Faut-il conserver l’utérus lors de la cure de prolapsus ? Réflexions à partir des résultats anatomo-pathologiques

ObjectivesTo evaluate the rate of pre-cancerous and cancerous endometrial lesions in hysterectomy during vaginal reconstructive pelvic surgery.Patients and methodsIn this retrospective and continuous study, a vaginal procedure including reconstructive pelvic surgery with vaginal mesh, hysterectomy and adnexectomy was performed in 152 patients between April 2001 and January 2006. An ultrasonography evaluation was done before surgery. A histopathological analysis of uterus, ovaries and tubes was also performed.ResultsIn the analysis of 136 cases, precancerous and cancerous lesions have been diagnosed while ultrasonography or cervical smear were normal: 2 (1.4%) endocervical dysplasia, 1 (0.7%) cervical epidermoid carcinoma, 10 (7.35%) endometrial complex non-atypical hyperplasia, 7 (5.1%) endometrial atypical hyperplasia and 2 (1.4%) endometrioid endometrial carcinoma. There was not any cancerous lesions in tubes or ovaries. At 10 months, mesh exposure was low at 2.9% (four cases).Discussion and conclusionThe important rate of cancerous and precancerous lesions raise the question of hysterectomy or hysteroscopy and endometrial biopsy in case of uterine preservation during a vaginal reconstructive pelvic surgery.     

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.     

Les débuts de l’obstétrique et de la gynécologie à Québec

The history of medicine in Canada started around 1639 with Robert Giffard, Michel Sarrazin, Jean Madry, and François Gaultier, “surgeons-barbers” who transmitted their art through apprenticeship from the early seventeenth century up to the mid-eighteenth century. The first school of medicine was established in Quebec City on January 18, 1819, and was recognized by Parliament in 1845. In 1837, formal teaching in obstetrics and gynaecology was provided at Hôpital de la Marine by Joseph Painchaud.The Faculty of Medicine of Laval University took over the School of Medicine in 1854 with 120 hours of formal teaching in obstetrics in two hospitals: Hôpital de la Marine and Hôpital de la Miséricorde. Progressively, obstetrics and gynaecology teaching was carried out at several hospitals adding Hôtel-Dieu de Québec and, eventually, Hôpitals Saint-Sacrement, Enfant-Jésus, and Saint-François d’Assise. The Department of Obstetrics and Gynaecology was formally recognized within the Faculty of Medicine in 1955.     

Parcours de soins des prématurés: satisfaction et vécu des parents

Objective

To evaluate the satisfaction and experiences of parents, whose premature newborn was hospitalized in a neonatal unit at birth, identify problems, and areas of improvement.

Methods

A self-administered questionnaire was given to parents of infants born before 37 weeks gestation in one of the 28 maternity wards of the Aurore perinatal network and hospitalized in a neonatal unit at birth. The study focused on the satisfaction of parents during the organization of care management, and their experiences were collected remotely. The questionnaire was handed out during consultation in public or private hospitals or private doctors’ offices during the infant’s first year of life, in May and June 2009.

Results

The care management of 204 hospitalized premature infants (70% of the expected number) was evaluated. More than 85% of the parents were “completely” or “rather” satisfied with the medical care their premature newborn received, regardless of which step in the hospitalization process was evaluated. Transferring from one neonatal unit to another was the step with the worst satisfaction score; almost 40% of parents were told less than 48 hours before, or they were not able to choose in 60% of cases. The transfer only brought them closer to home in 54.4% of cases. The experience of this process remained “negative” after hospitalization by 19.1% of parents. There was no relationship between this and gestational age. The absence of transfer to another unit at birth, hospital discharge preparation, follow-up organization, and giving information to the doctor, who will follow up the infant, were factors that contributed significantly to a hospitalization experience perceived as “positive” by the parents.

Conclusion

Efforts to improve the experiences of this course of care in a perinatal network must focus on continuing practices and preparation of each change such as transfer and retransfer, which should involve procedures agreed on between and within institutions. Setting up “developmental care” that is standardized at the network level could be a good start.     

Accouchement à domicile ou à l’hôpital : comparaison des risques à travers une revue de la littérature internationale

ObjectiveTo assess the safety of planned home birth compared to hospital birth, in low-risk pregnancies.MethodAn international literature review was conducted. Mortality, adverse outcomes and medical interventions were compared.ResultsHome birth was not associated with higher mortality rates, but with lower maternal adverse outcomes. Perinatal adverse outcomes are not significantly different at home and in hospital. Medical interventions are more frequent in hospital births.ConclusionHome birth attended by a well-trained midwife is not associated with increased mortality and morbidity rates, but with less medical interventions.     

Comparaison de deux Protocoles de soins pour la Prévention de la Septicémie Néonatale Précoce à Streptocoque du Groupe B

Group B streptococci are a major cause of neonatal sepsis, responsible for significant morbidity and mortality among newborn infants. We compared two intervention strategies: a) intrapartum chemoprophylaxis for patients with high risk factors; b) universal GBS ano-rectal screening early in the third trimester (26–28 weeks) and intrapartum chemoprophylaxis for colonized women with risk factors. Our goal was to assess the feasibility and cost-effectiveness of these prevention strategies and to choose the most appropriate protocol for our medical centre. Although prevention efficacy differs between these two strategies, we consider intrapartum prophylaxis for women with risk factors most appropriate and cost-effective.     

Le parcours complexe de la mise à la nomenclature des nouveaux tests. Exemple du dépistage prénatal non invasif de la trisomie 21

Scientific discoveries related to technological advances can allow the development of new test for diagnostic purposes. If the medical benefits are potentially interesting, the enthusiasm of physicians and patients to diagnostic transfer generate rapid transfer request. However, before routine availability, in vitro diagnostic medical devices must meet several criteria assessed by the French National Agency for Medicines and Health Products Safety. Moreover, before the possibility of reimbursement by the French National Health Insurance Fund, the French National Authority for Health should carry out a medico-economic assessment. Furthermore, the Biomedicine Agency, participates in defining the legal framework, medical guidelines for good practice and activity evaluation. Here, we review these aspects in relation to the trisomy 21 noninvasive prenatal testing.