Biomedical subjects
Publications and source records attributed to J C Monnier.
Acute liver failure occurred in a 33 WA pregnant 4th parity woman. Transfer to intensive care was required and liver transplantation was discussed. Search for the causal mechanism revealed viral hepatitis A. On the basis of this observation, the different hypotheses concerning this clinical situation are presented in addition to different aspects of an association with viral hepatitis (particularly hepatitis A).
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We report our personal experience with 35 laparoscopically prepared vaginal hysterectomies performed over a 3 year period, for January 1990 to January 1993. We give our indications for this new technique present our results. We compared our results with those reported in the literature evaluating indications, technique and complications and demonstrate the numerous advantages of this new technique. Finally, a decision protocol has been prepared in order to chose the optimal approach according to the preoperative work-up.
An antenatal echography performed at 32 weeks of amenorrhoea revealed a formation in the liver. Other tests during the antenatal period were unable to provide an exact diagnosis which was only established after exploratory laparotomy after birth. A review of the literature showed that this hepatic tumour has been diagnosed in 3 reported cases antenatally. Haemangioendothelioma occurring during the antenatal period is difficult to diagnose and the severe forms discovered by echography have a poor prognosis.
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The authors having studied retrospectively 23 pregnancies that were complicated by haemorrhagic proctocolitis or Crohn's disease, try to define by following the literature as well, how these diseases react on fertility and on pregnancy, and how pregnancy reacts on the diseases and the treatments that are available during pregnancy. As far as we know at present, the patients are sub-fertile in cases on ulcerative colitis and normally fertile in cases of Crohn's disease. These illnesses are not exacerbated by pregnancy, but pregnancies are affected by flare-ups of the condition, and therefore should be planned if possible for when the illness is in remission. Previous bowel resection does not alter the course of the pregnancy nor change the methods of delivery. These is no abnormal effect on the fetus or infant due to the treatment, but it is wiser to avoid using Azathioprine during embryogenesis.
The authors report a case of a patient who in the 24th week of a twin pregnancy became sero-positive for toxoplasmosis. This was diagnosed by cordocentesis as being infected, and the treatment was therefore started with pyrimethamine and sulfadiazine and folic acid at the 28th week of pregnancy. At 35 weeks, the patient had an acute medullary aplasia due to the absence of the folates. The mother's state was improved rapidly by giving her folinic acid and the twins were normal haematologically. In this case, the authors point out how important the folates are in a pregnancy, especially in twin pregnancies, and point out the precautions that have to be taken when treatment with pyrimethamine and sulfadiazine is started for congenital toxoplasmosis.
There have only been thirty cases of total post-partum hypopituitarism published in the literature and these have nearly all been secondary to Sheehan's syndrome. The authors report a case of partial anterior hypopituitarism associated with diabetes insipidus which arose after an uneventful Caesarean operation and the origin of which seems to lie in auto-immune hypophysitis. The authors first describe the morphological and endocrine changes that the hypophysis undergoes during pregnancy and then point out that auto-immune hypophysitis seems to have been only recently recognised. This can be used to explain some cases of post-partum hypophyseal insufficiency occurring almost silently without any history of third haemorrhage. Research has been made systematically for anti-hypophyseal antibodies and for specific antibodies of the organ, but has not always been positive. So the diagnosis of auto-immune hypophysitis is often made only after eliminating other reasons for it. A brief review of the physiopathological mechanisms of diabetes insipidus makes it possible to suggest that vasopressinase coming from the placenta together with prostaglandins could play a role.
The authors present a case of partial trisomy 12q associated with chylothorax, diagnosed at 30 weeks of pregnancy. Cordocentesis for the karyotype as well as thoracocentesis were carried out. In spite of the administration of tocolytic drugs the patient delivered a girl with multiple clinical abnormalities, who died at 7 days of age. From this case, the authors report 6 other cases of partial trisomy 12q in the literature, and, in the discussion they suggest the management after the diagnosis of hydrothorax has been made by ultrasound.
.5% to 3% of pregnancies are complicated by chronic hypertension. These pregnancies are at increased risk for the development of superimposed pre-eclampsia, abruptio placentae, and poor perinatal outcome. The risk of development of adverse outcomes are not identical for all the patients. Several questions must be solved during the pre-pregnancy visit: What is the seriousness of the chronic hypertension? Is the chronic hypertension essential or secondary? Are there any organic repercussions of chronic hypertension? Why and how organize a special survey for such pregnancies? This complete pre-pregnancy cheek up permit to identify the high risk patients and to inform them of necessity of adjusted monitoring of the future pregnancy.
In the last decade works on the responses of the mother's immune system to the presence of the feto-placental unit have burgeoned. The antigens that are presented to the mother are special because the trophoblast does not show classical transplantation antigens which are classically implicated in graft rejection. A class I antigen, antigen HLA-G is present in the extra-villous cytotrophoblast, different from classical antigens by virtue of its molecular weight and its reduced antigenic polymorphism. Many functions have been attributed to this antigen; most of them are still being evaluated. The most important immunological phenomena are found at the feto-placental interface. Several events occur simultaneously or successively. Recognition of the trophoblast brings about an inflammatory reaction which is the initial phase of graft rejection. The numerous cytokines that are produced in this initial phase allow decidualization to occur and for the embryo to implant when it has reached an adequate stage of evolution. Rapidly, immunosuppressant mechanisms stop this rejection reaction which if not stopped can cause the pregnancy to end. There is a delicate equilibrium between the different cytokines, those favourable to pregnancy and those damaging to pregnancy. The trophoblast which is resistant to factors which would cause rejection protects the fetus particularly if its growth is helped along by certain cytokines. On the other hand, other cytokines are prejudicial to the growth of the trophoblast and activate certain cytotoxic cells which become aggressive. The maternal immune system and the endocrine system work together to maintain this cytokine network which if destabilized leads to certain pathological situations. Disturbances can be due to poor maternal recognition particularly if the trophoblast does not give out good antigens, or if the mother is genetically programmed not to respond although the disturbance can come from external factors such as certain infections.
The methods used to carry out exeresis of ovarian cysts by celioscopy are now familiar. Today, the main concern is the selection of annexial tumors appropriate for celiosurgical treatment in order to limit their use to benign organic cysts only. By comparing the results of a sery of 200 cysts which were treated surgically with cases in the literature, the authors conclude that the three-pronged use of clinical, ultrasound and macroscopic data in the diagnosis of malignant tumors is reliable. Progress remains to be made however in identifying functional cysts which are sometimes mistaken for an organic structure and all too often are still dealt with surgically. In order to reduce the incidence of such errors, new perspectives are envisaged, knowing that diagnostic error is often related to change in their ultrasound structure or their persistence despite conventional estro-progestogen treatment.
Repeated unintentional abortions are an agonizing problems for many couples. When the cause is unexplained an immunological reason is often invoked. There have been many theories, but none have been able to be proven. Progress in immunology makes it possible to predict that these mechanisms will become better understood. At the present time the most recent work presented by the authors underlines the fact that there are probably several different immunological mechanisms causing abortion. When the mechanisms can be identified using current techniques, it may be possible to suggest the treatment suited to each one of these situations and to abandon empirical treatment as is at present used in these repeated abortions.
AIM: A review of the literature concerning the very rare anti-PP1Pk isoimmunisation with a personal case. CLINICAL MATERIAL: Anti-PP1k antibody gives rise to the high risk of abortion in the first and the second trimester (in a different series the risk is 50-70%). A 19-year-old patient who had this antibody was helped by a plasmaphoresis repeatedly between the 6th and the 25th week of pregnancy. Cordocentesis was carried out to estimate fetal haemoglobin from the 25th week onwards. A set caesarean section was carried out at 36 weeks because of intrauterine growth retardation and the development of fetal anaemia. DISCUSSION: The authors suggest research based on the known immunohaematological factors concerned with this isoimmunisation and on the main treatments available (plasmaphoresis, cordocentesis, and delivery at a set time). CONCLUSION: Until now there have been very few cases and only four similar cases to ours have been reported in the literature. That is why it is so difficult to suggest a well defined strategy for treating these patients.
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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 of 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.
Pregnancy is an aggravating factor for brain tumours on which it acts by three mechanism: acceleration of tumour growth, increase of peritumoral oedema and the immunotolerance to foreign tissue antigens that is proper to pregnancy. Histologically, the brain tumour most frequently encountered is glioma, usually revealed during the third trimester. Brain tumours is pregnant women have no special clinical features, and their diagnosis rests on computerized tomography or nuclear magnetic resonance completed, if required, by stereotactic biopsy. Following a review of the literature, the authors present an updated description of the neurological and obstetrical actions to be taken, illustrated by a report of eight personal cases. The indications for surgery depend on the site and histological nature of the tumour. As regards obstetrical measures, induced therapeutic abortion and caesarean section, no longer routinely performed, are now being replaced by vaginal delivery with systematic instrumental extraction. In both mother and foetus the prognosis has improved over the last ten year, but it remains very sombre.