Embolie amniotique : à propos de l’issue favorable d’un cas avec arrêt cardiaque inaugural et CIVD précoce compliquée d’un hémopéritoine d’origine iatrogène et d’un saignement sur un adénome hépatique

Amniotic fluid embolism is a relatively rare clinical entity and with difficult medical recognition. However, it is the second leading cause of maternal mortality. We report here the case of a 32-year-old patient who underwent elective caesarean section complicated by an amniotic fluid embolism with cardiac arrest. The presence of a major disseminated intravascular coagulation favored the occurrence of a retroperitoneal hematoma of iatrogenic origin on attempt of femoral venous catheterization and that of hemoperitoneum on bleeding of an hepatic adenoma. The diagnostic of amniotic fluid embolism was confirmed by the presence of amniotic cells in the bronchoalveolar lavage. The patient survived without sequelae.     

Spontaneous rupture of uterine vessels during pregnancy, about three cases

Spontaneous rupture of uterine vessels during pregnancy is an exceptional event which remains little known by the gynecologists. Being given its important morbi-mortality, we wanted to make a reminder of this pathology through three cases arisen in the CHU of Grenoble. All patients experienced acute abdominal pain. In two cases out of three, birth followed vaginal delivery. No maternal death was deplored. Fetal prognosis remains poor, as one is dead among our three cases. Clinical signs are sensible but not specific. Early management requires efficient resuscitation then surgical haemostasis, and has to be teatched in order to improve its prognosis.     

Vers une simplification de la technique de césarienne : suture péritonéale ou non ?

Objectives

To assess the postoperative morbidity of a technique for caesarean section without closing the visceral and parietal peritoneum.

Patients and methods

We conducted a prospective cohort study randomized 252 patients over a period of four months (from March 1 to June 30, 2009). We studied the early postoperative morbidity.

Results

Among the 252 patients, 137 were included in the group “with peritonisation” and 115 in the group “without peritonisation”. Clinical and hematology maternal characteristics were comparable in both groups. The duration of intervention was reduced significantly in the absence of peritonisation (31.1 instead of 41.4 minutes; P < 0.001). The postoperative pain was less but not significant between h0 and h12, however it is significant at h18, h24and h30 in the absence of peritonisation (respectively 2.37 versus 2.81; P = 0.030; 1.98 versus 2.37; P < 0.001 and 1.38 versus 1.72; P = 0.018). Resumption of transit was significantly faster “without peritonisation” (24.3 versus 24.7 hours; P < 0.001). However, there is no significant difference between the two groups as regards the immediate postoperative complications.

Conclusion

The absence of visceral and parietal peritoneum shortens the operative time and favors an earlier resumption of transit. It also decreases pain symptoms. We therefore recommend not to suture the parietal and visceral peritoneum during cesarean section.     

Hemoperitoneum due to rupture of an omental arterial aneurysm

We report a case of spontaneous hemoperitoneum due to rupture of an omental arterial aneurysm. This source of bleeding is unusual (2 cases published); the diagnosis was made preoperatively by doppler ultrasound and CT scan with IV contrast. Omental resection was performed and histological analysis confirmed the diagnosis. A literature review of the rare cases of hemoperitoneum due to rupture of a digestive arterial aneurysm is done.     

Suture péritonéale ou non au cours de la césarienne en 2008 ?

Non closure of the peritoneum at cesarean is still debatable, despite the national and international guidelines. This review aims at exposing risks and benefits of non closure of the peritoneum, focusing on the peritoneum adhesions. Many studies demonstrated no benefits at peritoneum closure in the duration of surgery, the immediate postoperative period and the short-term complications. Data about pelvic adhesion risk are more inconsistent. Different criteria were considered in the studies: adhesions incidence and density during subsequent cesareans or pelvic surgeries, duration of surgery and the delay between incision and birth during the subsequent cesarean and fertility known to be impaired by thick-pelvic adhesions. Most of the studies are exhibiting serious bias, leading to weak conclusions. However, two randomised controlled trials compared pelvic adhesion in the subsequent c-section, in step with closure or non closure of the parietal and visceral peritoneum at first caesarean. The results showed that non closure of the peritoneum does not increase or even reduce the adhesions risk. These results are consistent with results from three studies reporting no modification of patient fertility. As a conclusion, current data are supporting the national and international medical society recommendations about the benefits of the non closure of the peritoneum at caesarean section.     

Open pneumoperitoneum for the sake of Quality Assurance

The establishment of a pneumoperitoneum for coelioscopy is a maneuver which may have lethal consequences. The open or Hasson technique involves dissection of the abdominal wall layers and insertion of a blunt trocar under direct vision. The conclusions of a recent study comparing "open" and "blind" trocar insertion recommends that the "open" technique be routinely used as a measure of Quality Assurance. A programmed, standardized approach is the only way to prevent undesired complications. Surgeons often plead that the uniqueness of each patient argues against a rigidly standardized technique. But isn't this argument of patient variability just an alibi to avoid adherence to explicit and proven standards? When it comes to guaranteeing patient safety, shouldn't the demonstration that a technique diminishes risk be considered an adequate level of proof if there is no demonstrated benefit to the more dangerous approach? In laparoscopy, where are the proven benefits which would mitigate the undeniable increased risks of "blind" trocar insertion? Initial trocar insertion for laparoscopy by the "open" technique should be standard practice for reasons of safety. The calculus is simple. Given the innumerable laparoscopic surgeries performed every day, there are patients who die daily as a result of "blind" trocar insertion.