Comparaison de l’hospitalisation à domicile et de l’hospitalisation conventionnelle dans la prise en charge des ruptures prématurées des membranes

Objective

Premature prelabour rupture of membrane (PPROM) is associated with an increased risk for both mother and fetus. Expectant management is usually advised under hospital supervision. Home care is associated with reduced cost. However, its safety in PPROM management has not been well established. Our objective was to assess neonatal and maternal outcome in pregnancies complicated by PPROM comparing home care to in-hospital management.

Study design

Retrospective study in two tertiary centers over a two-year period between January 2009 and December 2010. We included all singleton pregnancies with a history of PPROM which occured between 24 and 35 weeks of gestation. We compared women with PPROM and in-hospital management in Center 1 (Group 1; N = 42) to women with PPROM and a home care after a short period of observation in Center 2 (Group 2; N = 32), and. We studied gestational age at delivery, pregnancy complications, mode of delivery and neonatal outcome.

Results

Demographic characteristics were similar at onset of PPROM between the two groups.Women in group 2 delivered later than in group 1 (234.8 ± 19.54 days vs 224.6 ± 22.02 days; P = 0.04). There was no difference between the groups in pregnancy complications including chorioamnionitis, delivery issue and neonatal outcome. The length of stay in neonatal intensive care unit was higher in group 1 compared to group 2 (N = 43.51 ± 2.67 days for group 1 vs. N = 24.21 ± 2.72 days for group 2; P = 0.0003).

Conclusion

Home care appears to be a safe option for women with PPROM between 24 and 35 weeks with stable condition. These preliminary findings suggest performing a randomized control trial with a higher number of women, including further data such as assessment of maternal satisfaction and cost analysis.     

Recommandations pour la prise en charge du cancer de l’ovaire pendant la grossesse

Evaluation of the fetus using prenatal ultrasound has resulted in increased detection of asymptomatic adnexal masses during pregnancy. Such masses are rarely malignant (1/10 000 to 1/50 000 pregnancies), but the possibility of borderline or cancer must be considered. It is a common assumption by both patients and physicians that if an ovarian cancer is diagnosed during pregnancy, treatment necessitates sacrificing the well-being of the fetus. However, in most cases, it is possible to offer appropriate treatment to the mother without placing the fetus at serious risk.The care of a pregnant woman with cancer involves evaluation of sometimes competing maternal and fetal risks and benefits. These recommendation approaches attempt to balance these risks and benefits; however, they should be considered advisory and should not replace specific interdisciplinary consultation with specialists in maternal-fetal medicine, gynecologic oncology, and pediatrics, as well as imaging and pathology, as needed.Second level ultrasound including Doppler is needed. MRI is not often necessary, and CA 125 is of low contribution. We suggest surgery be performed after 15 SA for ovarian masses which (1) persist into the second trimester, (2) are greater than 5 to 10 cm in diameter, or (3) have solid or mixed solid and cystic ultrasound characteristics. During antepartum surgical staging and debulking, homolateral salpingo-oophorectomy and peritoneal cytology and exploration are necessary. Women found to have advanced stage epithelial ovarian cancer should consider having completion of the debulking of the reproductive organs at the conclusion of the pregnancy. If chemotherapy is indicated, we recommend delaying administration, if possible, after the delivery or at least after 20 SA in order to minimize the potential fetal toxicity.     

Impact de la parole des parents sur les pratiques professionnelles,l’expérience de l’association Petite Émilie (Association pour les personnes confrontées à une interruption médicale de grossesse et à un deuil périnatal)

The association Petite Émilie was founded in 2003 to provide support for the parents who have experienced the same trauma. Gradually, the group welcomed more and more members, joined by professionals who heard parents’ words and their needs. A booklet was written, through this invaluable collaboration between parents and professionals (midwives, obstetricians, psychologists…), to open the dialogue between teams and families. Collaboration between parents and professionals with listening from/to each other made it possible to make the needs of the parents heard by the professionals, so that they consider their practices in order to try to adapt them.     

Faisabilité, morbidité et survie de la chirurgie avec CHIP dans la prise en charge des récidives du cancer de l’ovaire

ObjectiveThe management of recurrent ovarian cancer is based on intravenous chemotherapy with or without debulking surgery. The hyperthermic intraperitoneal chemotherapy (HIPEC) is sometimes proposed as a complement to complete surgery. The purpose of this study was to evaluate the feasibility, morbidity and survival of HIPEC associated with complete surgical cytoreduction in the management of patients with a first recurrence of ovarian cancer.Patients and methodsBetween 2005 and 2010, 27 patients underwent surgery for a recurrence of ovarian cancer. Among them, 17 patients (63%) have received HIPEC.ResultsSixteen patients (94%) were completely resected after surgery. No patient died postoperatively. Two patients had intraoperative complications: a bladder injury and a section of the ureter. Eight patients had postoperative complications including 3 grade 3 or higher (two organ failure and one reoperation). Fifteen patients had a recurrence with a median DFS of 11.9 months (95% CI [5.4–32.9]) from the HIPEC. The median overall survival from diagnosis was 107.8 months.Discussion and conclusionThese results showed that the association of HIPEC with a complete cytoreduction for recurrent ovarian cancer presents acceptable morbidity and survival. The results of the ongoing French multicenter study (CHIPOR) are expected to generalize this support.     

Influence de l’indice de masse corporelle sur la prise en charge et le pronostic des patientes avec carcinome endométrial

ObjectiveThe aim of this study was to evaluate the outcome of surgery, postoperative morbidity and prognosis of patients with endometrial cancer in function of the body mass index (BMI).Patients and methodsThe study cohort consisted of consecutive women undergoing surgery for endometrial cancer in our institution between January 2000, and September 2012. Individual records of all patients were reviewed and analyzed. Patient BMI was categorized as underweight, normal, overweight and obese.ResultsA total of 192 patients were evaluated. Patients were followed for one to 153 months with a mean of 52.56 months. The mean BMI and the range of each of the BMI categories were 16.97 kg/m² (14–18), 22.97 kg/m² (20–24.9), 27.61 kg/m² (25.7–29.4), 37.34 kg/m² (30–71). Women with higher BMI were more frequently affected by hypertension (8.3%, 31.43%, 58.13% and 59.7% respectively, P < 0.0001) and diabetes (16.67%, 4.3%, 13.9% and 29.85% respectively, P = 0.02). Women with normal BMI had more frequently postmenopausal replacement therapy than the other categories (P = 0.0004). Surgical operative time, mean length of hospitalization in days were not significantly different among the 4 groups. In the obese group there were significantly higher peroperative blood loss (P = 0.01), more wound abces (P = 0.05), more eventration (P = 0.02) and more reinterventions for complications (P = 0.03). Patients had the same protocols of treatment (surgery and adjuvant treatment) and histological characteristics were the same between groups but obese patients had much less positive lymph nodes (P = 0.03). There were no statistically significant difference in overall 5-years survival between groups (P = 0.54)Discussion and conclusionsOur study demonstrate a survival equivalency for obese and non-obese women even though obese women showed less positive lymph nodes.     

Impact de la prise en charge thérapeutique sur la survie chez les femmes très âgées avec cancer de l’endomètre

ObjectivesWe aimed to determine whether patients characteristics, clinicopathologic features and survival rates were worse in elderly women with endometrial cancer.Patients and methodsThe study cohort consisted of consecutive women undergoing surgery for endometrial cancer in our institution from January 2000 to October 2011. Patients were divided by age into two groups: patients aged 65 to 79 and those aged 80 or older. Clinical data included comorbidities, BMI (kg/m²), surgical procedures, surgical International Federation of Gynecology and Obstetrics (FIGO) stage, histological grade, relevant prognostic factors, occurrence of perioperative complications, adjuvant therapies, overall survival and long term disease specific mortality.ResultsAs expected, elderly women had more major comorbidities and were less likely to undergo optimal surgery, FIGO stages, histological grades. The 5-year disease specific survival was significantly poorer for the older group compared to younger women 64.5% 95%CI [54.3–73.8] vs 83.49% 95%CI [74.7–90.2] P = 0.008. Cancer-specific mortality was also higher in the elderly: 100% vs 41.17% (P = 0.005).Discussion and conclusionOldest patients with newly diagnosed endometrial cancer were found to have worse overall survival and higher cancer-specific mortality than younger patients because of less aggressive care. Clinical efforts must be managed toward the oldest patients with an early stage of endometrial cancer to maximize the therapeutic ratio, in particular surgical.     

Étude des aspects psychologiques des fausses couches à répétition à l’aide d’un questionnaire de personnalité approfondi : le MMPI-2

ObjectivesTry to analyse the experience of couples undergoing repeated miscarriages by answering the following questions: what can we learn from these men and women who suffered from repeated miscarriages?Patients and methodsA thorough personality questionnaire, the MMPI-2, presented to 50 couples who have had repeated miscarriages.ResultsThrough a hierarchical classification, different profiles appear in the men's group as well as in the women's group, revealing a somatization of psychological suffering. It is also revealing acute defensive personality profiles showing restricted affects in a lot of these men whose partners have suffered from multiple procreation failures. Such a narrower range of emotions can be a cause of additional pain for their partner and for themselves.Discussion and conclusionWe can therefore establish that, in these circumstances, the medical and/or psychological treatment should include both couple members to improve the marital adjustment and ease the couple towards another pregnancy which is always apprehended with the fear of another failure. A few etiological hypothesis may be evoked.     

Le blessé médullaire : quel sperme et quelle prise en charge en Assistance médicale à la procréation ?

Men with spinal cord injury present a unique infertile population. Only 10 % of them can father children without medical assistance, owing to potential impairments in erection, ejaculation and semen quality. The algorithm typically followed is to retrieve semen by Penile Vibratory Stimulation, in case of failure by Electro Ejaculation. Most of these patients have normal sperm concentrations but abnormally low sperm motility and vitality in the ejaculate. The reasons for poor semen quality in spinal cord injured men are reviewed. If semen cannot be obtained by Electro Ejaculation, or if the ejaculate from Penile Vibratory Stimulation or Electro Ejaculation contains an insufficient quantity or quality of sperm for in vitro fertilization with intracytoplasmic sperm injection, then retrieval of sperm from reproductive tissues is attempted. Despite abnormal semen quality, successful pregnancies with sperm from spinal cord injured male partners have occurred by intravaginal insemination, intrauterine insemination, and in vitro fertilization with intracytoplasmic sperm injection. The prevailing pregnancy and fecundity rates in couples with a spinal cord injured male partner are reviewed.