Transperineal ultrasound in routine uterine cervix measurement.

PURPOSE: Transvaginal ultrasound (TVUS) is used in routine practice to evaluate cervical length (CL). This technique is nevertheless invasive and often viewed as uncomfortable, which is less the case with transperineal ultrasound (TPUS). This study was conducted in light of recent technological improvements in the ultrasound field to evaluate whether TPUS could be used as an alternative to TVUS in CL assessment. METHODS: This was a prospective single-blind study. Pregnant women requiring CL measurement during their emergency consultation were offered a second assessment by TPUS after an initial TVUS. TPUS was performed by a third-year OBGYN resident, unaware of the CL measurement obtained via TVUS. RESULTS: Seventy-three women were included. The mean ∂ was 0.59 mm. The interclass Pearson correlation coefficient between the two techniques was 0.8987 (95% CI [0.8429; 0.9353]). None of the tested factors were found to be associated with a difference between TPUS and TVUS CL measurements. ROC curve analysis indicated that a transperineal CL cut-off measurement of 24.9 mm was predictive of a transvaginal CL measurement below 25 mm. This threshold enabled a 95% sensitivity [75.1-99.9%] and a 100% specificity [93.3-100%] for the TPUS CL measurement technique. CONCLUSION: TPUS should be acknowledged as a reliable alternative to TVUS for CL assessment in routine every day practice.

Management of labor during registrarship: A prospective study during a two-year registrarship program.

AIM: Labor management is often considered to be stressful. Increases in cesarean section (CSD) and assisted vaginal (AVD) deliveries rates have been ascribed to inexperience. To address this issue, we observed the obstetric management activity of four obstetrics and gynecology registrars throughout their 2-year registrarship program. METHODS: We performed a prospective, observational study of urgent and semi-/nonurgent CSD and AVD in a tertiary maternity unit. The registrars' obstetric management was compared with that of a referral group. Changes over time in the registrars' practice were also monitored. RESULTS: A total of 4328 deliveries (including 670 CSD and 736 AVD) were analyzed. The registrars and the experienced obstetricians managed 2930 and 1398 deliveries, respectively, with similar neonatal outcomes. There were no intergroup differences in either total CSD percentage (455 [15.5%] and 215 [15.4%] for registrars and experienced practitioners, respectively, P = 0.90) or AVD percentage (478 [16.3%] and 258 [18.5%], respectively, P = 0.08), or according to degree of urgency. Rates did not change over the course of the registrarship program, regardless of degree of urgency. CONCLUSION: Lower degree of experience was not associated with elevated CSD or AVD rates. Skills required to appropriately manage an obstetric ward seemed to have been acquired at the end of residency.

Impact of Age at Conization on Obstetrical Outcome: A Case-Control Study.

OBJECTIVE: The aim of the study was to assess whether an age younger than 25 years at conization affected future pregnancy outcome as an independent factor. MATERIALS AND METHODS: A retrospective study of 115 women who underwent both loop electrosurgical excision procedure (LEEP) and subsequent pregnancy follow-up in a referral center was conducted. Two groups were considered: patients younger than 25 years at the time of LEEP (n = 42) and 25 years or older (n = 73). Analyzed data were occurrence of preterm adverse obstetrical event and, specifically, preterm labor (PL) and preterm rupture of membranes; stratification based on term of occurrence was performed: less than 37 weeks of amenorrhea (WA), less than 34 WA, and less than 26 WA. RESULTS: Patients characteristics were comparable in terms of excised specimen thickness and pathological analysis, as well as for tobacco intoxication during pregnancy. Although there was no difference of term at delivery or total number of preterm adverse obstetrical events, we found a significant increase of events (19% vs 4.1%) and PL (19% vs 0%) before 26 WA in the group of patients younger than 25 years. After adjusting for excised specimen thickness, the same results were found for thickness of 15 mm or less (respectively, 16.7% vs 3.3% and 16.7% vs 0%). For thickness of greater than 15 mm, only ratio of PL before 26 WA was higher in the group of patients younger than 25 years (33.3% vs 0%). CONCLUSIONS: Age younger than 25 years at the time of LEEP seems to be is associated with a more frequent occurrence of extremely early preterm adverse obstetrical events, particularly PL.

Practice and expectations regarding simulation for residents in obstetrics and gynecology.

BACKGROUND: Simulation now has an important role in theoretical and practical aspects of medical education and training. METHODS: We performed an epidemiological, observational, multicenter study based on nationwide data collection. French obstetrics and gynecologic residents were invited to complete an anonymous survey. RESULTS: We received 305 answers. The most frequently offered gynecology sessions were laparoscopy on pelvitrainer (76%) and pelvic ultrasound (60%) while the most frequently offered obstetric sessions were breech delivery (61%), shoulder dystocia (62%) and postpartum hemorrhage (68%) managements. Regarding session frequency, 29.1% of residents thought that one session per month would be ideal. Two hundred and sixty three residents (96%) considered that simulation-training sessions were beneficial. One hundred and thirty-six residents (49%) had an opportunity to repeat sessions and a majority of them (96%) found a daily benefit following a training simulation session. CONCLUSION: Simulation programs were extremely popular among the surveyed residents. To improve OBGYN resident training, simulation should be an integral part of residency programs.

Risk factors for failed chorionic villus sampling: results of a 4-year retrospective study.

OBJECTIVES: Chorionic villus sampling (CVS) allows for earlier results for aneuploidy or genomic abnormalities compared to amniocentesis. Nevertheless, the inability to provide complete results has been described as being more frequent with CVS. This study was conducted in order to identify risk factors for such failures. STUDY DESIGN: A retrospective single-center study was performed from January 2014 to December 2018. Participants were divided into two groups depending on whether complete CVS results were issued ("successful CVS group") or not ("failed CVS group"). Failure affected preliminary short-term cultures, long-term cultures, or both. RESULTS: During the study period, 214 CVS were performed, 73 (34%) of which were classified in the failed CVS group. We observed significant intergroup differences between the successful and failed CVS groups for four variables: BMI (respectively 23.9 [±5.88] and 25.9 [±6.13] kg/m2), term at sampling (12.9 [±1.35] and 12.6 [±1.09] weeks gestation), trophoblastic location (posterior in 49 [40%] and 37 [66%] cases), and sampling approach (transcervical in 54 [43%] and 36 [64%] cases) (p < .05). In a stepwise binary logistic regression analysis, higher BMI, posterior trophoblastic location, and transcervical sampling approach were the only variables negatively influencing CVS success, with respective aOR [95% CI] of 0.947 [0.898; 0.996], 0.322 [0.160; 0.634], and 0.466 [0.238; 0.900]. CONCLUSIONS: In the presence of CVS failure risk factors, a discussion could be initiated regarding a deferred amniocentesis as a first option.

Transvaginal mesh repair of pelvic organ prolapse by the transobturator-infracoccygeal hammock technique: long-term anatomical and functional outcomes.

AIMS: To evaluate long-term anatomical and functional outcomes of the transobturator-infracoccygeal hammock repair for complex genital prolapse with a porcine collagen-coated polypropylene mesh. METHODS: A prospective observational study comparing pre- and postoperative outcomes, using pelvic organ prolapse quantification (POP-Q) measurements, pelvic floor distress inventory (PFDI), and pelvic floor impact questionnaire (PFIQ) scores. RESULTS: One hundred fourteen women with recurrent, advanced, or posthysterectomy genital prolapse were enrolled. During follow-up (median value 57 months), 101 patients were available for assessment. Overall anatomical success rate was 96%, with significant improvement in quality-of-life. Three patients experienced symptomatic recurrent posterior prolapse. Seven had persistent stress urinary incontinence. Mesh exposure occurred in 6.9% of cases, including an infected hematoma that required partial excision of the mesh. No severe adverse event or change in sexual function was observed. CONCLUSIONS: The transobturator-infracoccygeal hammock is well tolerated with effective long-term anatomical and functional results for complex genital prolapse. In our experience and compared to the data of the literature, the use of collagen-coated versus uncoated polypropylene meshes seems to decrease local morbidity.

General practitioners and endometriosis: Level of knowledge and the impact of training.

OBJECTIVE: To assess general practitioners' (GPs') knowledge of and practice in the diagnosis and management of endometriosis following the publication of updated French national guidelines in 2017. MATERIALS AND METHODS: A descriptive, anonymous, epidemiological survey of 102 GPs in the Picardie region of France. RESULTS: Only 25% of the GPs considered that they knew enough about endometriosis for their routine clinical practice. This proportion was 58.9% amongst GPs with an university diploma in gynaecology and 31.4% amongst those participating in continuing medical education courses on gynaecology. Only 19.6% of the GPs were aware of the updated French national guidelines. With regard to five main suggestive, localizing signs of endometriosis, dyspareunia, dysmenorrhoea and infertility were mentioned as being of diagnostic value by 55.9%, 37.3% and 43.1% of the GPs, respectively; in contrast, functional urinary tract disorders and painful defecation were not mentioned very often. GPs with a qualification in gynaecology and those participating in continuing medical education in gynaecology knew more about treating endometriosis. CONCLUSION: In the Picardie region of France, GPs appear to be only moderately aware of how to manage endometriosis; this probably contributes to the diagnostic delay associated with this condition. GPs with a university diploma in gynaecology and those participating in continuing medical education in gynaecology appeared to have a better grasp of the subject. Continuing medical education on this topic should therefore be promoted and expanded.

Treatment of concomitant prolapse and stress urinary incontinence via a transobturator subvesical mesh without independent suburethral tape.

OBJECTIVE: Evaluate the efficacy of a transobturator subvesical mesh for cystocele in concomitant stress urinary incontinence (SUI). DESIGN: Longitudinal observational study. SETTING: Tertiary referral urogynecology center. POPULATION: One hundred and five women with at least an anterior vaginal wall prolapse and concomitant SUI who underwent surgery. METHODS: After reduction of prolapse elements, the intervention consisted of a non-absorbable monoprosthesis placement with two transobturator expansions and, if necessary, associated hysterectomy or infraccocygeal sacropexy. No specific procedure was performed for SUI. MAIN OUTCOME MEASURES: All patients had a physical examination and a subjective symptoms assessment via questionnaire in the preoperative period and at one-year or more after surgery. The pelvic organ prolapse quantification system was used for anatomical results. For SUI, Ingelman-Sundberg classification and cough test were used. Loss of urine was measured by a one-hour pad test. Functional results were evaluated by visual analog scale, quality-of-life questionnaires, including the pelvic floor distress inventory and the pelvic floor impact questionnaire. RESULTS: Median follow-up was 45 months (range: 12-72). A total of 102 women (97%) were cured of their prolapse, of whom 72 (69%) were cured of their SUI and 13 (12%) showed improvement. Pad test, visual analogic scale and quality-of-life questionnaires were all improved (p < 0.05). Complications consisted of one rectal injury, one transitory urinary retention, and two hematomas. Of the erosions 6% was observed for monofilament polypropylene prostheses. CONCLUSION: Transvaginal monoprosthesis for the simultaneous correction of prolapse and SUI represents an effective treatment for bulky or recurrent prolapse as well as posthysterectomy vaginal vault prolapse.

Value of large loop excision of the transformation zone (LLETZ) without histological proof of high-grade cervical intraepithelial lesion: Results of a two-year continuous retrospective study.

OBJECTIVE: Large loop excision of the transformation zone (LLETZ) conization has been associated with adverse obstetrical outcomes. In an approach to reduce the number of performed LLETZ procedures, we conducted this study to evaluate whether "diagnostic" LLETZ should still be performed, by analyzing their yield in terms of detection (and treatment) of real high-grade squamous intraepithelial lesion (HSIL). METHODS: During a two-year study period, all patients who underwent a LLETZ procedure in our institution were retrospectively included. Study participants were divided into two groups according to LLETZ indication: a biopsy-proven HSIL group, and a non-biopsy-proven HSIL group. The results of the final histological examination were recorded, as well as excision margin status and specimen dimensions. RESULTS: During the two-year study period, 396 LLETZs were performed, 283 (71%) of which were indicated by biopsy-proven HSIL. In the non-biopsy-proven group, final histology showed 50 cases of HSIL (44%) and 4 cases of carcinoma (3.6%), versus respectively, in the biopsy-proven group, 221 (78%) HSIL and 28 (9.9%) carcinoma (p<0.001). Regarding margin status and specimen dimensions, no intergroup difference was observed between the two groups. CONCLUSION: So called "diagnostic" LLETZ allowed the detection of severe cervical lesions in almost half of cases, without increasing specimen dimensions in comparison with classical conization indications. Moreover, they also allowed an efficient treatment as showed by similar margins status. Our results therefore strengthen the idea that "diagnostic" LLETZ, when specific indications are respected, should not be overlooked as a major part of our therapeutic arsenal.

Can certain factors for recurrence of placenta-mediated pregnancy complications be identified after an initial small-for-gestational-age birth?

Introduction: After a small-for-gestational-age (SGA) birth, recurrence of placenta-mediated pregnancy complications (PMPCs) is a cause for anxiety when contemplating another pregnancy. We sought to identify factors potentially associated with this recurrence.Material and methods: This retrospective single-center observational study was conducted in a tertiary maternity unit between 1 January 2010 and 31 December 2017. We included all women having experienced a non-syndromic SGA birth and who were subsequently monitored for at least one other pregnancy in our institution. PMPCs were defined as recurrent SGA births, three consecutive first-trimester miscarriages, or preeclampsia.Results: Ninety-four women were included over a 7-year study period. Recurrent PMPCs were recorded in 30 (32%) cases, of which 29 featured recurrent SGA births. None of the following characteristics were significantly associated with recurrence: presence of preeclampsia during the initial pregnancy (six [20%] versus 25 [39%] cases in the recurrent PMPCs and non-recurrent PMPCs groups, respectively; p = .11), results of the histopathologic placental examination or thrombophilia screen, or implemented treatment during subsequent pregnancies.Conclusions: PMPCs recur frequently. No risk factor for recurrence was identified in our study. Results of etiologic assessments and treatments implemented after an initial SGA birth should therefore not modify level of clinical and ultrasound monitoring provided during subsequent pregnancies.Rationale: Recurrence of placenta-mediated pregnancy complications is a cause for anxiety when contemplating another pregnancy. We did not identify any risk factor after an initial small-for-gestational-age birth in our study; surveillance should therefore not be modified by the etiologic assessments' results.

Risk factors for unsatisfactory colposcopy after large loop excision of the transformation zone: The results of a four-year multicenter prospective study.

OBJECTIVES: Not being able to completely examine the cervical squamocolummar junction (SCJ) in colposcopy after large loop excision of the transformation zone (LLETZ) is an important issue regarding surveillance, as high-grade cervical intra-epithelial neoplasia recurrence risk is high. This study was conducted in order to identify risk factors for post-LLETZ unsatisfactory colposcopy. METHODS: This prospective multicenter observational study was performed in nine French University hospitals, with inclusions running from December 2013 to December 2017. All patients scheduled for LLETZ were included and were divided into two groups after the two to four months post-procedure colposcopic examination: a satisfactory and an unsatisfactory post-LLETZ colposcopy group. RESULTS: In total, 601 cases were analyzed and 71 post-LLETZ colposcopies (12%) were described as unsatisfactory (including 19 cervical stenosis). In a univariate analysis, we only observed a statistically significant increase of the following parameters in the unsatisfactory post-LLETZ group in comparison with the satisfactory post-LLETZ group: parity (2.11 [±1.55] and 1.49 [±1.24] respectively, p < .01), depth of the LLETZ specimen (10.9 mm [±3.37] and 9.76 [±3.79] respectively, p < .01), age (45.9 years [±11.7] and 37.9 [±9.42] respectively, p < .001) and an unsatisfactory pre-LLETZ colposcopy (43 satisfactory pre-LLETZ colposcopies [61%] and 456 [86%] respectively, p < .001). In a stepwise binary logistic regression analysis, only the two latter parameters were found to be independently associated with unsatisfactory post-LLETZ colposcopies. CONCLUSIONS: Surgeons should consider other therapeutic strategies when contemplating iterative diagnosis-LLETZ in older women with initially invisible SCJ, as an appropriate post-LLETZ surveillance is at higher risk of being impossible to achieve.

Fertility and pregnancy outcomes following uterine devascularization for severe postpartum haemorrhage.

BACKGROUND: To evaluate the fertility and pregnancy outcomes following uterine devascularization for postpartum haemorrhage (PPH). METHODS: All patients who required uterine devascularization, i.e. bilateral uterine artery ligation (Group A), and either bilateral utero-ovarian ligament (Group B) or suspensory ligament of ovary ligation (Group C) in cases of persistent haemorrhage, for PPH with no concomitant procedures from December 1997 to March 2004 were included. Data were retrieved from medical files and telephone interviews. RESULTS: Data were available for 32 of the 40 (80%) patients included in the study. All patients but 4 had a return to normal menses. Postpartum amenorrhea was secondary to ovarian failure in two cases, and synechiae or necrotic uterus each in one case. These four patients belonged to Group C, whereas no adverse events were observed in groups A and B. Thirteen patients had 16 pregnancies with 13 term deliveries, 1 ectopic pregnancy and 2 abortions. Clinical course of the 13 complete gestations were uneventful but PPH recurred in 4 (31%) due to placenta accreta in three cases. CONCLUSIONS: Uterine artery ligation, whether or not associated with utero-ovarian ligament ligation, for PPH does not appear to compromise the patients' subsequent fertility and obstetrical outcome.

Infracoccygeal sacropexy reinforced with posterior mesh interposition for apical and posterior compartment prolapse.

OBJECTIVE: To assess the efficacy, safety and functional outcome of infracoccygeal sacropexy reinforced with posterior mesh interposition performed alone or in combination with the implantation of other prosthetic materials for prolapse repair. STUDY DESIGN: Seventy-two patients requiring prolapse repair for apical and/or posterior compartment prolapse, operated between March 2002 and September 2005. Patients underwent physical examination for prolapse assessment according to the international pelvic organ prolapse staging system and were evaluated for objective and subjective prolapse symptoms pre- and post-operatively. Objective success was defined by the midline posterior vaginal wall at stage 0 or 1, while subjective success was defined by a score above or equal to 7.5 measured on a visual analogue scale (0, very disappointed; 10, very satisfied). Follow-up was done at 6 weeks, 6 months and then once a year. RESULTS: Seventy-two patients with a mean age of 65 years were followed-up with a median of 26.3 months (range 10-43). Stages 3 and 4 represented 65.3% of all apical and/or posterior compartment prolapse. Fifty-nine patients had a concomitant anterior prolapse repair. Both objective and subjective success rates were 97.2%. All subjective prolapse symptoms decreased after surgery. The only intraoperative complication was one rectal injury. Vaginal erosion rate was 13.9% and mesh infection rate was 4.2%. Vaginal erosions statistically occurred less often with monofilament polypropylene (5.7%, 2/35) than with multifilament polypropylene (13.6%, 3/22) or polyester (33.3%, 5/15) (p<.04). CONCLUSION: Infracoccygeal sacropexy reinforced with posterior mesh interposition provides effective and promising results in correcting apical and/or posterior compartment prolapse. Analysis of long-term success rates and comparison with previously accepted surgical procedures are required to determine the place of this procedure in the strategy of genital prolapse repair.

Factors associated with removal difficulties of etonogestrel-containing contraceptive implants (Nexplanon®).

OBJECTIVES: Nexplanon®'s new applicator system was designed to limit deep implant placements, known to lead to difficult removals. However, removal difficulties still exist and induce specific and potentially severe complications. Our objective was to identify risk factors associated with difficult removals. STUDY DESIGN: A retrospective single-center study was performed from January 2015 to December 2016. Participants were divided into two groups depending on whether implant was removed during a standard ("standard removal" group) or difficult consultation ("difficult removal" group) after an initial failed removal attempt. RESULTS: The difficult and standard removal groups comprised 63 and 660 women, respectively. In a univariate analysis, significant intergroup differences were found for weight gain (3.7 ±â€¯7.3 kg in the difficult removal group vs. 1.3 ±â€¯5.1 in the standard removal group), proportion of placements performed in private practice (66.7% vs. 19.8%, respectively), and duration of Nexplanon® placement (29.4 ±â€¯11.3 months versus 26 ±â€¯13.6, respectively). We also reported more frequent sub-brachial fascia placements when Nexplanon® was implanted by a private practitioner (7.5% cases versus 0.4% in hospital implantations, p < 0.001). In a stepwise binary logistic regression analysis, placement by a private practitioner, weight gain >1 kg since placement, and duration of implant placement >25 months were confirmed as independent risk factors for removal difficulties (respective risk ratios 7.63 [95% IC 4.35-13.33], 2.10 [1.18-3.70], and 1.91 [1.06-3.44], p < 0.05). CONCLUSIONS: Awareness of these three simple parameters might help physicians to identify "at risk-patients", and suggest a specific consultation before risking a potentially hazardous removal (with its associated, specific morbidity). Our results also emphasize importance of training in implant insertion.

[Vesicovaginal fistula after transobturator tape]. / Fistule vésico-vaginale après bandelette transobturatrice.

The transobturator approach is gradually replacing the retropubic approach for the treatment of female stress urinary incontinence and suburethral tape. The major argument in favour of this approach is the decreased risk of bladder injury during insertion of the needles, which nevertheless remains a minor complication. Provided another more median approach is used in closer contact with the bone, followed by prolonged bladder catheterization for 24 to 48 hours, this complication has no consequences. However, the authors report a case of bladder injury during insertion of transobturator tape (TOT) in a patient with no particular history, attributable to the technique itself as it occurred during finger dissection towards the obturator membrane. This complication led to secondary formation of a vesicovaginal fistula after insertion of the tape, despite satisfactory repair of the bladder This case illustrates that TOT is not devoid of risks to the bladder; with sometimes even serious consequences. TOT should not be inserted when bladder suture is required. If a fistula is observed after insertion of TOT the tape should be completely removed as soon as possible, but correction of urinary incontinence may persist.

Could Patients Older than 75 Years Benefit from a Systematic Breast Cancer Screening Program?

BACKGROUND/AIM: To assess prognosis of women aged 75 and older according to breast cancer (BC) diagnosis circumstances. PATIENTS AND METHODS: A retrospective cohort study was conducted in the Amiens, France, regional oncologic referral center between 2005 and 2015. Two groups were formed depending on whether the patients followed clinical manifestations (CM) or a prescribed systematic mammography (SM). RESULTS: Three hundred and ninenty-three patients were selected. CM and SM represented 72% and 14.5% of BC diagnosis circumstances, respectively. In the SM group statistically significant differences included: earlier stage cancer diagnosis (tumor stages 0 and 1 accounted for 6.3% and 61.4% of cases, respectively), less lymph node invasions (35.7% and 8.8%) and metastases (19.1% and 0%), more frequent possibility of conservative surgery (25.6% and 74.5%), improved global and disease-free survival rates (by 14.2 and 18.4 months). CONCLUSION: Screening seems to improve prognosis of older BC patients; this constitutes a strong argument for reconsidering age limits of national BC screening programs.

[Vaginal prolapse and stress urinary incontinence: combined treatment by a single prosthesis]. / Prolapsus vaginal et incontinence urinaire d'effort: traitement combiné par une prothèse unique.

OBJECTIVES: To evaluate the efficacy and possible short-term and medium-term complications of vaginal prosthetic surgery with transobturator fixation to treat prolapse and stress urinary incontinence (SUI) that are often associated in a single operation. MATERIAL AND METHOD: From February 2002 to August 2004, 45 patients with a mean age of 66 +/- 11 years presenting essentially stage 3 or 4 cystocele associated with SUI (documented for 40 cases and revealed by reduction of the prolapse for the other five) were operated according to the transobturator infracoccygeal sling technique. RESULTS: With a mean follow-up of 31 +/- 9 months, the success rate of the technique was estimated to be 98% anatomically (only one failure) and 91% in terms of urinary symptoms (73% of patients were cured, 18% were improved and 9% failed). No cases of urinary retention were observed, except for one patient with a secondarily infected pelvic haematoma requiring evacuation and the partial removal of the prosthesis. The mean residual urine on discharge was 83 ml. Two patients developed de novo overactive bladder The prostheses exposure rate was 18%. CONCLUSION: Combined treatment of vaginal prolapse and associated urinary incontinence is possible by the use of a single transvaginal prosthesis. The medium-term anatomical results are very good. The results on continence are good and a subsequent specific procedure is always possible in the case of failure or insufficient improvement. The prostheses exposure rate is similar to that observed with synthetic transvaginal prostheses.

Late complications of operative hysteroscopy: predicting patients at risk of uterine rupture during subsequent pregnancy.

The main purpose of this study was to identify predictors of uterine rupture following operative hysteroscopy. We also attempted to assess possible clinical or imaging methods in order to detect and avoid impending ruptures. A MEDLINE and EMBASE search of the English, German and French literatures was performed to retrieve case reports of uterine rupture following operative hysteroscopy. A total of 14 cases were retrieved. Twelve patients had a history of hysteroscopic metroplasty. Uterine perforation complicated operative hysteroscopy in eight cases and electrosurgery was used in nine cases. The interval between hysteroscopy and subsequent pregnancies varied from 1 month to 5 years with an average range of 16 months. Hysterosalpingogram follow-up was carried out in six cases and was considered normal in five cases. During pregnancy, serial ultrasound scans were performed in two cases to detect impeding rupture without success. Hysteroscopic metroplasty subjected patients to high risks of uterine rupture during subsequent pregnancies. Uterine perforation and/or the use of electrosurgery increase this risk but are not considered an independent risk factor. Uncomplicated hysteroscopic resection of submucous myomas and endometrial polyps did not alter obstetrical outcome. Apart from favourable use of scissors for hysteroscopic metroplasty, no accurate methods to prevent or detect impending ruptures in subsequent pregnancies were found. Physicians providing care for patients with previous hysteroscopic metroplasty or complicated operative hysteroscopy, should be aware of the potential risks for uterine rupture during pregnancy.

Prognostic factors of second primary contralateral breast cancer in early-stage breast cancer.

The aim of the present study was to investigate the therapeutic outcome of early-stage breast cancer (pT1aN0M0) and to identify prognostic factors for secondary primary contralateral breast cancer (CBC). A total of 85 patients with mammary carcinomas were included. All patients had undergone breast surgery and adjuvant treatment between January 2001 and December 2008 at the Central Hospital of Grenoble University (Grenoble, France). The primary end-points were disease-free survival and secondary CBC, and the potential prognostic factors were investigated. During a median follow-up of 60 months, 10 of the 85 patients presented with secondary primary cancer, of which six suffered with CBC. No patient mortalities were reported. The rates of CBC were 2.35, 3.53 and 7.06% at one, two and five years, respectively. The cumulative univariate analysis showed that microinvasion and family history are potential risk factors for newly CBC. The current study also demonstrated that secondary CBC was more likely to occur in patients with microinvasion or a family history of hte dise. In addition, the systematic treatment of secondary CBC should include hormone therapy.

[Management of an ovarian cyst during pregnancy]. / Prise en charge d'un kyste de l'ovaire pendant la grossesse.

OBJECTIVE: With routine ultrasonographic examination during the first trimester, the discovery of an ovarian cyst has become relatively common in the beginning of pregnancy. Between a waiting policy and interventionism, where is the optimal management situated? The objective of this article, based on the analysis of articles published on the subject in the data base of Medline, was to reply to this question. IN GENERAL: Most of unilocular and anechoic ovarian cysts with thin borders during the first trimester are corpus luteum cysts. They are not generally present after the end of the first trimester. Except in the case of complications, abstention is advocated in their respect. After 16 weeks of amenorrhea, organic cysts are the most frequent, mainly dermoid cysts. Only ovarian cysts at risk of complication are to be considered. They are essentially ovarian cysts which, whatever their echogenic features, have a size > or =6 cm. Their prevalence is estimated between 0.5 and 2 per thousand of pregnancies. The complications of these cysts are represented mainly by torsion, intracystic bleeding and rupture. THE TIME FOR SURGERY: Emergency surgery during the first trimester, especially before 9th week of amenorrhea, for complication of an ovarian cyst is associated with a high rate of abortion. In the second part of pregnancy, foetal morbidity with prematurity provoked by emergency surgery is considerable. The ideal period for scheduled surgery is probably the beginning of the second trimester. The probability of operating on a functional cyst becomes small and the rate of abortion is minimized. Coelioscopy is then often possible and does not appear to have much impact on the pregnancy. If we are sure of the organic character of an ovarian cyst, after 9 weeks of amenorrhea, then surgery is recommended.