Induction du travail après une version par manœuvres externes pour siège réussie : un sur-risque de césarienne?

OBJECTIVE: To assess the effect of successful external cephalic version (ECV) on the risk of caesarean section (CS) during attempted vaginal delivery after induction of labour. METHODS: A unicentric matched retrospective observational case-control cohort study with exposed and unexposed groups. All pregnant women who had an induction of labour after a successful external cephalic version (sECV) between 1998 and 2016 were included. A total of 88 cases were compared with 176 controls (spontaneous cephalic presentation), matching for the year of delivery, parity, gestational age, indication and mode of induction of labour. The main outcome measure was the risk of caesarean. A univariate analysis and a multivariate logistic regression analysis were performed. RESULTS: The caesarean section rate was significantly higher after sECV (22% versus 13.1%; p = 0.039) especially for postdate pregnancy (55% versus 8.2%; p <0.05). For the univariate analysis, age (31 years and 4 months versus 24 years and 6 months; p <0.01) and maximal speed of oxytocin infusion (72 ml/h versus 68 ml/h; p = 0.04) were higher in the case group. The multivariate analysis showed that the risk of caesarean section was significantly increased after an sECV (aOR 1.946; 95% CI 1.017-3.772) and after the use of prostaglandins for ripening (aOR 1.951; 95% CI 1.097-3.468), and decreased for multipara (aOR 0.208; 95% CI 0.114-0.377). CONCLUSION: Women who have a successful ECV are at increased risk of caesarean section after subsequent induction of labour.

Prognosis associated with initial care of increased fasting glucose in early pregnancy: A retrospective study.

AIM: To evaluate whether the initial care of women with fasting plasma glucose (FPG) levels at 5.1-6.9mmol/L before 22 weeks of gestation (WG), termed 'early fasting hyperglycaemia', is associated with fewer adverse outcomes than no initial care. METHODS: A total of 523 women with early fasting hyperglycaemia were retrospectively selected in our department (2012-2016) and separated into two groups: (i) those who received immediate care (n=255); and (ii) those who did not (n=268), but had an oral glucose tolerance test (OGTT) at or after 22 WG, with subsequent standard care if hyperglycaemia (by WHO criteria) was present. The number of cases of large-for-gestational age (LGA) infants, shoulder dystocia and preeclampsia with initial care of early fasting hyperglycaemia were compared after propensity score modelling and accounting for covariates. RESULTS: Of the 268 women with no initial care, 134 had hyperglycaemia after 22 WG and then received care. Women who received initial care vs those who did not were more likely to be insulin-treated during pregnancy (58.0% vs 20.9%, respectively; P<0.00001), gained less gestational weight (8.6±5.4kg vs 10.8±6.1kg, respectively; P<0.00001), had a lower rate of preeclampsia [1.2% vs 2.6%, respectively; adjusted odds ratio (aOR): 0.247 (0.082-0.759), P=0.01], and similar rates of LGA infants (12.2% vs 11.9%, respectively) and shoulder dystocia (1.6% vs 1.5%, respectively). When initial FPG levels were ≥5.5mmol/L (prespecified group, n=137), there was a lower rate of LGA infants [6.7% vs 16.1%, respectively; aOR: 0.332 (0.122-0.898); P=0.03]. CONCLUSION: Treating women with early fasting hyperglycaemia, especially when FPG is ≥5.5mmol/L, may improve pregnancy outcomes, although this now needs to be confirmed by randomized clinical trials.

[Effects of a policy for reasonable use of oxytocin during spontaneous labor at term]. / Impact d'une politique d'utilisation raisonnée de l'oxytocine de synthèse lors du travail spontané à terme.

OBJECTIVE: To assess the effect of a modified definition of dystocia and of a different timing of interventions during spontaneous labor on the rate of oxytocin use and on its consequences on labor outcome. METHODS: We compared oxytocin use and labor outcome before and after the introduction of a new protocol for the management of spontaneous labor. By protocol, oxytocin use and/or artificial rupture of the membranes was restricted to cases without progress in cervical dilatation for≥1h and/or no progress of fetal descent for≥1h at full dilatation. The main outcome measure was the rate of oxytocin use. Secondary outcome criteria were the consequences on labor (duration of labor, tachysystole and uterine hyperstimulation, abnormal fetal heart rate, cesarean delivery rate) and neonatal outcome. RESULTS: Oxytocin use was strongly reduced from 2015 (69.2%) to 2016 (39.8%; P<0.01) and 2017 (31.9%; P<0.01). Abnormal FHR rates decreased simultaneously (respectively 52%, 37% et 29%, P<0.05), as well as uterine hyperstimulation (respectively 33.6%, 21.3% et 23.0%; P<0.05). The cesarean delivery rate did not vary significantly from 2015 (11.5%) to 2016 (8.4%; NS) but it decreased from 2015 to 2017 (11.5% to 2.6%, respectively; P<0.05). No difference was found in postpartum hemorrhage rates or in neonatal outcome. The duration of labor was significantly longer for women who delivered in 2017, compared with 2015 (372 minutes versus 306 minutes, respectively; P<0.05). After multivariate analysis, FHR abnormalities were reduced (aOR 0.65 IC 95% [0.49-0.86]) as well as cesarean deliveries during labor (aOR 0.5 IC 95% [0.26-0.97]) in 2017 only, compared with the reference year 2015. CONCLUSION: A simple and easy-to-use definition of dystocia and of interventions required during labor allowed a strong reduction of oxytocin use during labor with subsequent benefits such as reduced rates of FHR abnormalities, uterine hyperstimulations and cesarean deliveries, at the cost of a limited prolongation of labor, mainly in nulliparous women.

Is episiotomy worthwile to prevent obstetric anal sphincter injury during operative vaginal delivery in nulliparous women?

OBJECTIVES: Episiotomy is a marker of Obstetric Anal Sphincter Injury (OASIS) condition, therefore, unmeasured factors could have biased the strength of the association between episiotomy and reduced OASIS during Operative Vaginal Delivery (OVD). The aim of this study was to compare the OASIS rate during OVD according to episiotomy practice. STUDY DESIGN: Retrospective cohort study of all nulliparous pregnant women attempting an OVD between 2014-2017. To avoid unmeasured bias, all maternal and delivery data were prospectively captured after the birth. The strong relationship between parity and episiotomy practice (indication bias) lead to analyze only nulliparous women. Association between mediolateral episiotomy and OASIS following OVD was performing by using multivariate logistic regression analysis including significant variable in univariate analysis and relevant factors known to be associated both with OASIS and/or OVD. RESULTS: Over the study period, 1709 (17.1%) women had an OVD, among them 40 (2.3%) had OASIS. In the 1342 (78.5%) nulliparous women, OASIS rate were 2% and 5.1% with and without episiotomy (p < 0.01). In multivariate analysis a lower incidence of OASIS with the use of episiotomy (OR 0.267 IC 0.132-0.541) were observed. The persistent occiput posterior position was associated with an increase risk of OASIS (OR 6.742 IC 2.376-19.124). Spatula/forceps, as compared to vacuum operative vaginal delivery increased the risk OASIS (OR 2.847 IC 1.311-7.168). Area under the curve of the model was 0.745. CONCLUSION: Episiotomy is a modifiable risk factors which can contribute to reduce the risk of OASIS in nulliparous women with operative vaginal delivery. This intervention should be included in a global management of the second stage of labor.

[Induction of labor in women with previous caesarean delivery with balloon catheter: Is it worth it?] / Déclenchement par ballonnet en cas d'utérus cicatriciel et col défavorable : la tentative en vaut-elle la chandelle ?

OBJECTIF: Balloon catheters for labor induction at term after previous cesarean section is an alternative option to iterative cesarean section. The aim of this study was to analyze the maternal and neonatal outcomes of the trial of labor after cesarean (TOLAC) in women with unfavorable cervix and balloon catheter induction, 2 years after introduction of this process. METHODS: Unicentric observational study of women with term cephalic singleton, unfavorable cervix (simplified Bishop score<5) after TOLAC using double-balloon catheter. Were analyzed the mode of delivery and severe maternal (uterine rupture, post-partum hemorrhage, severe perineal tears) and neonatal (neonatal unit admission, APGAR<7 at 5minutes, pH<7.1) outcomes. Predictive factors for failed TOLAC were analyzed by using multivariate logistic regression. RESULTS: Between 2016-2017, 455 (75.4%) women had TOLAC, whose 59 (13%) women with balloon catheter. The overall vaginal delivery (VD) was 73.9%. After Balloon catheter, the VD rate was 50.8%, versus 79.1% after spontaneous labor, and 68.2% after alone oxytocin/artificial membrane rupture induction (P<0.05). Previous VD (aOR 0.176 CI-95% [0.048-0.651]) and prior sweeping membrane (aOR 0.161 CI-95% [0.034-0.761]) was protective for cesarean section after TOLAC. Severe maternal and neonatal morbidities were observed in 10 (17%) and 8 (13.6%) cases, respectively. CONCLUSION: Double-Balloon catheter is an option for unfavorable cervix and term induction after previous cesarean section. However, the TOLAC in women whose unfavorable cervix is not without maternal and neonatal risk, especially due to its failure.

Predicting the likelihood of a live birth for women with endometriosis-related infertility.

OBJECTIVE: Endometriosis affects 10% of women in reproductive age and alters fertility. Its management is still debated notably the timing of surgery and ART in infertility. Several tools have been created to guide the practitioner and the couple yet many limitations persist. The objective is to create a nomogram to predict the likelihood of a live birth after surgery followed by assisted reproductive technology (ART) for patients with endometriosis-related infertility. STUDY DESIGN: All women in a public university hospital who attempted to conceive by ART after surgery for endometriosis-related infertility from 2004 to 2016 were included. We created a model using multivariable linear regression based on a retrospective database. RESULT: Of the 297 women included, 171 (57.6%) obtained a live birth. Age, duration of infertility, number of ICSI-IVF cycles, ovarian reserve and the revised American Fertility Society (rAFS) score were included in the nomogram. The predictive model had an area under the curve (AUC) of 0.77 (95% CI, 0.75-0.79) and was well calibrated. The external validation of the model was achieved with an AUC of 0.71 (95% CI, 0.69-0.73) and calibration was good. The staging accuracy according to AUC criteria for the nomogram compared to the currently used Endometriosis Infertility Index to predict live births were 0.77 (95% CI, 0.75-0.79) and 0.60 (95% CI: 0.57-0.63), respectively. CONCLUSION: This simple tool appears to accurately predict the likelihood of a live birth for a patient undergoing ART after surgery for endometriosis-related infertility. It could be used to counsel patients in their choice between spontaneous versus ART conception, or oocyte donation.

[First line management without IVF of infertility related to endometriosis: Result of medical therapy? Results of ovarian superovulation? Results of intrauterine insemination? CNGOF-HAS Endometriosis Guidelines]. / Prise en charge de l'infertilité en première intention hors FIV : performances du traitement médical ? Performances de la stimulation ovarienne ? Performances des inséminations ? RPC Endométriose CNGOF-HAS.

INTRODUCTION: Using the structured methodology of French guidelines (HAS-CNGOF), the aim of this chapter was to formulate good practice points (GPP), in relation to optimal non-ART management of endometriosis related to infertility, based on the best available evidence in the literature. MATERIALS AND METHODS: This guideline was produced by a group of experts in the field including a thorough systematic search of the literature (from January 1980 to March 2017). Were included only women with endometriosis related to infertility. For each recommendation, a grade (A-D, where A is the highest quality) was assigned based on the strength of the supporting evidence. RESULTS: Management of endometriosis related to infertility should be multidisciplinary and take account into the pain, the global evaluation of infertile couple and the different phenotypes of endometriotic lesions (good practice point). Hormonal treatment for suppression of ovarian function should not prescribe to improve fertility (grade A). After laproscopy for endometriosis related to infertility, the Endometriosis Fertility Index should be used to counsel patients regarding duration of conventional treatments before undergoing ART (grade C). After laparoscopy surgery for infertile women with AFS/ASRM stage I/II endometriosis or superficial peritoneal endometriosis, controlled ovarian stimulation with or without intrauterine insemination could be used to enhance non-ART pregnancy rate (grade C). Gonadotrophins should be the first line therapy for the stimulation (grade B). The number of cycles before referring ART should not exceed up to 6 cycles (good practice point). No recommendation can be performed for non-ART management of deep infiltrating endometriosis or endometrioma, as suitable evidence is lacking. DISCUSSION AND CONCLUSION: Non-ART management is a possible option for the management of endometriosis related to infertility. Endometriosis Fertilty Index could be a useful tool for subsequent postoperative fertility management. Controlled ovarian stimulation can be proposed.

[Deeply infiltrating endometriosis and infertility: CNGOF-HAS Endometriosis Guidelines]. / Endométriose profonde et infertilité, RPC Endométriose CNGOF-HAS.

Deeply infiltrating endometriosis is a severe form of the disease, defined by endometriotic tissue peritoneal infiltration. The disease may involve the rectovaginal septum, uterosacral ligaments, digestive tract or bladder. Deeply infiltrating endometriosis is responsible for disabling pain and infertility. The purpose of these recommendations is to answer the following question: in case of deeply infiltrating endometriosis associated infertility, what is the best therapeutic strategy? First-line surgery and then in vitro fertilization (IVF) in case of persistent infertility or first-line IVF, without surgery? After exhaustive literature analysis, we suggest the following recommendations: studies focusing on spontaneous fertility of infertile patients with deeply infiltrating endometriosis found spontaneous pregnancy rates about 10%. Treatment should be considered in infertile women with deeply infiltrating endometriosis when they wish to conceive. First-line IVF is a good option in case of no operated deeply infiltrating endometriosis associated infertility. Pregnancy rates (spontaneous and following assisted reproductive techniques) after surgery (deep lesions without colorectal involvement) varie from 40 to 85%. After colorectal endometriosis resection, pregnancy rates vary from 47 to 59%. The studies comparing the pregnancy rates after IVF, whether or not preceded by surgery, are contradictory and do not allow, to date, to conclude on the interest of any surgical management of deep lesions before IVF. In case of alteration of ovarian reserve parameters (age, AMH, antral follicle count), there is no argument to recommend first-line surgery or IVF. The study of the literature does not identify any prognostic factors, allowing to chose between surgical management or IVF. The use of IVF in the indication "deep infiltrating endometriosis" allows satisfactory pregnancy rates without significant risk, regarding disease progression or oocyte retrieval procedure morbidity.

[Endometriosis and fertility preservation: CNGOF-HAS Endometriosis Guidelines]. / Endométriose et préservation de la fertilité, RPC Endométriose, CNGOF-HAS.

Fertility preservation (FP) techniques are progressing rapidly these past few years thanks to the oocyte vitrification. Indication of FP techniques is now extended to non-oncological situation that may induce risk of premature ovarian failure. Ovarian endometriosis can lead to premature ovarian failure and further infertility due to the high risk of ovarian cysts recurrence and surgery. To date, there is no cohort study regarding FP and endometriosis as well as no recommendation. Our purpose is to review the arguments in favor of FP in this specific area and to elaborate strategies according to each clinical form.

[Management of assisted reproductive technology (ART) in case of endometriosis related infertility: CNGOF-HAS Endometriosis Guidelines]. / Stratégies de prise en charge de l'infertilité en assistance médicale à la procréation dans un contexte d'endométriose, RPC Endométriose, CNGOF-HAS.

The management of endometriosis related infertility requires a global approach. In this context, the prescription of an anti-gonadotropic hormonal treatment does not increase the rate of non-ART (assisted reproductive technologies) pregnancies and it is not recommended. In case of endometriosis related infertility, the results of IVF management in terms of pregnancy and birth rates are not negatively affected by the existence of endometriosis. Controlled ovarian stimulation during IVF does not increase the risk of endometriosis associated symptoms worsening, nor accelerate the intrinsic progression of endometriosis and does not increase the rate of recurrence. However, in the context of IVF management for women with endometriosis, pre-treatment with GnRH agonist or with oestrogen/progestin contraception improve IVF outcomes. There is currently no evidence of a positive or negative effect of endometriosis surgery on IVF outcomes. Information on the possibilities of preserving fertility should be considered, especially before surgery.

[Management of endometriosis: CNGOF-HAS practice guidelines (short version)]. / Prise en charge de l'endométriose : recommandations pour la pratique clinique CNGOF-HAS (texte court).

First-line investigations to diagnose endometriosis are clinical examination and pelvic ultrasound. Second-line investigations include pelvic examination performed by a referent clinician, transvaginal ultrasound performed by a referent echographist, and pelvic MRI. It is recommended to treat endometriosis when it is symptomatic. First-line hormonal treatments recommended for the management of painful endometriosis are combined with hormonal contraceptives or levonorgestrel 52mg IUD. There is no evidence to recommend systematic preoperative hormonal therapy for the unique purpose of preventing the risk of surgical complications or facilitating surgery. After endometriosis surgery, combined hormonal contraceptives or levonorgestrel SIU 52mg are recommended as first-line therapy in the absence of desire of pregnancy. In case of initial treatment failure, recurrence, or multiple organ involvement by endometriosis, medico-surgical and multidisciplinary discussion is recommended. The laparoscopic approach is recommended for the surgical treatment of endometriosis. HRT may be offered in postmenopausal women operated for endometriosis. In case of infertility related to endometriosis, it is not recommended to prescribe anti-gonadotropic hormone therapy to increase the rate of spontaneous pregnancy, including postoperatively. The possibilities of fertility preservation should be discussed with the patient in case of surgery for ovarian endometrioma.

Management of endometriosis: CNGOF/HAS clinical practice guidelines - Short version.

First-line diagnostic investigations for endometriosis are physical examination and pelvic ultrasound. The second-line investigations are: targeted pelvic examination performed by an expert clinician, transvaginal ultrasound performed by an expert physician sonographer (radiologist or gynaecologist), and pelvic MRI. Management of endometriosis is recommended when the disease has a functional impact. Recommended first-line hormonal therapies for the management of endometriosis-related pain are combined hormonal contraceptives (CHCs) or the 52mg levonorgestrel-releasing intrauterine system (IUS). There is no evidence base on which to recommend systematic preoperative hormonal therapy solely to prevent surgical complications or facilitate surgery. After surgery for endometriosis, a CHC or 52mg levonorgestrel-releasing IUS is recommended as first-line treatment when pregnancy is not desired. In the event of failure of the initial treatment, recurrence, or multiorgan involvement, a multidisciplinary team meeting is recommended, involving physicians, surgeons and other professionals. A laparoscopic approach is recommended for surgical treatment of endometriosis. HRT can be offered to postmenopausal women who have undergone surgical treatment for endometriosis. Antigonadotrophic hormonal therapy is not recommended for patients with endometriosis and infertility to increase the chances of spontaneous pregnancy, including postoperatively. Fertility preservation options must be discussed with patients undergoing surgery for ovarian endometriomas.

Successful external cephalic version is an independent factor for caesarean section during trial of labor - a matched controlled study.

INTRODUCTION: To assess the mode of delivery and Caesarean Section (CS) rate after successful External Cephalic Version (ECV). MATERIAL AND METHODS: A matched case-control study. Data were gathered from a tertiary care university hospital register from 1996-2015. All pregnant women who delivered after successful External Cephalic Version (ECV). Among 643 women who attempted ECV, we identified 198 with successful ECVs and compared them with the next two women who presented for labor management with spontaneous cephalic presentation, matching for delivery date, maternal age, parity, body mass index, and delivery history using univariate and stepwise logistic regression. The main outcome measure was the risk of caesarean. RESULTS: The caesarean section rate was higher after successful ECV (respectively 20.7% versus 7.07%, P<0.05). Caesarean section for abnormal fetal head position (forehead, bregma, face) was higher after successful ECV (28.6% versus 0%). After adjustment for matching and confounding variables (variation of the caesarean section rate over the study period, gestational maternal complications, antepartum fetal complications, term of delivery, induction of labor, oxytocin use for dystocia, neonatal cephalic perimeter), a successful ECV increased the risk of caesarean section (adjusted OR 3.17, 95% CI 1.86-5.46). By stratifying on week, a trend for increased risk for caesarean section was observed at the week after ECV and at post term (28.6% before 37+6, 14.8% at 38+0-38+6, 13.8% at 39+0-39+6, 14.2% at 40+0-40+6 and 33.3% beyond 41+0 weeks' gestation, P=0.06). CONCLUSIONS: Women who have a successful ECV are at increased risk of caesarean section compared with women who experience spontaneous cephalic presentation.

Non-ART pregnancy predictive factors in infertile patients with peritoneal superficial endometriosis.

OBJECTIVE: To study the predictive factors for non-ART pregnancy in infertile women after laparoscopic diagnosis and surgery for isolated superficial peritoneal endometriosis (SUP). STUDY DESIGN: Retrospective observational study from January-2004 to December-2015 in a tertiary care university hospital and Assisted Reproductive Technology (ART) centre. Infertile women with laparoscopic surgery for SUP (with histologic diagnosis) were included. The surgical treatment was followed by spontaneous fertility or post-operative ovarian stimulation (pOS) using superovulation (gonadotrophins)±Intra Uterine Insemination (IUI). The main outcomes were the non-ART clinical pregnancy rates and its predictive factors. RESULT(S): Over the period study, 315 women were included. Of these, 133 (42.3%) women had non-ART pregnancy. The mean time to conceive was 6 months (±6days). Univariate analysis for non-ART pregnancy after surgery showed that: (i) no difference was observed according to age, length of infertility, Body Mass Index (BMI), the rate of previous pregnancy, and the pre-operative ovarian stimulation rate; (ii) diminished ovarian reserve and previous miscarriage were higher in the non-pregnant women group (8.3 versus 19.1%, p<0.05; 3.5% versus 9%, p=0.06, respectively); (iii) the mean EFI score and pOS were higher in pregnant women (7.7 versus 7.2, p=0.02; 49.2% versus 26.7%, p<0.01); and (iv) IUI did not show any benefit for pregnancy (22% after superovulation versus 27.2% after superovulation and IUI). In the multivariate analysis, only pOS (adjusted OR 2.504, 95% CI [1.537-4.077]) and DOR (aOR 0.420, 95% CI [0.198-0.891]) remained significantly associated with the incidence of pregnancy. CONCLUSION(S): After laparoscopic surgery for peritoneal superficial endometriosis related infertility, ovarian stimulation improved pregnancy rate, while diminished ovarian reserve had a worse prognosis for pregnancy.

[Cord accident after external cephalic version: Reality or mostly myth?] / Accident funiculaire après version par manœuvre externe : mythe ou réalité ?

OBJECTIVES: To study the occurrence of cords accident (nuchal cords, prolapse, and braces) after external cephalic version according to its failure or success. METHODS: Retrospective study between 1998-2015 comparing in the cord accident diagnosed at delivery (by midwife or doctors according to mode of delivery): Patients with attempt ECV: Group 1 cephalic presentation after successful ECV with trial of labor, and Group 2 failed ECV followed by elective cesarean or trial of labor. Patients with no attempt ECV Group 3 spontaneous cephalic presentation matching for delivery date, maternal age, parity, body mass index, and delivery history with group 1, Group 4 Breech presentation without attempt ECV with trial of labor. RESULTS: A total of 776 women with breech presentation were included (198 in group 1, 446 in group 2, 396 in group 3 and 118 in group 4). The prevalence of cord accident did not differ according to ECV attempt (17.08 % versus 18.9 %), to cephalic presentation (group 1: 24.7 % versus group 3: 25 %) and to breech presentation (group 2: 16.9 % versus group 4: 17.2 %). The trial of labor after failed ECV did not increase the risk of cord accident when compared with elective cesarean (17.4 % versus 16 %). A prolapse cord was only observed after trial of labor, i.e. in groups 1, 2 and 4 without difference (respectively 1, 0.8 and 1.7 %). In each group, the rate of cesarean was not different according to the presence of nuchal cord. CONCLUSION: Success or failed External cephalic version is not associated with an increased risk of cord accident.

Use of the endometriosis fertility index in daily practice: A prospective evaluation.

OBJECTIVE: To perform a prospective evaluation of postoperative fertility management using the endometriosis fertility index (EFI). STUDY: This prospective non-interventional observational study was performed from January 2013 to February 2016 in a tertiary care university hospital and an assisted reproductive technology (ART) centre. In total, 196 patients underwent laparoscopic surgery for endometriosis-related infertility. Indications for surgery included pelvic pain (dysmenorrhoea, and/or deep dyspareunia), abnormal hysterosalpingogram, and failure to conceive after three or more superovulation cycles with or without intra-uterine insemination. Multidisciplinary fertility management followed the surgical diagnosis and treatment of endometriosis. Three postoperative options were proposed to couples based on the EFI score: EFI score ≤4, ART (Option 1); EFI score 5-6, non-ART management for 4-6 months followed by ART (Option 2); or EFI score ≥7, non-ART management for 6-9 months followed by ART (Option 3). The main outcomes were non-ART pregnancy rates and cumulative pregnancy rates according to EFI score. Univariate and multivariate analyses with backward stepwise logistic regression were used to explain the occurrence of non-ART pregnancy after surgery for women with EFI scores ≥5. Adjustment was made for potential confounding variables that were significant (p<0.05) or tending towards significance (p<0.1) on univariate analysis. RESULTS: The cumulative pregnancy rate was 76%. The total number of women and pregnancy rates for Options 1, 2 and 3 were: 26 and 42.3%; 56 and 67.9%; and 114 and 87.7%, respectively. The non-ART pregnancy rates for Options 1, 2 and 3 were 0%, 30.5% and 48.2%, respectively. The ART pregnancy rates for Options 1, 2 and 3 were 50%, 60.6% and 80.3%, respectively. The mean time to conceive for non-ART pregnancies was 4.2 months. The benefit of ART was inversely correlated with the mean EFI score. On multivariate analysis, the EFI score was significantly associated with non-ART pregnancy (odds ratio 1.629, 95% confidence interval 1.235-2.150). CONCLUSION: In daily prospective practice, the EFI was useful for subsequent postoperative fertility management in infertile patients with endometriosis.

Delivery outcomes of term pregnancy complicated by idiopathic polyhydramnios.

OBJECTIVE: Polyhydramnios is associated with an increased risk of cesarean section. The aetiology of polyhydramnios and the characteristics of the labour may be confounding factors. The objective was to study the characteristics and mode of delivery in case of pregnancy complicated with idiopathic polyhydramnios. METHODS: This retrospective matched and controlled study included all pregnant women with idiopathic polyhydramnios (amniotic index>25cm or single deepest pocket>8cm) diagnosed at the 2nd or 3rd trimester and persistent at term delivery (>37weeks of pregnancy) in our institution. We excluded pregnancies in which the polyhydramnios could be explained by infection, gestational diabetes, congenital malformation, abnormal karyotype, placental anomalies, alloimmunization as well as pregnancies in which an amniocentesis for the purpose of diagnosis had not been performed. Data were gathered from a tertiary care university hospital register from 1998-2015. Cases of polyhydramnios were matched with the following two women who presented for labour management with spontaneous cephalic presentation, matching for delivery date, maternal age, parity, body mass index. The main outcome measure was the risk of cesarean section. Univariate and multivariate adjusted analysis were performed. RESULTS: We identified 108 women with idiopathic polyhydramnios and compared them with 216 matched women. Among them, 94 and 188 attempted a trial of labour. Maternal age, mean term delivery and birthweight were 31 years, 39+5weeks gestation and 3550 g. We did not observe differences in maternal characteristics, epidural analgesia and rate of abnormal fetal heart tracing. Induced labour and non-vertex presentations (forehead, bregma, face) were more frequent in the polyhydramnios group (respectively 57.9% versus 27.8%, P<0.05 and 7.8% versus 1%, P<0.05). Cesarean section rate was higher in the case of polyhydramnios in the overall population (45.4% versus 8%, P<0.05) and remained higher after exclusion of cases of induced labour and non-vertex presentation (38.4% versus 3.8%, P<0.05). Amniotomy was more frequent in pregnancies with polyhydramnios (55.8% versus 39.1%, P<0.05). After adjustment for matching and confounding variables, polyhydramnios was found to be a risk factor for cesarean section (OR 21.02; CI 95% 8.004-55.215, P<0.01). CONCLUSION: Idiopathic polyhydramnios increased the risk of prolonged first stage of labour, non-vertex presentation and cesarean section.

Bartholin gland abscess during pregnancy: Report on 40 patients.

OBJECTIVE(S): To study the clinical and bacterial characteristic of Bartholin gland abscesses during pregnancy and the obstetric and neonatal outcomes. STUDY DESIGN: Retrospective cohort study of all patients with surgical treatment of Bartholin gland abscesses between 2004 and 2015 in our university center. Clinical and bacterial characteristics between pregnant and non-pregnant women were compared. RESULTS: During the period study, 156 patients were included (40 pregnant and 116 non pregnant). The incidence of Bartholin gland abscesses during pregnancy was 0.13%. Eight (20%) abscesses occurred in the first, 18 (45%) in the second, 11 (47.5%) in the third trimester and 3 (7.5%) in the post-partum course. No severe perineal and neonatal infections occurred during pregnancy. One late miscarriage and one preterm delivery were observed. We found more multiparity in the pregnant woman group than in non-pregnant women (62.5% versus 45%, p<0.05). A history of Bartholin gland abscesses were also more frequent in pregnant women (55% versus 30.1%, p<0.05). First line antibiotic therapy was more frequent in non-pregnant women (20% versus 45%, p<0.05). The rate of positive culture did not differ between the two groups (70% versus 55.2%). Among negative pus cultures, no patient in the pregnant woman group had received a first line antibiotic therapy, in contrast with non-pregnant women (0% versus 25%, p<0.05). E. coli was the most common pathogen in the two groups (48.9% of positive cultures and 28.2% of the overall population). The distribution of bacterial taxa was not different between the two groups. CONCLUSION: Bacterial characteristics did not differ from non-pregnant women. Pregnancy could increase the occurrence of Bartholin gland abscesses in patients with previous surgical treatment of abscesses. When appropriate management is applied, maternal and neonatal outcomes are favorable, and severe infections are not to be expected.

[Focus on methods for detection of sentinel nodes in breast cancer]. / Mise au point sur les méthodes de détection des ganglions sentinelles dans le cancer du sein.

The sentinel node procedure (GS) is the recommended technique for axillary surgical exploration in localized breast cancer with no clinical or radiological lymph node involvement. This surgical technique is based on a dual isotope and colorimetric detection. Although it allows a significant reduction in morbidity compared to axillary dissection (CA), this procedure induces a number of organizational constraints, in particular for the radioisotope injection. Specially for this reason, other GS methods have emerged in recent years, some of which appear promising (detection by fluorescence and magnetic iron). The objective of this paper was to carry out a synthesis of the reference method of detection (radioisotope) GS and analyze the recent literature on new detection methods.

[Disproportion between placenta weight and birth weight: Physiologic or pathologic]. / Disproportion fœto-placentaire à terme : physiologique ou pathologique.

OBJECTIVES: To study risk factors, maternal and neonatal outcome with a high placental weight to birth weight ratio (PW/BW). MATERIALS AND METHODS: Two groups of full term singleton pregnancies were created in this single centre retrospective population-based study (a high PW/BW above 0.25 and group control with normal PW/BW between 0.15 and 0.25). Maternal and neonatal outcomes were compared. RESULTS: Compared with the group with normal PW/BW ratios, the high PW/BW ratio group was associated with increased rates of pre-eclampsia (15.5% versus 1.7%, P<0.05) and small for gestational age (8% versus 0%, P<0.05). Neither maternal risk factors nor neonatal outcome difference were shown after adjusting confounding factors. CONCLUSION: High PW/BW with placentomegaly is associated with increased risk of pre-eclampsia at term underlying a mixture of condition in its pathogenesis.