[Retrospective validation of a model to predict the outcome of pregnancies of unknown location]. / Évaluation rétrospective d'un algorithme d'aide à la décision concernant les grossesses de localisation indéterminée.

OBJECTIVE: The prediction model M6 classifies pregnancy of unknown location (PUL) into a low-risk or a high-risk group in developing ectopic pregnancy (EP). The aim of this study was to validate the two-step M6 model's ability to classify PUL in French women. MATERIAL AND METHODS: All women with a diagnosis of PUL over a year were included in this single center retrospective study. Patients with a diagnosis of EP at the first consultation of with incomplete data were excluded. For each patient, the M6 model calculator was used to classified them into "high risk of EP" and "low risk of EP" group. The reference standard was the final diagnostic: failed PUL (FPUL), intrauterine pregnancy (IUP) of EP. The statistical measures of the test's performance were calculated. RESULTS: Over the period, 255 women's consulted for a PUL, 197 has been included in the study. Final diagnosis were: 94 FPUL (94/197; 47.7%), 74 IUP (74/197; 37.6%) et 29 EP (29/197; 14.7%). The first step of the M6 model classified 16 women in the FPUL group of which 15 (15/16; 93.7%) correctly. The second step of the M6 model classified 181 women: 90 (90/181; 49.7%) in the "high risk of EP" group of which 63 (63/90; 70%) were FPUL/IUP and 27 (27/90; 30%) were EP. 91 (91/181; 50.3%) was classified in the "low risk of EP" group of which 90 (90/91; 98.9%) were FPUL/IUP and 1 (1/91; 1.1%) were EP. EP were correctly classified with sensitivity of 96.4%, negative predictive value of 98.9%, specificity of 58.8% and positive predictive value of 30.0%. CONCLUSIONS: The prediction model of PUL M6 classified EP in "high risk of EP group" with a sensitivity of 96.4%. It classified 50.3% of PUL in a "low risk of EP" group with a negative predictive value of 98.9%.

[Antibiotics in first-line in case of bartholinitis: Retrospective Study of 33 Cases]. / Place de l'antibiothérapie en première intention en cas de bartholinite aiguë : à propos d'une série de 33 cas.

OBJECTIVES: Acute Bartholinitis is a common pathology affecting nearly 2% of women in their lifetime. Many treatments are used, although their effectiveness is not demonstrated in the literature. The main objective was to evaluate the success rate of first-line antibiotic therapy. The secondary objective was to identify factors associated with successful treatment. METHODS: We conducted a retrospective unicentric study between January 2014 and June 2018 at the University Hospital Center of Nancy. Inclusion criteria were the presence of acute bartholinitis treated with first-line antibiotic therapy. Exclusion criteria were patients lost to follow-up after initiation of treatment. The primary endpoint was the absence of surgical treatment within 30 days of initiation of antibiotic therapy. Factors associated with successful medical treatment were sought. RESULTS: Thirty-three patients were included. The success rate of medical treatment was 48.5% at 30 days. In the case of symptoms that had been evolving for less than 3 days, the success of medical treatment was more frequent (75% vs. 35.3%, P=0.02). Medical treatment was more effective in lesions of less than 2cm (68.7% vs. 23.5%, P=0.01). After adjustment, the only factor associated with successful medical treatment was lesion size≤2cm [ORa=5.31 (1.05-26.81)]. CONCLUSION: First-line antibiotic therapy for acute bartholinitis seems effective but should be targeted according to certain eligibility criteria.

[Treatment of fibroadenomas by high-intensity focused ultrasound: What results? Review]. / Prise en charge des fibroadénomes par échothérapie : quels résultats ? Revue de la littérature.

OBJECTIVES: To assess benefits and adverse effects of high-intensity focused ultrasound (HIFU) as a treatment for fibroadenomas (FA). METHODS: To ensure the quality of the methodology, the PRISMA criteria have been met at all stages of the development of this review. We searched MEDLINE from inception to May 2017, without any restriction. KEYWORDS: fibroadenoma, focused ultrasound, HIFU and fibroadenomata were used. Data were extracted and the results were compared. Two reviewers independently extracted study characteristics and outcome data. RESULTS: Of 20 identified abstracts, 5 primary studies met inclusion criteria. All studies reported a reduction in the size of FA treated with an increasing effect over time. Pain tolerance was most often assessed as moderate. Adverse effects of HIFU were not severe in all studies. CONCLUSIONS: HIFU appears to be a promising technique in the treatment of fibroadenomas with a volume decrease of approximately 50 % at 6 months of therapy.

The definition of Endometriosis Expert Centres.

Endometriosis is a common condition that causes pain and infertility. It can lead to absenteeism and also to multiple surgeries with a consequent risk of impaired fertility, and constitutes a major public health cost. Despite the existence of numerous national and international guidelines, the management of endometriosis remains suboptimal. To address this issue, the French College of Gynaecologists and Obstetricians (CNGOF) and the Society of Gynaecological and Pelvic Surgery (SCGP) convened a committee of experts tasked with defining the criteria for establishing a system of care networks, headed by Expert Centres, covering all of mainland France and its overseas territories. This document sets out the criteria for the designation of Expert Centres. It will serve as a guide for the authorities concerned, to ensure that the means are provided to adequately manage patients with endometriosis.

[Definition of endometriosis expert centres]. / Définition des centres experts en endométriose.

OBJECTIVES: The Collège national des gynécologues obstétriciens français (CNGOF), in agreement with the Société de chirurgie gynécologique et pelvienne (SCGP), has set up a commission in 2017 to define endometriosis expert centres, with the aim of optimizing endometriosis care in France. METHODS: The committee included members from university and general hospitals as well as private facilities, representing medical, surgical and radiological aspects of endometriosis care. Opinion of endometriosis patients' associations was obtained prior to writing this work. The final text was presented and unanimously validated by the members of the CNGOF Board of Directors at its meeting of October 13, 2017. RESULTS: Based on analysis of current management of endometriosis and the last ten years opportunities in France, the committee has been able to define the contours of endometriosis expert centres. The objectives, production specifications, mode of operation, missions and funding for these centres were described. The following missions have been specifically defined: territorial organization, global and referral care, communication and teaching as well as research and evaluation. CONCLUSION: Because of its daily impact for women and its economic burden in France, endometriosis justifies launching of expert centres throughout the country with formal accreditation by health authorities, ideally as part of the National Health Plan.

[Echographic diagnosis of missed early miscarriage: Assessment of image quality]. / Diagnostic échographique de grossesse arrêtée précoce : étude de la qualité des clichés.

OBJECTIVE: Ultrasound examination plays a central role in case of suspected non-viable pregnancy. A wrong diagnosis might have major consequence in terms of inadequate care, especially in cases of false positive non-viable pregnancy diagnosis. Ultrasound criterions are today well defined. Our objective was to evaluate the feasibility and reproducibility of a novel image-quoting method of first-trimester non-viable pregnancy. METHODS: Thirty images of non-viable pregnancy were twice evaluated with blinded proofreading. Two quotations were evaluated: the first for the images of gestational sacs without embryo (gestational sac score), the second for the images with embryo (embryo score). RESULTS: The ICC (interclass correlation coefficient) was>0.75 for inter- and intra-observer reproducibility both for the quotations of the gestational sac and for the embryo with a low variability. Reproducibility of quoting crown rump length measurements <5mm was low at first proofreading but after adjustment of the quoting modalities, ICC was also>0.75. CONCLUSION: The inter- and intra-observer reproducibility of our quoting methods is high with a low variability. They might be a useful tool in current practice in the future.

[Endometriosis and miscarriage: Systematic review]. / Endométriose et fausse couche spontanée. Méta-analyse et revue systématique de la littérature.

OBJECTIVES: In spontaneous pregnancies, endometriosis appears to be a risk factor of miscarriage. The aim of this study is to evaluate the association between endometriosis and miscarriage in spontaneous pregnancy. METHODS: We searched the Cochrane Library, Medline of eligible studies from inception to December 2016, without any restriction. We selected studies that compared endometriosis-affected pregnant women to disease-free pregnant women. To ensure the quality of the methodology, the PRISMA criteria have been met at all stages of the development of this meta-analysis. The primary adverse pregnancy outcomes studied was miscarriage. Three reviewers independently extracted the studies' characteristics and outcome data. RESULTS: Of 225 identified abstracts, 4 primary studies met our inclusion criteria by comparing spontaneous pregnant patients with endometriosis to disease-free women. Miscarriage rate was higher in the endometriosis group (OR 1.77 [CI 95% 1.13-2.78]). CONCLUSION: In spontaneous pregnancies, endometriosis appears to be a risk factor of miscarriages (almost 80% increased risk). Further prospective studies are needed to confirm these results in order to establish the exact impact of endometriosis on spontaneous pregnancy course.

Organization and first results of cervical cancer screening program in Mayotte, from 2010 to 2014.

OBJECTIVES: Our main goal was to report the organization of individual screening for uterus cancer in Mayotte, the last French department since 2011, and its first results. MATERIAL AND METHODS: Epidemiological and observational study describing the prior situation, the beginning of the screening with pap smears in 2010, the colposcopy consultations and the treatment of the patients by the Mayotte network for screening of cancers since 2010. RESULTS: The screening allowed an improvement of the global cover rate from 5% to 24% in 5 years. The best results concern the woman from 25 to 39 years old, with a rate that rose from 14 to 46%. CONCLUSION: This study confirms the possibility and the efficiency of a screening program on this island, which is French by law, by much closer to developing countries on many other sides.

[New approach of learning curve for robotic-assisted gynecologic oncology surgery]. / Nouvelle approche de la courbe d'apprentissage en chirurgie oncogynécologique robot-assistée.

OBJECTIVES: Define the phases composing the learning curve of total hysterectomy (TH) and radical hysterectomy with pelvic lymphadenectomy (RHPL) robot-assisted performed by a single surgeon with no prior experience in laparoscopic surgery. METHODS: We retrospectively analyzed 72 procedures (TH, n=34 and RHPL, n=38) conducted between 2002 and 2011. The surgeon console time (CT) was used to determine the learning curve of TH and RHPL using CUSUM analysis. Epidemiological data, perioperative and postoperative complications were compared from the different phases of the learning curve. RESULTS: CUSUM analysis of surgeon console time (CUSUMCT) identified two learning phases for the TH group (phase 1: initial learning, phase 2: surgical skill increase). For the RHPL group, three learning phases were identified (phase 1: initial learning, phase 2: extending surgical indications, phase 3: control of surgical skills). Perioperative and postoperative complication rates did not differ significantly between the learning phases. Surgeon CT decreased from the 9th case (P=0.01) for the TH group and from the 13th case (P=0.04) for the RHPL group. DISCUSSION: CUSUM analysis of the learning curve in robotic-assisted gynecologic oncology surgery identified two phases of learning curve for simple procedures such as total hysterectomy and three phases for more complex procedures as radical hysterectomy with pelvic lymphadenectomy.

[Management of severe or persistent postpartum hemorrhage after vaginal delivery]. / Prise en charge obstétricale en cas d'hémorragie du post-partum qui persiste malgré les mesures initiales ou qui est sévère d'emblée, après accouchement par voie basse.

INTRODUCTION: This chapter is an update of the 2004 recommendations for the management of persistent or severe postpartum hemorrhage (PPH) after natural childbirth. Severe PPH is defined by estimated blood loss greater than 1000mL (gradeC). Persistent bleeding within 15 to 30minutes after diagnosis and initial treatment (gradeC) or abundant immediately (professional consensus) should lead to a further management. MATERIALS AND METHODS: A systematic review of the literature concerning the management of persistent or severe PPH was conducted on Medline and Cochrane Database, with no specified time period. RESULTS AND DISCUSSION: The initial clinical evaluation is the same whatever initial severity. Each possible cause of bleeding must be evaluated: uterine vacuity must be checked and birth canal lesions must be researched and repaired (gradeC). Sulprostone is effective for the treatment of severe or persistent PPH (EL4) and its use is recommended for the management of PPH resistant to oxytocin administration (grade B). In the current state of the literature, there is no argument for replacing sulprostone in France by dinoprostone or prostaglandins F2α (professional consensus). If oxytocin has been administered, it is not recommended to use misoprostol (EL1) as adjuvant treatment because there is no evidence of benefit in this indication (grade A). Balloon intra-uterine tamponade appears to be an efficient mechanical treatment of uterine atony in case of failure of the initial management by sulprostone. Tamponade allows avoiding the need for further interventional radiology or surgery in most cases (EL4). Intra-uterine tamponade may be offered in case of failure of sulprostone and prior to surgical management or interventional radiology (professional consensus). Its use is left to the discretion of the practitioner. Tamponade should not delay the implementation of further invasive procedures.

[Association of mifepristone and misoprostol for the medical management of early pregnancy failure]. / Évaluation de l'association mifépristone-misoprostol pour la prise en charge médicale des fausses couches retardées.

OBJECTIVES: A retrospective monocentric clinical trial was performed to evaluate the efficacy of the association of mifepristone and misoprostol for the management of early pregnancy failure. PATIENTS AND METHODS: Ninety-two women with early pregnancy failure or anembryonic pregnancy were first treated with 600 mg of mifepristone and 48 hours later with 400 µg of misoprostol by oral administration. Successful treatment, defined as an empty uterus, was searched at day 3, with the association of misoprostol-mifepristone alone or with complementary medical treatment, prostaglandins or ocytocine. RESULTS: The overall treatment success was 82% (75 of 92 women) with 69 successful cases at day 3 (75%). Six of 92 women (7%) needed a second-line medical treatment. For the last 17 women (18%), the failure of the associated tested medical treatment lead to a secondary surgery. No prognostic factor for the successful medical treatment has been highlighted. DISCUSSION AND CONCLUSION: A high efficacy for the management of early pregnancy failure is demonstrated for the mifepristone and misoprostol medical treatment. The specific contribution of mifepristone, although proven in the cases of termination of evolutive pregnancies, should be further evaluated in the future for the specific management of early pregnancy failure. Nevertheless, no prognostic factor for the success of the propose treatment can be determined, as the amount of patients enrolled in this study was not sufficient.

[Operative risk related to tobacco in gynecology]. / Risque opératoire lié au tabac en gynécologie.

If tobacco has been recognized for many years as a major risk factor for cardiovascular, lung diseases and cancer in the general population, women are insufficiently aware of the consequences and the specific gynecological operative risks related to this intoxication. Thus, a regular tobacco consumption increases the risk for many gynecological conditions may require surgical treatment with in addition a significant negative impact on the healing process and the risk of postoperative complications. The operative risk must be explained by surgeons in daily practice gynecological, pelvic surgery or breast screening. The issue of smoking cessation should precede surgery has been established by a consensus conference of experts on perioperative smoking held in 2005. The implementation of these recommendations during the preoperative period requires improvement of staff training and better practices to allow smoking cessation effective and sustainable. It is lawful in this context to delay scheduled surgery of 6 to 8 weeks to allow an optimal smoking cessation and to continue smoking cessation for the time necessary for healing to reduce the excess operative risk associated with smoking.

[Management of post-abortum infections]. / Prise en charge des infections du post-abortum.

In countries where induced abortions are legal and medically supervised, the frequency of post-abortion infections is low and maternal death is infrequent. Nevertheless, short and long term consequences of post-abortion infections must be addressed. Sexually transmitted pathogens are frequently in cause here. Risk factors include in particular young age (less than 24 years), low socioeconomic level, late pregnancy, nulliparity, and history of previous untreated pelvic inflammatory disease. Diagnosis is based on clinical criteria and an inflammatory syndrome occurring within 2 to 3 weeks after spontaneous or induced abortion. A pelvic ultrasound is recommended in order to ensure the uterus vacuity and to look for a possible pelvic abscess, and bacteriological samples must be performed. Management consists in a regimen combining two antibiotics intravenously, with the possible addition of intravenous heparin in case of pelvic thrombophlebitis. Antibiotics can be discontinued 48 h of a clinical improvement and further treatment by oral route brings no benefit. Intrauterine retention associated with post-abortion endometritis must be addressed either by medical or surgical method.

[Invasive conservative care in cases of severe post-partum haemorrhage: future fertility and pregnancy outcome consequences]. / Prise en charge invasive conservatrice pour hémorragie du post-partum : fertilité et devenir obstétrical.

The development of conservative surgical approaches and interventionnal radiology for conservative treatment in cases of severe post-partum haemorrhage allows nowadays a preservation of the genital tract in most of the cases in developed countries. The consequences of these techniques for the future fertility and pregnancy outcome are not fully evaluated. Very few cases of infertility are reported and the majority of the patients seem to recover regular menstrual menses after application of any of the described conservative approach. Pregnancy outcomes appear unchanged without any consequence concerning foetal growth. However, complications might occur, impairing future fertility or pregnancy outcome: uterine synechia have been described after arterial embolization, ovarian failures occurred after stepwise surgical approach including lombo-ovarian artery ligature, synechia and uterine infection impaired uterine compression sutures. Furthermore, recurrence of post-partum haemorrhage and abnormal placentation rates seem to be higher for future pregnancies.

[Contribution of robot-assisted surgery in the management of female infertility]. / Apport de la chirurgie robot-assistée dans la prise en charge de l'infertilité féminine.

Although considerable progresses were made in the field of medically assisted procreation, surgery keeps its place in the therapeutic armamentarium of female infertility. Indeed, its results are very interesting, both in its tubal, myometrial and endometriosis indications. Laparotomy is the first step in the development of any surgical technique. Laparoscopy brings benefits concerning recovery, but also in terms of fertility because of the reduction of postoperative adhesions. Nevertheless, comfort of the surgeon, so the ease of skills, are often altered, especially for complex operations such as those implicated in infertility treatment. Robot-assistance takes here all its interest. It allows indeed a quality in the realization of precise and complex skills, and results at least as interesting as standard laparoscopy can be provided. An overview of robot-assistance in surgery of female infertility is here presented. A review of world literature furnished multiple studies evaluating the tubal robotic surgery, and demonstrating its interesting results. Other indications could, according to us, emerge and be evaluated in this area, such as myomectomy and endometriosis surgery.

Pelvic arterial ligations for severe post-partum hemorrhage. Indications and techniques.

In cases of serious bleeding postpartum, resuscitation and surgical techniques are complementary and should be adapted to both the etiology and severity of bleeding. In extremely severe cases, the performance of a hysterectomy should not be delayed. For women with stable hemodynamic status, so-called "conservative" surgical techniques can instead be used. In this study, we describe and discuss the indications and feasibility of various techniques of vascular ligation. Uterine mattress suture compression techniques and abdomino-pelvic packing are also described. When conservative management is feasible, the first line approach should be bilateral distal ligation of the uterine arteries: this simple and low-risk technique is immediately effective in 80% of cases. If bleeding persists, uterine devascularization can be completed by a triple ligation as described by Tsirulnikov, with or without supplemental proximal ligation of the uterine arteries. This procedure should be performed in preference to the so-called "stepwise ligation sequence", which involves ligation of the ovarian pedicles and poses a risk of subsequent ovarian failure. Bilateral hypogastric artery ligation is also an effective and widely used first-line technique for experienced surgeons. This approach is technically challenging for less-experienced surgeons and is reserved for cases of failed triple ligation.

[Kiwi vacuum extractor versus forceps and spatula: maternal and fetal morbidity evaluation in 169 fetal extractions]. / Ventouse Kiwi versus forceps et spatules : évaluation de la morbidité maternelle et fœtale. À propos de 169 cas.

AIM: To evaluate maternal and fetal complications resulting from the use of the Kiwi vacuum extractor and to compare them with those resulting from the use of forceps or spatula. PATIENTS AND METHODS: Patients who had instrumental extraction between November 2006 and April 2007 were included in a unicentric retrospective study. Complications resulting from the use of Kiwi vacuum extractor and those of other instruments were compared. RESULTS: One hundred and sixty-nine patients where included, 79 had extraction with Kiwi vacuum extractor. The two populations (women having extraction with Kiwi and woman having extraction with spatula or forceps) were similar in terms of maternal characteristics, progress of labour and delivery. The rate of episiotomies was significantly lower with KIWI (73.1% versus 94.4%; P=0.0001), as well as was postpartum haemorrhage rate (8.9 % versus 18.9%; P=0.04). No perineal tear of second or third degree occurred with Kiwi. Kiwi vacuum extractor was associated with a higher rate of shoulder dystocia (12.8% versus 6.7%, NS), but related fetal complication rates were similar in the two groups. The extraction failure rate was significantly higher with Kiwi (11.4% versus 4.4%; P=0.04), but cesarean section rate was similar for the two groups (1.3 % versus 4.4%). DISCUSSION AND CONCLUSION: This study is the first comparing complications occurring after extraction with KIWI vacuum extractor to those occurring with other instruments. Although the results are limited by the retrospective nature of the study and the small size of the workforce, our study suggests that Kiwi vacuum extractor is associated with a lower rate of maternal complications and a rate of fetal complication similar to other kind of instruments. This instrument should be promoted and taught to younger patricians. Our study also revealed higher failure and shoulder dystocia rates. Larger studies are needed to better evaluate risks factor concerning these two complications in order to optimise the use of Kiwi vacuum extractor.

Radiofrequency ablation of retained placenta accreta after conservative management: preliminary evaluation in the pregnant ewe and in normal human placenta in vitro.

OBJECTIVE: To evaluate radiofrequency (RF) efficiency and safety for the ablation of retained placenta in humans, using a pregnant sheep model. DESIGN: Experimental study. SETTING: Laboratory of Surgery School, Nancy, France. POPULATION/SAMPLE: Three pregnant ewes/ten human placentas. METHODS: Various RF procedures were tested in pregnant ewes on 50 placentomes (individual placental units). Reproducibility of the best procedure was then evaluated in a further 20 placentomes and on ten human term placentas in vitro after delivery. MAIN OUTCOME MEASURES: Placental tissues destruction, lesions' size, myometrial lesions. RESULTS: Low power (100 W) and low target temperatures (60 degrees C) lead to homogenous tissue destruction, without myometrial lesion. No significant difference was observed in terms of lesion size and procedure duration for in the placentomes of pregnant ewe in vivo and in human placentas in vitro. The diameter of the ablation could be correlated with the tines deployment. CONCLUSION: The placental tissue structure is very permissive to RF energy, which suggests that RF could be used for the ablation of retained placenta, providing optimal control of tissue destruction. These results call for further experimental evaluations.

[Radioguided occult lesion localization in breast cancer (ROLL): new techniques?]. / Techniques préopératoires de repérage isotopique des lésions infracliniques mammaires (Trilim) dans les cancers du sein: techniques d'avenir?

Radioguided occult lesion localisation (ROLL) is a new technique which allows identification of non palpable breast lesion in breast cancer using, on the model of sentinel node procedure, injection of a radiotracer over the tumour lesion. With a gamma detection probe, it is then possible during surgery to identify in the same time the lesion and the sentinel lymph nodes. Compared with the wire-guided localisation (WGL), ROLL seems easier to achieve for radiologists, the excision procedure seems to be simpler with a good lesions resection in sano rate and a good cosmetic result.