the French law was written, anonymity in gamete donation was inherited from the practice of the French CECOS but it has now become controversial. Many European countries have opened the access to the genetic origins. There is no evidence for this practice to be an efficient protection of the respect of human body and the disinterested nature of donation. Concerning gametes, it seems that it protects a social object, the parental project, but that it has no influence on the protection of parenthood, filiation, and the concept that humankind is not only biological. At last, we analyse the most important human rights documents to assume the hypothesis that anonymous gamete donation, although not violating the human rights, is an implement for Foucault's biopower, far from protecting the ethical foundations of human dignity.     

L'œdème aigu du poumon chez des patientes en menace d'accouchement prématuré traitées par inhibiteurs calciques : place de facteurs prédisposants ou pharmacologiques spécifiques ?

Calcium channel blockers of the dihydropyridin's family have been associated with the onset of an acute pulmonary edema when they are used as a treatment of preterm labor. We report here four cases of pulmonary edema in pregnant women treated with nicardipine (Loxen) for preterm labor. The physiopathology of pulmonary edema, the pharmacology of calcium channel blockers of dihydropyridin's family and the detailed analysis of our cases and those of the literature make us discuss of the role of these agents and associated population and risk factors in such complication.     

Abdominal radical trachelectomy: Is it safe for IB1 cervical cancer with tumors ≥ 2 cm?

Objectives

As abdominal radical trachelectomy (ART) has become a favored fertility-sparing procedure, the relative contraindication of a tumor ≥ 2 cm in size has been questioned. The aim of the study was to report the surgical and oncological safety of ART for selected patients with cervical cancer ≥ 2 cm in size.

Methods

We conducted a retrospective review of a prospectively maintained database of patients undergoing ART at our institution from 04/2004 to 01/2013. The largest tumor dimension was determined by physical exam, MRI or final pathology. Clinical and pathological data were tabulated. All patients were followed postoperatively.

Results

Of the 133 patients who underwent planned ART, 62 (46.6%) had tumors ≥ 2 cm in size (2–4 cm). Forty-six patients were documented by exam or MRI, while 16 were documented by pathology reports. The mean age was 30.4 years, and 42 patients (67.7%) were nulliparous. Fifty (80.7%) had squamous carcinoma, 7 (11.3%) had adenocarcinoma and 5 (8%) had adenosquamous carcinoma. Due to frozen-section results, 6 patients (9.7%) underwent an immediate hysterectomy. Due to high-risk features on final pathology, 27 patients (43.5%) were treated with adjuvant chemotherapy (n = 20) or chemoradiation (n = 7). In total, 55 (88.7%) of 62 patients with a tumor ≥ 2 cm in size preserved their fertility potential. Among these patients, 35 underwent ART without further adjuvant treatment. At a median follow-up of 30.2 months, there were no recurrences.

Conclusions

Expanding the ART inclusion criteria to cervical cancers ≥ 2 cm in size allows a fertility-sparing procedure in young women who would have otherwise been denied the option with no apparent compromise in oncological outcome. However, this may result in higher rates of conversion to hysterectomy or the need for adjuvant chemotherapy/or chemoradiation.