[Guidelines for Clinical Practice of the French College of Obstetricians and Gynecologists 2021: Prophylactic procedures associated with gynecologic surgery]. / Recommandations pour Pratique Clinique du Collège des Gynécologues Obstétriciens français 2021 : gestes prophylactiques associés en chirurgie gynécologique.

OBJECTIVE: To draw up recommendations on the use of prophylactic gynecologic procedures during surgery for other indications. DESIGN: A consensus panel of 19 experts was convened. A formal conflict of interest policy was established at the onset of the process and applied throughout. The entire study was performed independently without funding from pharmaceutical companies or medical device manufacturers. The panel applied the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system to evaluate the quality of evidence on which the recommendations were based. The authors were advised against making strong recommendations in the presence of low-quality evidence. Some recommendations were ungraded. METHODS: The panel studied 22 key questions on seven prophylactic procedures: 1) salpingectomy, 2) fimbriectomy, 3) salpingo-oophorectomy, 4) ablation of peritoneal endometriosis, 5) adhesiolysis, 6) endometrial excision or ablation, and 7) cervical ablation. RESULTS: The literature search and application of the GRADE system resulted in 34 recommendations. Six were supported by high-quality evidence (GRADE 1+/-) and 28 by low-quality evidence (GRADE 2+/-). Recommendations on two questions were left ungraded due to a lack of evidence in the literature. CONCLUSIONS: A high level of consensus was achieved among the experts regarding the use of prophylactic gynecologic procedures. The ensuing recommendations should result in improved current practice.

[Impact of luteal phase support by human chorionic gonadotropin (hCG) in intrauterine inseminations]. / Impact du soutien de la phase lutéale par Human Chorionic Gonadotropine (hCG) dans les inséminations intra-utérines.

OBJECTIVES: The objective of our study is to evaluate the impact of luteal phase support by hCG in intrauterine inseminations preceded by ovarian gonadotropin stimulation. METHODS: A retrospective study was conducted at the CHU of Nice between March 1, 2016 and October 31, 2017. During this period, 300 intrauterine inseminations were included in data analysis. Ovarian stimulation was performed by gonadotropins and a GnRH antagonist was added, if needed. Following a modification of standard operative procedure in the department, patients who performed an intrauterine insemination from December 1, 2016 received luteal phase support with two injections of hCG 1500 IU, performed at three days of interval. Pregnancy and ovarian hyperstimulation syndrome were the primary and secondary study endpoints, respectively. RESULTS: Out of 300 inseminations included in the analysis, 144 were performed with luteal phase support and 156 without support. No statistically significant difference in pregnancy rate was observed between these two groups (19.4% of pregnancy in the luteal phase support group and 15.38% in the group without luteal phase support, P=0.353). No ovarian hyperstimulation syndrome occurred over the course of the study. CONCLUSION: Our study shows a slight improvement of pregnancy rate in the group subjected to luteal phase support by hCG after intrauterine insemination, but the benefit was not significant. A randomised prospective study based on a large cohort could help to assess the effect of luteal phase support during intrauterine inseminations.

[Contraceptive prescriptions following repeated volontary induced abortions]. / Prescriptions contraceptives après interruptions volontaires de grossesses à répétition.

OBJECTIVES: The main objective of this study was to evaluate if the increasing number of repeated abortions in France is linked to a failure to reassess post-abortion contraceptive methods. METHODS: This is a multicentered, descriptive, retrospective study of post-abortion contraceptive practices of patients who underwent a repeated volontary abortion between September one and December 31, 2017, in four abortion centers, in public hospitals in the Alpes-Maritimes and East Var. RESULTS: Of the 217 patients who participated to the study, 78.8% used a different contraceptive method post-abortion vs. the method used during the conception. Only 51.8% of long-acting reversible contraception (LARC) prescribed have been used at the post abortion consultation. DISCUSSION AND CONCLUSION: The repeated abortion may be partly explained by a transient or prolonged absence of contraception. Screening for breaks in the contraceptive history is therefore essential to adapt and maintain contraception at each stage of the patient's life. Some of the professional practices which do not favour an early placement of LARC devices prescribed at the time of abortion, contrary to the new recommendations. The evolution of professional practices still seems necessary to try to help reduce the repeated use of abortion.

[Barriers to the use of emergency contraception in a population consulting for an abortion]. / Évaluation lors d'une IVG des freins à l'utilisation de la contraception d'urgence.

OBJECTIVES: In France, one pregnancy out of three is unplanned. Half of those pregnancies lead to abortion. However, the use of emergency contraception is far from systematic. It is therefore relevant to question the reasons and factors linked to the low rate of use of emergency contraception. METHODS: A retrospective observational study was conducted in the orthogenic service of the University hospital Center of Nice, over a six weeks period. Patients were consulting in the context of voluntary termination of pregnancy and were subjected to a questionnaire during a semi-structured interview. The collected data were: age, degree of education, profession, size of their home town municipality, legal status, obstetrical history, contraception used at the time of unplanned pregnancy, emergency contraception background and justification for not using an emergency contraception. RESULTS: A total of one hundred and five questionnaires were studied. The absence of emergency contraception was due to an underestimation of the risk of pregnancy in 81% of cases. Among characteristic variables of the studied population, none was related to the non-use of emergency contraception. CONCLUSIONS: Independently of the patient profile, underestimation of the risk of pregnancy is the main cause of non-use of emergency contraception. It seems crucial to inform women with childbearing age and their families about their fertility and the basic mechanisms of fertility in order to reduce the number of unplanned pregnancies in France.

Papillomavirus genotyping on formaldehyde fixed paraffin-embedded tissues in vulvar intraepithelial neoplasia.

PURPOSE: Few studies have described the epidemiology of human papillomavirus (HPV) in vulvar intraepithelial neoplasia (VIN). The aim of this study was to genotype HPV on formalin fixed paraffin-embedded tissues in VIN lesions. METHODS: A 5-year retrospective study was conducted by including all patients attending the teaching hospital of Nice with a diagnosis of VIN between 1st January 2010 and 31st December 2014. For all patients, HPV genotyping was performed with the PapilloCheck® microarray kit, routinely used on cervical cytology samples, and optimized for formaldehyde fixed paraffin-embedded tissues in VIN. RESULTS: Forty patients were included in the study: 39 patients had usual VIN and one presented with differentiated VIN. Among the 39 patients with usual VIN, the prevalence of HPV was 90% (35/39). Thirty-two patients had high grade VIN (82%) and seven low grade VIN (18%). In high grade VIN, the most represented HPV types were: HPV 16 (21/32 66%), HPV 56 (3/32 9%) and HPV 33 (2/32 6%). In low grade VIN, the most represented HPV types were: HPV 16 (4/7 57%) and HPV 6 (3/7 43%). Interestingly, 5/39 (13%) of patients diagnosed with usual VIN also had co-existing lichen sclerosus. CONCLUSIONS: We have optimized a HPV genotyping technique, routinely used on cervical cytology samples, and on paraffin fixed embedded tissue showing VIN. Moreover, we have identified five patients with lichen sclerosus co-existing with usual VIN. This association has rarely been reported and proves that these two entities can coexist.

Which Foetal-Pelvic Variables Are Useful for Predicting Caesarean Section and Instrumental Assistance?

OBJECTIVE: To assess the variables useful to predict caesarean delivery (CD) and instrumental assistance, through the analysis of a large number of foetal-pelvic variables, using discriminant analysis. MATERIALS AND METHODS: One hundred and fourteen pregnant women were included in this single-centre prospective study. For each mother-foetus pair, 43 pelvic and 18 foetal variables were measured. Partial least squares-discriminant analysis was performed to identify foetal-pelvic variables that could statistically separate the 3 delivery modality groups: spontaneous vaginal delivery (SVD), CD, and instrument-assisted delivery (IAD). RESULTS: For the SVD versus CD model, voluminous foetuses and women with a narrow pelvic inlet had a greater risk for requiring CD. The most efficient variables for discrimination were the transverse diameter and foetal weight. The antero-posterior inlet and obstetric conjugate were considered in this model, with the former being a useful variable but not the latter. For the SVD versus IAD model, the most important variables were the foetal variables, particularly the bi-parietal diameter. Women with a reduced antero-posterior outlet diameter and a narrow pubic arch were more at risk of requiring an IAD. CONCLUSION: The antero-posterior inlet was an efficient variable unlike the obstetric conjugate. The obstetric conjugate diameter should no longer be considered a useful variable in estimating the arrest of labour. Antero-posterior inlet diameter was a sagittal variable that should be taken into account. The comparison of sub-pubic angle and bi-parietal and antero-posterior outlet diameters was useful in identifying a risk of requiring instrumental assistance.

[Training of residents in obstetrics and gynecology: Assessment of an educational program including formal lectures and practical sessions using simulators]. / Formation des internes de gynécologie obstétrique : évaluation d'un programme pédagogique intégrant cours théoriques et sessions pratiques sur simulateurs.

OBJECTIVES: Evaluate an educational program in the training of residents in gynecology-obstetrics (GO) with a theory session and a practical session on simulators and analyze their learning curve. METHODS: Single-center prospective study, at the university hospital (CHU). Two-day sessions were leaded in April and July 2013. An evaluation on obstetric and gynecological surgery simulator was available to all residents. Theoretical knowledge principles of obstetrics were evaluated early in the session and after formal lectures was taught to them. At the end of the first session, a satisfaction questionnaire was distributed to all participants. RESULTS: Twenty residents agreed to participate to the training sessions. Evaluation of theoretical knowledge: at the end of the session, the residents obtained a significant improvement in their score on 20 testing knowledge. Obstetrical simulator: a statistically significant improvement in scores on assessments simulator vaginal delivery between the first and second session. Subjectively, a larger increase feeling was seen after breech delivery simulation than for the cephalic vaginal delivery. However, the confidence level of the resident after breech delivery simulation has not been improved at the end of the second session. Simulation in gynecological surgery: a trend towards improvement in the time realized on the peg-transfer between the two sessions was noted. In the virtual simulation, no statistically significant differences showed, no improvement for in salpingectomy's time. Subjectively, the residents felt an increase in the precision of their gesture. Satisfaction: All residents have tried the whole program. They considered the pursuit of these sessions on simulators was necessary and even mandatory. CONCLUSION: The approach chosen by this structured educational program allowed a progression for the residents, both objectively and subjectively. This simulation program type for the resident's training would use this tool in assessing their skills and develop learning curves.

[Role of imaging in cases of bleeding after spontaneous or induced abortion]. / Rôle de l'imagerie en cas de métrorragies après fausse couche spontanée ou interruption volontaire de grossesse.

Post-abortum hemorrhage is a common clinical situation and etiological diagnosis has to be made early to avoid further complications such as persistent bleeding, infection or adhesions that may compromise fertility. Retained products of conception are the most common cause of bleeding. The diagnosis is based on endovaginal color doppler ultrasound showing a thickened and hypervascular endometrial echo-complex extending partly to the myometrium. The main differential diagnosis is uterine arteriovenous malformation, mostly iatrogenic. Diagnosis is based on the presence of myometrial confluent cystic lesions filled with turbulent and high velocity arterial flow on endovaginal color doppler ultrasound. The distinction between these two etiologies of post-abortion bleeding is mandatory because of totally different treatment: typically medical and/or surgical in case of retained products of conception and by selective arterial embolization in case of vascular malformation.

[Instrumental extractions using Thierry's spatulas: evaluation of the learning curve]. / Évaluation de la courbe d'apprentissage des extractions par spatules de Thierry.

OBJECTIVES: To determine the learning curve of fetal extractions with Thierry's spatulas. PATIENTS AND METHODS: Single-center prospective study following the progress of six residents in obstetrics and gynecology in learning fetal extractions by Thierry's spatulas. The instrumental extractions procedures performed by the residents were evaluated by the senior obstetrician on call according to a validated scoring rubric. In parallel, the residents would fill out a questionnaire on their own perception of their abilities at the time of the procedure. RESULTS: The six residents participated in 160 extractions using Thierry's spatulas between November and May 2011. Sixty-three (39.6%) were evaluated, i.e. an average number of 12±6 extractions per resident. After validating respectively 0, 1, 2 or 3 semesters, the mean global assessment scores (graded out of 5) obtained by the residents were 3.54, 3.18, 4.43 and 4.61. The overall average score was significantly higher when the resident participated in more than 20 extractions before the studied extraction (4.0 vs. 3.7, P<0.001). After attending more than 20 extractions, no resident had obtained the maximum evaluation score of 5/5 nor was deemed capable of performing extractions without supervision. DISCUSSION AND CONCLUSIONS: Learning extractions with Thierry's spatulas, including an objective assessment by senior doctors and a self-assessment by the residents, is a constant process over the first six months of training. Specific training simulator should be developed to enable students to achieve a threshold number of extractions, ensuring the safety of the procedure in the birthing rooms.

[Distribution of human papillomavirus genotypes amongst HIV-negative and HIV-positive women diagnosed with ASC-US cytology. Preliminary data of a local retrospective study]. / Répartition des génotypes de papillomavirus humain dans les frottis ASC-US de patientes infectées ou non par le VIH-1. Résultats préliminaires d'une enquête rétrospective locale.

OBJECTIVES: Analysis of the distribution of human papillomavirus (HPV) genotypes amongst HIV-negative and HIV-positive women diagnosed with atypical squamous cells of undetermined significance (ASC-US). PATIENTS AND METHODS: We performed a retrospective study of HPV genotype distribution in 313 ASC-US Pap smears from women who consulted at the University Hospital of Nice between 2008 and 2012. HPV genotyping results, conducted on PapilloCheck(®) HPV DNA Chip, and information on the status of HIV patients were retrospectively collected. The odds ratio were calculated by logistic regression. RESULTS: In co-infected HIV/HPV women we observed a low prevalence of HPV16, a high prevalence of oncogenic HPV low risk and a high prevalence of HPV 68 compared to non-co-infected women. By grouping HPV HR based on their prevalence in cervical cancer of the uterus and their genetic proximity we observe that HPV 18, 45, 68 (the "alpha-7") are 7.4 times more represented (CI95 [2.48 to 22.35]) than HPV 16, 31, 33, 52, 58 (the "alpha-9") in the population of women co-infected with HIV. DISCUSSION AND CONCLUSION: Given that HPV "alpha-7" are responsible for 46.3% of adenocarcinomas, the high prevalence of these HPV found in ASC-US Pap smears of co-infected women should be put in relation with the highest prevalence of glandular abnormalities found in this population. HPV genotyping could become an essential tool for gynecological care for HIV positive women.

Evaluation of single incision laparoscopic surgery "low-fidelity" simulation training.

GOAL: Evaluate the learning curve of SILS (Single Incision Laparoscopic Surgery) on a simulator, based on two tests of the Fundamentals of Laparoscopic Surgery certification program (FLS(®)), in a population of novice medical students, and compare their performance to those of senior surgeons practicing both "conventional" laparoscopic surgery and SILS. MATERIALS AND METHODS: Monocentric prospective study with four groups: two groups of novice medical students, and two groups of senior surgeons. The two FLS(®) tests used for evaluation were the peg transfer and the precision cutting tasks. RESULTS: No statistically significant differences were found between the novice groups, whether they started their first session directly, or immediately after watching a video presentation of the exercises. For the novice medical students, the average completion time of both tests improved significantly between the first and the sixth sessions with a short learning curve. The group of experienced seniors performed fastest in both tests. For the peg transfer task, the skills of the novice medical students were comparable to those of non-experienced seniors after the 4th session and improved after 6 sessions (P=0.017). For the precision cutting task, the average timing of the novice group became better than that of the non-experienced seniors, starting from the third session. CONCLUSIONS: FLS(®) "low fidelity" simulator training is effective for the training of novice medical students. To minimize the risk of technical errors, novice medical students should practice a minimum of six simulator-training sessions before starting their practical learning of SILS in the operating room.

[Vaginal metastasis revealing an adenocarcinoma of the transverse colon]. / Métastase vaginale révélatrice d'un adénocarcinome du côlon transverse.

Secondary localization to vagina had a severe prognosis, suggesting a disseminated metatastic disease. We report the case of prevalent vaginal metastasis of adenocarcinoma of the transverse colon. A 65 years old patient has consulted for vaginal mass. After delayed diagnosis, she presented with disseminated metastatic disease with peritoneal carcinomatosis. After neoadjuvant chemotherapy, the following treatment consisted of complete cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy and vaginal adjuvant radiotherapy. No recurrence occurred after one year. Vaginal metastasis of colon cancer are rare. The dark prognosis might justify a systematic gynecological examination of women presenting colorectal neoplasy.

[Conservative treatment of a compressive adenomyosis: report of a case]. / Traitement conservateur d'une adénomyose compressive: à propos d'un cas.

Adenomyosis is frequent, mostly asymptomatic. A hypertrophy of the smooth muscular cells around ectopic endometrial glands might induce a compressive syndrome. We report the case of an embolization of a voluminous adenomyosic uterus which has triggered venous iliac's compression in patient refusing surgery. This treatment was efficient in reduction of uterin volume, without recurrence after three years. MR imaging is the exam of choice particularly when diagnosis is still uncertain and allows a non-invasive and good evaluation, and follow-up. Embolization is not actually recommended. But, it appears to be efficient, relatively safe and contributes to the conservation of fertility.

Virtual traumatology of pregnant women: the PRegnant car Occupant Model for Impact Simulations (PROMIS).

This study report documents the development of a finite element (FE) model for analyzing trauma in pregnant women involved in road accidents and help the design of a specific safety device. The model is representative of a 50th percentile pregnant woman at 26 weeks of pregnancy in sitting position. To achieve this, the HUMOS 2 model, which has been validated in a wide range of dynamic tests, was scaled to the morphology of a woman in the 50th percentile and coupled with a model of gravid uterus. During scaling, special attention was paid to the pelvic region which is known to differ considerably in morphological terms between men and women. The gravid uterus model includes a placenta, a fetus, uterosacral ligaments and the amniotic fluid by means of fluid structure interaction formulation. The uterus and the female model were coupled using an original method whereby the growth of an uterus was simulated to compress the abdominal organs in a realistic manner. The model was validated based on experimental tests described in the literature. Additional tests based on abdominal loadings with a seatbelt on Post Mortem Human Surrogates (PMHS) coupled to silicone uterus were also performed. Results highlighted the role of the possible interaction of the fetus in the pregnant woman abdominal response. Experimental corridors taking into account the presence of this fetus could therefore be proposed.

[Fertility preservation among patients with cancer: report of a French regional practical experience]. / Préservation de la fertilité en oncologie : bilan des pratiques en Région PACA-Corse.

OBJECTIVE: Improvement in cancer treatments has led to reconsider the importance of quality of life after cancer, especially concerning maintening the potential of fertility since it is often altered after healing. Our objective was to estimate the knowledge and practices of the physicians in the field of Oncology in a French Region (Provence Alpes- Côte d'Azur). PATIENTS AND METHOD: Prospective survey, conducted between January and April 2012, amongst oncologists working in Provence Alpes Côte d'Azur region, through questionnaires distributed during multidisciplinary meetings in oncology. RESULTS: Among 225 replies, 54% of the physicians had sent no patient to any oncofertility consultation during the previous six months (n=120). Besides, 33% of the oncologists (n=68) declared they had difficulties in addressing their patients to oncofertility consultation, and 58% of them (n=39) considered they lacked information on techniques and indications of fertility preservation. CONCLUSION: This study provides an estimation of the current practices in PACA region concerning oncofertility and underlines the physicians' need of information. In this context, the regional oncology network has set up a regional network « cancer and fertility ¼ in order to facilitate the access to fertility preservation prior to any potentially sterilizing treatment for all patients.

[Prolactinoma: from quest of pregnancy to delivery]. / Adénome à prolactine : du désir de grossesse à l'accouchement.

Prolactinoma is the most frequent hormone-secreting pituitary tumor (100 for million patients) and a major cause of both female and male reproductive function disorders. Physician, gynecologist, urologist and sexologist can face this situation during their career. As part of the fertility restoration, treatment gives very satisfactory results. With adequate management, most women are expected to achieve successful pregnancies. The natural history of these tumors during pregnancy depends on their size with a risk of a clinically relevant estimate between 5 to 30 %. Their management is complex, requiring finding balance between effects of pregnancy on tumor growth and potential risks of overtreatment on fetal development. The aim of this study is to discuss the management of prolactinoma on woman before, during and after pregnancy, and to evaluate the medical and surgical alternatives regarding the actual literature.

[Post-menopausal ovarian hyperthecosis]. / Hyperthécose ovarienne post-ménopausique.

Ovarian hyperthecosis is infrequent but it represents the first cause of post-menopausal hyperandrogenia. Pathophysiology of ovarian hyperthecosis remains poorly understood but the metabolic syndrome observed in most patients suggests that insulin resistance associated with high, postmenopausal LH levels, might play a role as in polycystic ovarian syndrome. We report here four patients who presented post-menopausal hyperandrogenia. Although high, tumoral, plasma testosterone levels, lack of focused radiological lesions except enlarged ovaries, associated to the metabolic syndrome, suggested ovarian hyperthecosis. Bilateral annexectomy allowed histological confirmation of hyperthecosis showing specific luteinized stromal cells and led to the complete suppression of the inappropriate androgen secretion.

[A recurrent cutaneous fistula secondary to the migration of a clip: report of a complication of tubal sterilization]. / Fistule cutanée récidivante secondaire à la migration d'un clip de Filshie : une complication de stérilisation tubaire.

The tubal sterilization is a safe and recognized sterilization method. The complications of this intervention are rare and mainly concern failure of surgical procedure or clip migrations. We report the first case of spontaneous migration of a clip behind the psoas followed by a chronic osteitis.

The place of simulation in the surgical resident curriculum. The pedagogic program of the Nice Medical School Simulation Center.

INTRODUCTION: Surgical training relies on medical school lectures, practical training in patient care and in the operating room including instruction in anatomy and experimental surgery. Training with different techniques of simulators can complete this. Simulator-based training, widely used in North America, can be applied to several aspects of surgical training without any risk for patients: technical skills in both open and laparoscopic surgery, the notion of teamwork and the multidisciplinary management of acute medicosurgical situations. METHOD: We present the curriculum developed in the Simulation Center of the Medical School of Nice Sophia-Antipolis. All residents in training at the Medical School participate in this curriculum. RESULTS: Each medical student is required to pursue theoretical training (familiarization with the operating room check-list), training in patient management using a high fidelity mannequin for various medical and surgical scenarios and training in technical gestures in open and laparoscopic surgery over a 2-year period, followed by an examination to validate all technical aptitudes. This curriculum has been approved and accredited by the prestigious American College of Surgeons, making this the first of its kind in France. CONCLUSION: As such, it should be considered as a model and, in accordance to the wishes of the French Surgical Academy, the first step toward the creation of true schools of surgery.