Le suivi échographique de la deuxième partie du travail

In the second stage of labor, fetal head rotation and fetal head position are determinant for the management of labor to attempt a vaginal delivery or a cesarean section. However, digital examination is highly subjective. Nowadays, delivery rooms are often equipped with compact and high performance ultrasound systems. The clinical examination can be easily completed by quantified and reproducible methods. Transabdominal ultrasonography is a well-known and efficient way to determine the fetal head position. Nevertheless, ultrasound approach to assess fetal head descent is less widespread. We can use translabial or transperineal way to evaluate fetal head position. We describe precisely two different types of methods: the linear methods (3 different types) and the angles of progression (4 different types of measurement). Among all those methods, the main pelvic landmarks are the symphysis pubis and the fetal skull. The angle of progression appears promising but the assessment was restricted to occipitoanterior fetal position cases. In the coming years, ultrasound will likely play a greater role in the management of labor.     

Efficacité de la programmation des cycles FIV en antagonistes par les estrogènes

ObjectiveAssess the efficiency of estradiol programming in In Vitro Fertilization (IVF) with antagonists by comparing with classical long luteal agonist protocol.Patients and methodsIt is a prospective randomized study, comparing 426 cycles in the arm estradiol antagonist with 412 cycles in the arm long agonist. Estradiol 4 mg/day begins on the 25th day of the previous cycle and continues during the menses until the first day of the stimulation which is from Thursday to Sunday whatever the beginning of the menses. The luteal protocol use Decapeptyl^® 0,1 mg which begins on the 20th day of the previous cycle.ResultsOur two populations are similar. No pick-up has been done on Sunday. We have got significantly less oocytes and embryos in estradiol-antagonist (6,8 ± 5,3 vs 7,6 ± 5,7) and (3,7 ± 3,2 vs 4,1 ± 3,6) respectively. The ongoing pregnancy rate is comparable in the two groups: 28,6 % for estradiol antagonist 27,9 % for agonist for the whole population and 37 % vs 34,8 % respectively when at least one top embryo was transferred.Discussion and conclusionProgramming antagonist cycles with estradiol allows the organization of the center; it is easy to implement and seems to give results as good as a long agonist protocol.     

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.     

Hémopéritoine exceptionnel du troisième trimestre de la grossesse

We report a case of spontaneous break of the wide ligament revealed by an abdominal pelvic painful syndrome of rough appearance in 36 weeks + 2 days with an acute foetal suffering and an important hemoperitoneal to a primigeste of 32 years. The laparotomy explorer allowed to make the diagnosis but the foetal forecast was dramatic. The foetal extraction has to be made as a matter of urgency and at the same time that the vascular haemostasis.     

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.     

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 la proximité mère-bébé sur le sommeil du nouveau-né et celui de sa mère, et sur l’allaitement. Quelle proximité recommander sans mettre en danger la sécurité de l’enfant ?

Newborn babies show moreslow-wavesleep and wake periods (and breastfeeds) when close to their mothers. Newborns sleeping in close proximity to their mothers (bedding-in) facilitates frequent feeding in comparison with rooming-in. After six weeks, the rates of exclusive breastfeeding (and any kind of feeding) are two times more. The lactant mother has modified Sleep-wake patterns and diurnal vigilance, and the mother can wake up instantly at any moment. Mother-baby closeness helps breastfeeding, which helps mother’s sleep. With regard to the current recommendations in France, it seems necessary and possible to adopt a higher closeness between the mother and the newborn. A lot of studies on factors of risk for unexpected infant deaths did not neither differentiate groups according to the place of cosleeping (bed, sofa or other) nor the type of feeding (breastfeeding or other), thus leading to recommendations not always adapted to the needs of breastfed infants and their parents. Familial counselling allows to deliver adapted information to answer the mother’s resting needs as well as the infant’s closeness needs, without endangering the baby’s security, whether in the hospital or at home.     

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.