[Supplementation in cases of pathological pregnancies].
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Biomedical subjects
Publications and source records attributed to G Boog.
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OBJECTIVE: Evaluate of fetal and neonatal risk in cases of maternal varicella or zona. METHODS: A review of the literature of varicella occurring during pregnancy, including a series of 1,373 cases reported by Enders. RESULTS: The role of prenatal diagnosis is discussed as a function of fetal risk, which is dependent on gestational age at the time of varicella infection.
In order to assess the perinatal health policy in a French department in comparison with other policies, we performed a prospective transversal survey in the Loire-Atlantique for 5 weeks. Newborns were registered according to clinical data using the Paris pediatricians classification (classes 1 to 4) and maternity wards by number of health personnel and facilities using the American Academy of Pediatrician classification (I-III). 1316 newborns were registered. This survey showed that the health care organization in maternity wards is rational in the Loire-Atlantique for newborns in classes 1 and 4. However, care for newborns in classes 2 and 3 could be provided in maternity wards in classes II and III if available personnel and equipment is improved.
OBJECTIVE: Primary antiphospholipid syndrome (APS) is by definition associated with high obstetric risk. We performed a retrospective study of pregnancies in women with this syndrome in an attempt to define a common means of caring these patients. STUDY DESIGN: Women with APS followed in Internal Medicine Department and in Gynecology Department since 1989 were studied retrospectively. RESULTS: Fifteen women with primary APS had a total of 51 pregnancies, 39 (76%) of which ended in embryonic (n = 24) or fetal (n = 15) loss. Only 6/39 untreated pregnancies led to a live birth, including 2 cases of intrauterine growth retardation. Among the 12 pregnancies treated preventively for obstetric complications, 6 led to a live birth. The treatments used were dissimilar and included aspirin, corticosteroids and heparin, either alone or in association. Four of these 6 live births were obtained by aspirin alone. Gravidic toxemia was observed in one untreated patient. CONCLUSION: The obstetric prognosis for untreated APS is appalling. The benefit of heparin therapy in association with aspirin remains to be demonstrated, ideally in a protocol comparing aspirin alone with aspirin and heparin.
Appropriate management of fetal malformations needs confirmation by a tertiary center and search for associated abnormalities and further investigations oriented to causal and prognostic factors. Therapeutic decisions are taken by a multidisciplinary term: pregnancy termination, maternal transfer to a tertiary center, premature delivery or cesarean extraction. Some malformations require immediate surgical treatments, others can be followed up and later corrected. Intrauterine treatments are nowadays evaluated, such as chronic derivations, operative fetoscopy or open fetal surgery. In case of fetal death, a post mortem examination must be performed in order to improve genetic counseling.
Carbon dioxide laser conisation is a very reliable surgical technique for cervical intraepithelial dysplasia. As cervical morphology and function are better preserved than with other techniques, obstetrical morbidity should be lower in the often young and pauciparous women who undergo this procedure. In our study comparing the course of 71 pregnancies (55 children) in 54 operated women with that of 82 pregnancies (59 children) in these same women before conisation, the rates for complications at the beginning of pregnancy were similar (respectively, 14.1% and 13.4%, early spontaneous abortions; 2.8% and 2.4%, extrauterine pregnancies; and no late spontaneous abortions). The increased risks of premature delivery (13.2% vs. 8.5%), chorioamnionitis (1.9% vs. 0%), premature rupture of membranes (1.9% vs. 0%) and prematurity (11.3% vs. 1.7%) were not statistically significant. Only the percentage of natural term births was significantly reduced (73.6% vs. 90%; P = 0.025), but this difference was no longer apparent after correction for the prevalence of associated obstetrical pathologies and prematurity and/or cesarean factors which was significantly greater for the 53 pregnancies that developed after carbon dioxide laser conisation.
Using the "Polymerase Chain Reaction-Sequence Specific Oligoprobes" (PCR-SSOp) technique, we studied the HLA-DPB locus in both partners of 59 couples with a history of three spontaneous abortions, and of 38 control couples in order to determine the role of this centromeric region of the major histocompatibility complex (MHC) in the immune reaction needed for a favorable course of pregnancy. As no particular phenotypes were noted, and also neither excessive HLA-DP homozygosity in sterile women nor excessive HLA-DP allele sharing between sterile partners, this MHC class II sub-region would seem to play no role either directly or by linkage disequilibrium, in the development of normal pregnancy.
Isolated malignant non Hodgkin lymphomas (MNHL) of uterine cervix are rare, and the therapeutic strategy is not always clearly established. The authors report a case of a 78-years-old woman presenting a MNHL FIGO stage IIB and Ann Arbor stage IE. Extention evaluation was negative. The histologic and immunohistochemical examination revealed a centroblastic lymphoma type G in the Working Formulation (WF). The patient was successfully treated by surgery followed with combination chemotherapy and external radiation therapy. Intermediate grade primary MNHL of the uterine cervix are the most frequent. The opportunity of surgery is discussed because lymphoma is a general disease with blood dissemination. We propose a therapeutic strategy according to patient age and the wishes for pregnancy. The young woman could undergo polychemotherapy, perimenopausal woman a combination of chemotherapy and radiation therapy, and post-menopausal woman surgery followed by external radiation therapy.
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Axillary lymph node dissection, which is now mandatory in the conservative breast cancer surgery and classically involves Berg's two lower levels, is burdened with numerous complications. In 1988 and 1989, two technical modifications were introduced and are described here: padding of the axilla as preventive treatment of postoperative lymphocele and, more recently, functional axillary lymphadenectomy (FAL) in which the medial cutaneous nerve of the arm, the two perforating intercostal nerves and above all the lateral thoracic pedicle (external mammary artery and vein) are spared. These two technical innovations, more respectful of anatomy, are aimed at reducing the morbidity of conservative breast cancer at a time when detection enables breast cancers to be treated at an increasingly early stage, which results in a increase of negative axillary dissections. The postoperative period is simplified (no drainage, immediate mobilization), and the hospital stay is reduced to 2 days. Complementary treatments can thus be started early on, without any functional or cosmetic damage while the number of lymph nodes removes remains the same as in the conventional axillary dissection technique. The authors describe the operative procedures and analyse the 100 cases of conservative breast cancer they have treated with padding and FAL. These two technical modifications are now systematically used by them in the management of breast cancers.
After studying the risk factors of eclamptic toxemia, the author describes the various methods of prevention proposed. A salt-free diet has no effect. Increased intake of zinc or magnesium has no impact. Calcium (600 to 2,000 mg/d) may reduce the incidence of toxemia among teenagers from 27.9% to 4%. Low dose aspirin appears to be equally effective. Cod liver oil is currently being tested.
Neonatal retarded growth and hypotrophy are more frequent in monochorial, biamniotic twin pregnancies than in bichorial ones. The authors consider the various pathogeneses which have been suggested to account for this phenomenon.
RU 486 is an anti-progesterone steroid used in obstetrics to achieve maturation of the cervix before an endouterine procedure in late abortions during the first 3 months, in therapeutic pregnancy termination during months 3-6 or 6-9 and in expelling fetuses which have died in utero. RU 486 has also been proposed for use in inducing or facilitating labor at term.
Over a 6-year period, 40 young women under 20 years of age with cervical intraepithelial neoplasia (CIN) grade I (58%) to grade III (10%) were treated by laser vaporisation or excisional conisation. This prevalence of CIN in young women (nearly 4% of laser-treated cases) underscores the need for detection of cervical abnormalities in all teenagers engaged in sexual relations. The colposcopically-guided carbon dioxide laser technique is the treatment of choice for vaporisation and conisation of intraepithelial lesions (extending to the periphery of the cervix in 20% of cases) and for vaporisation of associated condylomatous lesions of the cervix (75%), vagina (23%), vulva (48%) and/or anus (8%).
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A fetal thyroid goiter detected by ultrasonography at 20 weeks of amenorrhea (WA) was diagnosed at 23 WA by a second ultrasound examination and a TSH assay in amniotic fluid. Since a sample of fetal blood at 27 WA showed that hypothyroidism was compensated and that goiter size and amniotic fluid volume were stable, intra-amniotic injection of 300 micrograms of L-thyroxine was delayed until 36 WA. This injection was performed before delivery to avoid potential perinatal complications (dystocia and neonatal respiratory distress) caused by large goiters.
The authors report a series of 42 cases of cystic hygroma of the fetal neck diagnosed antenatally. Cystic hygroma is one of the signs suggestive of chromosomal or congenital abnormalities that occur very early and are very specific. A diagnosis can be made from the ninth week of amenorrhoea onwards by vaginal ultrasound. 73% of the karyotypes that were obtained were abnormal. The large majority (54% = have Turner's Syndrome, but there are some of the karyotypes that are normal. Our figures correspond with those in the literature. Several factors were analysed to show the influence of this pathology on the prognosis which is overall awful (only 11.5% of infants were born alive an only 7.5% survived). Factors for a good prognosis would be a normal karyotype and the spontaneous resolution of cystic hygroma in the second trimester of the pregnancy. Hydrops is a factor of poor prognosis and it occurs in 60% of cases of cystic hygroma but unfortunately 30% of cases where the karyotype is normal have severe malformations (bone, kidney and digestive tract). The resolution of the cystic hygroma in the second trimester of pregnancy does not exclude an abnormal karyotype or a severe congenital malformation associated with the condition. As cases do recur in the same family there is an indication that a suspicion that the condition can be an autosomic, recessive or even dominant condition. The authors advise that the diagnosis should be made early and thoroughly in order to carry out chorionic villus sampling to determine the karyotype early before the very important sign for abnormality disappears as it may.