Biomedical subjects
Publications and source records attributed to D Vinatier.
A case of primary choriocarcinoma of the ovary in a 32-year-old woman, 1 month after a voluntary interruption of pregnancy, is reported. A review of the literature shows that this tumour is rare and the distinction between a gestational and a non-gestational choriocarcinoma is difficult. The distinction between these two diagnoses and specific treatment are discussed.
Uterine arteriovenous malformation is a rare condition. We report a case with acquired arteriovenous malformation arising from the left uterine artery. She was diagnosed by color Doppler ultrasound and treated with a selective uterine artery embolization.
The use of laparoscopy in the management of gynaecological malignancies has significantly increased over the last 5 years. Patients with cervical, vaginal, endometrial and ovarian cancer can be managed laparoscopically either for staging or for treating. The feasibility of procedures through the laparoscope (such as hysterectomies, bilateral oophorectomies, pelvic and para aortic lymphadenectomies, omentectomies, colostomies, bowel resections, oophoropexies, radical hysterectomies and ovarian cancer debulking) has been demonstrated by skilled gynaecologists. Many of these procedures have been heralded as avant garde 'surgical standards' without appropriate evaluation of efficacy, effectiveness and efficiency. Larger series of patients have now replaced case reports to try to answer the numerous unanswered questions regarding the value of these procedures. Several prospective trials were begun to compare laparotomy and laparoscopy. If the results of these trials confirm the hope, laparoscopic management of gynaecological malignancies will leave the limited club of specialists to become a widely used technique. But the patients will benefit from laparoscopic procedures only when in the hands of well-trained surgeons.
The immune system probably plays a role in the onset and development of endometriosis. A general picture can be proposed. In some women refluxing endometrial cells are not destroyed, either because the patient is genetically programmed not to respond to endometrial antigens, or because the reflux is so abundant that the scavenging capacity of the peritoneal immune cells is overloaded. Refluxing cells could be protected due to an abnormal adherence to the mesothelium which exceptionally expresses certain adhesive molecules. Undestroyed, these endometrial cells would cause an inflammation with activation of macrophages. Not only does the peritoneum protect these endometrial cells, but it also produces abnormal quantities of chemotactic and angiogenic cytokines (interleukin-8). Macrophages facilitate development via growth factors such as transforming growth factor P. Immunosuppressive factors block the cytotoxic activity of natural killer (NK) cells. Activated macrophages present antigens of endometrial cells to T cells which will co-operate with B cells to synthesize autoantibodies. Synthesized antibodies protect the ectopic endometrium and could worsen the dysfunction of local NK cells. A vicious circle is set up involving all the partners of the immune system. It is as yet impossible to pinpoint the triggering mechanism. The primary defect could be localized on the endometrium, macrophages already activated by an extrinsic factor (infection, spermatozoa, chemical substances), the uterus or the tubo-uterine junction. The two pathophysiological theories put forward to explain endometriosis are linked by a defective immune system. Indeed, once the vicious circle is set up, growth and angiogenic factors could induce metaplasia of the already irritated mesothelium.
Anti-TJa alloimmunization is an extremely rare condition which can cause miscarriages during the first and second terms of pregnancy. At 20-year-old female patient, an anti-TJa carrier, was given plasma transfusions in the course of her first two pregnancies. The cordocentesis, which was the main follow-up test during the first pregnancy, could not be carried out during the second pregnancy due to the presence of a huge subchorionic hematoma. Both pregnancies were characterized by fetal growth retardation, which was particularly considerable in one. Due to chronic fetal distress, both infants were delivered prematurely by cesarean section. The immunohematological data concerning anti-TJa alloimmunization and the different palliative treatments available to date are reviewed.
Thrombocytopenia-absent radius (TAR) syndrome is an autosomal-recessive disorder characterized by a thrombocytopenia and a bilateral radial aplasia with normal thumbs. Only TAR syndrome, out of diseases which may present with radial aplasia, typically has normal thumbs. The prenatal diagnosis is rarely made. We report two observations of TAR syndrome diagnosed in utero in the sibling. The malposition of fetal hands detectable as soon as 11 weeks of gestation requires careful search for longitudinal limb defect of the forearm, especially radial ray defect. The radial aplasia is associated with numerous causes (chromosomal, teratogenic, genetic, multifactorial). The determination of fetal hematologic values revealing a thrombocytopenia allows the prenatal diagnosis of the index case of TAR syndrome.
The authors studied the course of pregnancy in 112 adolescents under the age of 15 years 3 months seen over the last decade. 10% of pregnancies were marked by anaemia, 23% by excessive weight gain and 20% by toxaemia of pregnancy. Although the delivery is often premature, it is usually simple, with rapid labour and expulsion. Forceps were required in 8% of cases and the ventouse was used in 11% of cases. Epidural anaesthesia was performed in 50% of deliveries. Despite an almost normal pregnancy and a eutocic delivery, 21% of babies presented a malformation.
The authors report a case of rupture of the uterus 22 weeks after the LMP, due to placenta praevia percreta and requiring emergency hysterectomy to arrest bleeding, followed by urinary complications. With the predisposing factors of the scars of 4 previous cesarean sections and the low anterior insertion of the placenta, this exceptional case--in terms of its rarity and gravity--led the authors to undertake a review of the literature seeking other cases of this greatly feared obstetric complication. They review the clinical, ultrasonographic (notably the use of color Doppler) and paraclinical (MRI, cystoscopy) diagnostic approach necessary to make an accurate diagnosis of placenta percreta (if possible before any hemorrhagic complications). This situation virtually invariably requires hysterectomy to arrest bleeding, under very difficult conditions because of the massive hemorrhage involved. Mortality remains high and morbidity principally concerns the urinary complications frequently encountered.
The authors describe some situations where meta-analyses would have been of great benefit if they have been done or sufficiently published. They emphasize several problems ensued by this new method: if possible, meta-analyses have to be done each time a new trial is analysed, according to a precise method. Cumulative meta-analysis should rely on a regular and prospective registration of clinical trials. In all cases, meta-analyses should be available to a large number of physicians, in the main interest of patients.
We report our experience concerning the laparoscopic treatment of ectopic pregnancy (EP). One-hundred and nine women with EP were treated in our department over a 4 year period, between February 1988 (date of our first laparoscopic surgery for EP) and December 1991. Twenty-two these women underwent laparotomy and the remaining 87 laparoscopic surgery alone. Four therapeutic failures were noted in women treated by laparoscopy. Our results are compared with those of other series and the indications, as well as the modalities of laparoscopic treatment are detailed. It is concluded that laparoscopic surgery of EP is a reliable method which must always be considered, except for a few rare indications.