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.     

Étude observationnelle de la faisabilité et de la morbidité de l’hystérectomie vaginale ambulatoire : à propos de 30 cas

ObjectiveOutpatient surgery is nowadays a major evolution axis of the surgery in France. Outpatient vaginal hysterectomy is possible with the use of electrosurgical bipolar vessel sealing allowing the reduction of operative time and postoperative pain. Our aim was to study the feasibility and morbidity of outpatient vaginal hysterectomy by assessment of postoperative pain and satisfaction.Patients and methodsThirty patients were enrolled in this observational study. All patients underwent an outpatient vaginal hysterectomy with a standardized operative technic. Pain was evaluated by administering a 10 cm visual analogic scale (VAS) at the first and second postoperative days. The total duration of analgesic treatment was noticed. Patient's satisfaction was recorded at the postoperative visit one month after the intervention and by a telephonic interview.ResultsThe mean operative time was 59.3 (25–110) minutes and the mean uterine weight was 170.2 (60–710) grams. No intraoperative complications were reported. Among the thirty patients, 3 (10%) were not discharged the same day. At the first and second postoperative days, the VAS was 4.40 and 4.35 respectively. The mean total duration of analgesic's use was 5 days (3–8 days). Patients were very satisfied of medical care in 36.7% of cases (11/30), satisfied in 53.3% (16/30) and not much satisfied in 10% (3/30). In total, 83.3% (25/30) have agreed to repeat the procedure in the ambulatory sector.Discussion and conclusionOutpatient vaginal hysterectomy seems to be a possible and a safe technique with a high patient's satisfaction in France at the present time.     

Intérêt du sulfate de magnésium dans la prévention de la paralysie cérébrale de l’enfant né prématuré

This review concentrates on best evidence emerging in recent years on cerebral palsy prevention by administration of magnesium sulphate in mothers being at risk of preterm birth before 33–34 weeks’ gestation. It has been shown in the Cochrane database and in three meta-analysis of five randomised trials (Magpie Trial [neuroprotection of the preeclamptic mother], MagNet [neuroprotection/other intent: tocolysis], ACTOMgSO₄ [neuroprotection], PRE-MAG [neuroprotection] and BEAM [neuroprotection]) that prenatal low-dose of magnesium sulphate given to mothers at risk of preterm birth has no severe deleterious effects in mothers and does not increase paediatric mortality in verypreterm infants. Moreover, it has a significant neuroprotective effects on occurrence of cerebral palsy at two years of age (with a 0.69 relative risk and a 95% confidence interval 0.54–0.87) and, in the neuroprotection subgroup, on the combined outcome of pediatric mortality or cerebral palsy (with a 0.85 relative risk and a 95% confidence interval: 0.74–0.98). The number needed to treat (NNT) to prevent one case of cerebral palsy was 63 (95% CI: 39 to 172) and the NNT for an extra survivor free of cerebral palsy in the neuroprotection subgroup was 41 (95% CI: 22 to 357), justifying that magnesium sulphate should be discussed as a stand-alone treatment or as part of a combination treatment.     

La révolution du financement mondial de la santé : pourquoi la santé maternelle a-t-elle raté le train ?

The first decade in the new millennium has seen a significant increase in world health funding. When the summary of the Millennium Development Goals (MDGs) was publicly unveiled in mid-2010, MDG 5 (Maternal Health) revealed the least progress. Did maternal health miss the boat? The Secretary-General of the United Nations (UN) took the opportunity to launch a Global Strategy for Women’s and Children’s Health, also known as the Every Woman Every Child initiative. Has the time of maternal health finally come? Is it possible to turn the tables? It is these questions that the authors of this article will attempt to answer. They will first assess whether maternal health has missed out on the opportunities offered by the increase in world health funding. If this is the case, why? They will then evaluate whether the new initiative will bring about significant changes. In order to do so, they will compare several elements of the approaches used by HIV/AIDS activists with those used by maternal health activists. They suggest that true progress needs international funding. In other words, promises must be turned into firm and reliable commitments. They conclude that the absence of an organisational structure within the current initiative means that a revolution in world maternal health funding is not likely to happen.     

Quelle utilisation de la progestérone pour prévenir la prématurité ?

Widely prescribed in the years 1970–1980 to prolong gestation, progesterone has regained interest after the publication of randomized trials since 10 years. In women at increased risk of preterm birth with a history of preterm delivery or late miscarriage, the use of progesterone, especially intramuscularly may reduce the incidence of spontaneous preterm birth. In contrast, in cases of preterm labor or twin pregnancies, progesterone efficacy to reduce preterm birth has not been demonstrated. In women with asymptomatic midtrimester sonographic short cervix, randomized studies show conflicting results and new studies are necessary before its widespread utilisation.     

Intérêt de la réalisation de recoupes systématiques dans la chirurgie conservatrice du cancer du sein

The quality of surgical margins in lumpectomy are strong criteria to define risk of locoregional recurrence when conservative treatment is undertaken. Intraoperatively, the limits of adequate resection are sometimes difficult to define. This is why some teams propose the realization of systematic cavity margins during the excision of lumpectomy during the same operation. We expose the potential benefits of this type of practice using data from the literature.     

Simulation haute-fidélité et sentiment d’efficacité personnelle. Application à l’évaluation d’un programme de formation à la réanimation du nouveau-né en salle de naissance

This study assesses the evolution of self-efficacy perception of 195 participants in a training program for newborn resuscitation in the delivery room, performed in situ by multi-professional teams, and using high-fidelity simulation. Participation to the program was shown to strongly improve professionals’ self-efficacy perception. This positive effect does not depend on the profession of the participants and remains after 4 months. Participation to such training programs could help improve the practices of professionals in newborn resuscitation situations in the delivery room in the future.     

Hématome infecté du cul-de-sac de Douglas : une complication spécifique de la chirurgie de l’endométriose profonde postérieure du fond vaginal

ObjectiveSurgical management of deep pelvic endometriosis may be responsible for various complications, such as infected pelvic haematic collection of the Douglas pouch. The aim of this study is to describe this unfavourable outcome and to estimate its frequency in the series of women managed by our team.Patients and methodsRetrospective study enrolling 163 women undergoing surgical removal of deep posterior endometriosis involving the vagina, from January 2008 to September 2011. We indentified women presenting with postoperative fever associated with computed tomographic findings suggesting an abscess of the Douglas pouch. Women characteristics, complication's management and outcomes were analysed in each case.ResultsTen patients presented an inflammatory syndrome associated to hypothetical Douglas pouch abscess, revealed 6 days postoperatively on average. All women reported increasing pelvic pain, fever higher than 38.5 °C, increased level of leucocytes and C reactive protein, and liquid collection of the Douglas pouch. Surgical management was carried out in nine women, revealing a pelvic collection of cloudy haematic liquid. Various bacteria were identified in six cases out of nine, suggesting liquid contamination through vagina opening. Postoperative outcome were immediately favourable.Discussion and conclusionInflammatory syndrome associated with infected haematic collection of the Douglas pouch is a postoperative complication of the surgical removal of deep endometriosis involving the posterior vagina. Surgical removal of the haematic collection allows rapid and definitive favourable outcomes.     

Intérêt de l’échelle d’évaluation de la précarité EPICES en obstétrique

ObjectivesTo describe a validated and multifactorial deprivation score to study the relationship between socioeconomic deprivation and perinatal risks.Patients and methodsThe index of deprivation EPICES (Evaluation of Precarity and Inequalities in Health Examination Centers) was used to characterize the deprivation status of 234 women in post-partum in comparison with perinatal morbidity. The cutoff value of 30.7 was the threshold to define deprivation.ResultsTwo hundred and eight patients were included in this retrospective study from whom 48 (23%) had a score of deprivation higher than 30.7. Maternofetal morbidity was more severe in deprived patients.Discussion and conclusionThe current results show that the EPICES score could be a useful obstetrical tool for the identification of deprived women during pregnancy.     

Protocoles de replacement d’embryons congelés : le cycle spontané donne-t-il de bons résultats ?

ObjectiveFrozen embryos’ transfer optimize the pregnancy rates per retrieval. In France, 60% of transfer cycles occur in stimulated cycles. The aim of this study was to evaluate the outcomes of frozen embryo transfers in spontaneous, substituted and stimulated cycle.Patients and methodsThis retrospective study includes patients who are 18–43 years old and had a frozen embryo transfer between 1st January 2008 and 31st December 2008. Three transfer protocols have been used: the spontaneous cycle (group 1), substituted cycle (group 2), and stimulated cycle (group 3). The characteristics of couples, embryonic parameters and data transfer cycles, and their outcomes were evaluated.Result(s)Among the 333 patients, 132 were included in the first group, 24 in the second group and 177 in the third group. After checking the homogeneity of the three groups, we found pregnancy rates (respectively 20.49 vs 13.04% and 11.32%, P = 0.0348), and deliveries (respectively 13.93 vs 8,7 and 6.29%, P = 0.0314), significantly higher in spontaneous cycles.Discussion and conclusionCurrently there is no consensus on the best technique for endometrial preparation for frozen embryo transfer. Our results support transfers in spontaneous cycle for normo-ovulating patients. Natural cycles can achieve good pregnancy rates while minimizing the costs and side effects.