Effectiveness of elective cervical cerclage according to obstetric history.

OBJECTIVE: To assess the effectiveness of elective history-indicated cervical cerclage according to obstetrical history. STUDY DESIGN: We analyzed pregnancy outcome of a retrospective cohort of women who have had history-indicated McDonald's cerclage. Principal outcome was gestational age (GA) at delivery. RESULT: Between January 2003 and December 2013, 205 women were included. We analyzed population in two risk groups: 1- Low-risk (≤2 prior preterm birth (PTB)/second trimester loss (STL), or prior success of cerclage), 2- High risk (≥3 prior PTB/STL, or prior failure of cerclage). In the high-risk group, there was a higher frequency of deliveries before 37 weeks (47.5% vs. 24.5%, P=0.001, OR=2.79, 95% CI [1.49-5.23]). Fifty percent of women (n=6/12) delivered before 37 weeks in case of three or more prior PTB/STL, and 51% (n=24/47) in case of prior failure of cervical cerclage. CONCLUSION: Elective cervical cerclage may be indicated for women with≤2 prior PTB/STL, or prior successful cerclage. For women with≥3 prior PTB/STL, trachelorraphy or cervico-isthmic cerclage could be possible alternatives to cervical cerclage.

Endometriosis-related infertility: ovarian endometrioma per se is not associated with presentation for infertility.

STUDY QUESTION: Is there an association between the endometriosis phenotype and presentation with infertility? SUMMARY ANSWER: In a population of operated patients with histologically proven endometriosis, ovarian endometrioma (OMA) per se is not associated with an increased risk of presentation with infertility, while previous surgery for endometriosis was identified as a risk factor for infertility. WHAT IS KNOWN ALREADY: The increased prevalence of endometriosis among subfertile women indicates that endometriosis impairs reproduction for reasons that are not completely understood. STUDY DESIGN, SIZE, DURATION: This was an observational, cross-sectional study using data prospectively collected in all non-pregnant patients aged between 18 and 42 years, who were surgically explored for benign gynaecological conditions at our institution between January 2004 and March 2013. For each patient, a standardized questionnaire was completed during a face-to-face interview conducted by the surgeon during the month preceding surgery. PARTICIPANTS/MATERIALS, SETTING, METHODS: Surgery was performed in 2208 patients, of which 2066 signed their informed consent. Of the 1059 women with a visual diagnosis of endometriosis, 870 had histologically proven endometriosis and complete treatment for their endometriotic lesions, including 307 who presented with infertility. Univariate analysis and multiple logistic regression analysis were performed to determine factors associated with infertility. MAIN RESULTS AND THE ROLE OF CHANCE: The following variables were identified as risk factors for endometriosis-related infertility: age >32 years (odds ratio [OR] = 1.9; 95% confidence interval [CI]: 1.4-2.4), previous surgery for endometriosis (OR = 1.9; 95% CI: 1.3-2.2), as well as peritoneal superficial endometriosis (OR = 3.1; 95% CI: 1.9-4.9); Conversely, previous pregnancy was associated with a lower rate of infertility (OR = 0.7; 95% CI: 0.6-0.9 and OR = 0.6; 95% CI: 0.4-0.9, respectively). OMA is not selected as a significant risk factor for infertility. LIMITATIONS, REASON FOR CAUTION: The selection of our study population was based on a surgical diagnosis. We cannot exclude that infertile women with OMA associated with a diminished ovarian reserve, as assessed during their infertility work-up, were referred less frequently to surgery and might therefore be underrepresented. In addition we cannot exclude that our group of infertile women present associated other causes of infertility. WIDER IMPLICATIONS OF THE FINDINGS: Identification of risk and preventive factors of endometriosis-related infertility can help improve clinical and surgical management of endometriosis in the setting of infertility. STUDY FUNDING/COMPETING INTERESTS: None. TRIAL REGISTRATION NUMBER: None.

[Surgical treatments of presumed benign ovarian tumors]. / Traitements chirurgicaux des tumeurs ovariennes présumées bénignes.

The surgical management of presumed benign ovarian tumors (PBOT) must ensure complete removal of the cyst, reduce the risk of recurrence (especially in case of endometrioma), prevent any risk of tumor dissemination, and must preserve healthy ovarian tissue. Asymptomatic PBOT should not be punctured. Expectation is preferable to puncture. Laparoscopy is the gold standard for surgical treatment. Single-port laparoscopy is feasible and being evaluated. Peritoneal exploration and peritoneal cytology are conventionally performed. Ovarian cystectomy, oophorectomy and salpingo-oophorectomy are the standard techniques. Suture after cystectomy is not recommended. The extraction of the cyst using an endoscopic bag is recommended. Peritoneal washing after surgery is recommended. The use of anti-adhesions barriers is not recommended routinely. In case of dermoid cyst, cystectomy by mesial incision may decrease the risk of intraoperative rupture. In case of endometrioma, the intraperitoneal cystectomy is recommended as first-line surgery. Exclusive bipolar coagulation should be avoided because of increased risk of recurrence and lower pregnancy rates. There is no argument to support the use of plasma energy and CO2 laser in the treatment of endometriomas. Ethanol sclerotherapy may be proposed in patients with recurrent endometriomas after surgery and referred to medically assisted procreation, although there is no comparative trial with cystectomy.

[Induction of labour and breech presentation: experience of a French maternity ward]. / Induction du travail et présentation du siège : expérience de la maternité de l'hôpital Robert-Debré, Paris.

INTRODUCTION: For a few years, we can notice a progressive increase in the practice of systematic caesarean delivery as far as breech delivery is concerned. This is true notably since the publication of Hannah's "Term Breech Trial" in 2000 which recommends systematic caesarean delivery in the case of breech presentation. But the conclusions of this North-American study are questionable, knowing that French practice is often quite different from Hannah's study. OBJECTIVE: In the maternity ward of the French hospital Robert-Debré, Paris, vaginal delivery may be authorized as far as breech presentation is concerned if defined obstetrical criteria are met. Labour can be induced when a maternal or fetal indication exists. In the following study, we tried to assess our practice. STUDY DESIGN: Our retrospective study included 624 patients with a breech presentation, of which 501 within the group of spontaneous labour (group 1) and 123 within the group of cervical preparation and induced labour (group 2), for the period going from 1 January 2000 to 31 December 2008. RESULTS: The results do comfort our attitude since they show equivalent results in terms of delivery mode and neonatal issues between breech presentations with spontaneous labour on one hand, and with labour induced by cervical maturation on the other hand. CONCLUSION: The primary objective of this study was to evaluate an unusual operating practice in a well-trained level 3 obstetrical team. The results do comfort our attitude since they show equivalent results in terms of delivery mode and neonatal issues between breech presentations with spontaneous labour on one hand, and with labour induced by cervical maturation on the other hand. It seems however difficult to extrapolate our results and apply them to usual practice due to the lack of power of a retrospective and non-randomized study. Setting up a randomized and prospective study seems however difficult because of the medical and ethical problems it would raise.

Mycobacterium heckeshornense: an emerging pathogen responsible for a recurrent lung infection.

Mycobacterium heckeshornense was responsible for a severe, recurrent and chronic pulmonary infection in an immunocompetent 65-year-old woman. The pathogen, initially identified as Mycobacterium xenopi and considered as a contaminant, led to a delayed adapted antimicrobial treatment. Although M. heckeshornense is phenotypically closely related to M. xenopi, its pathogenicity is noticeably higher. Accurate molecular diagnosis methods and treatment guidelines are needed to improve the management of patients infected by this uncommon pathogen.