Evaluating the safety of high-intensity focused ultrasound treatment for rectal endometriosis: results from a French prospective multicentre study including 60 patients.

STUDY QUESTION: Is increasing the intensity of high-intensity focused ultrasound (HIFU) by 30% in the treatment of rectal endometriosis a safe procedure? SUMMARY ANSWER: This study demonstrates the safety of a 30% increase in the intensity of HIFU in the treatment of rectal endometriosis, with no Clavien-Dindo Grade III complications overall, and namely no rectovaginal fistulae. WHAT IS KNOWN ALREADY: A feasibility study including 20 patients with rectal endometriosis demonstrated, with no severe complications, a significant improvement in digestive disorders, dysmenorrhoea, dyspareunia, and health status, although the volume of the endometriosis nodule did not appear to be reduced. STUDY DESIGN, SIZE, DURATION: A prospective multicentre cohort study was conducted between 2020 and 2022 with 60 patients with symptomatic rectal endometriosis. Following the failure of medical treatment, HIFU treatment was offered as an alternative to surgery. PARTICIPANTS/MATERIALS, SETTING, METHODS: As the main objective of this study was to examine safety, all adverse events observed during the 6 months of follow-up were analysed and graded according to the National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE) and Clavien-Dindo classifications. Secondary objectives included evaluating the evolution of symptoms using validated questionnaires: gynaecological and digestive pain symptoms with a visual analogue scale, health status with the Medical Outcomes Study 36-item Short Form (SF-36) questionnaire, average post-operative daily pain level, and analgesic medication required in the 10 days following treatment. MRI was also performed at Day 1 to detect early complications. Finally, we performed a blinded MRI review of the evolution of the nodule at 6 months post-treatment. MAIN RESULTS AND THE ROLE OF CHANCE: The procedure was performed under spinal anaesthesia for 30% of the patients. The median duration of treatment was 32 min. Fifty-five patients left the hospital on Day 1. MRI scans performed on Day 1 did not highlight any early-onset post-operative complication. Using the Clavien-Dindo classification, we listed 56.7% Grade I events, 3.4% Grade II events, and no events Grade III or higher. At 1, 3, and 6 months, all gynaecologic, digestive and general symptoms, as well as health status, had significantly improved. The evolution of the nodule was also significant (P < 0.001) with a 28% decrease in volume. LIMITATIONS, REASONS FOR CAUTION: The main objective was safety and not effectiveness. The study was not randomized and there was no control group. WIDER IMPLICATIONS OF THE FINDINGS: HIFU treatment for rectal endometriosis results in an improvement of symptoms with low morbidity; as such, for selected patients, it could be a valuable alternative to surgical approaches following the failure of medical treatment. STUDY FUNDING/COMPETING INTEREST(S): The study was funded by the company EDAP TMS. Professors Dubernard and Rousset are consultants for EDAP TMS. Dubernard received travel support from EDAP-TMS. Dr F. Chavrier received industrial grants from EDAP-TMS. He has developed a device for generating focused ultrasonic waves with reduced treatment time. This device has been patented by EDAP-TMS. Dr Lafon received industrial grants from EDAP-TMS; he declares that EDAP-TMS provided funding directly to INSERM to support a young researcher chair in therapeutic ultrasound, which is unrelated to the current study. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov identifier NCT04494568.

[Suicidality in the perinatal period: Descriptive study on factors associated with suicidal ideation among women hospitalized in the perinatal period at the specialized hospital center]. / Suicidalité en période périnatale : quels sont les facteurs associés ?

OBJECTIVES: Suicide is the leading cause of maternal mortality in high-resource countries. The onset of suicidal ideation is a major risk factor for suicide attempts. Suicidality has a major impact on the mother-baby relationship and on child development. The main objective of the study was to identify factors associated with the occurrence of perinatal suicidal ideation in women requiring hospitalization. The secondary objectives of the study were to describe the socio-demographic and clinical characteristics of this specific population, to specify the follow-up procedures at hospital discharge and to develop a semi-directed interview framework for psychiatric evaluation of perinatal patients admitted to a psychiatric hospital in order to better identify those at risk of suicide and improve overall management, particularly in terms of referral to existing perinatal care services. METHODS: Descriptive and retrospective study carried out at the Specialized Hospital Center of women hospitalized in the perinatal period between 2014 and 2019. The inclusion criteria were: inpatient pregnant or postpartum within one year of delivery, 16 to 43 years. A keyword search was performed to retrieve the computerized records. All records matching the inclusion criteria were included. We studied the occurrence of suicidal ideation according to the main known clinical and socio-demographic risk factors. RESULTS: The sample included 25 pregnant patients and 57 post-partum patients. The presence of a psychiatric history increased the risk of suicidal ideation by 4.38 (P<0.03). The association between the occurrence of a stressful life event and the risk of suicidal ideation onset was close to significant (P<0.10). One third of the patients had been admitted for a reason related to suicidality. Less than one-third of the patients had been referred to existing perinatal services. CONCLUSIONS: Suicidality in the perinatal period has a major impact on the dyad as well as on the whole family. The search for suicidal ideas must be systematic during psychiatric interviews, a fortiori when a psychiatric history has been authenticated. Every patient hospitalized in adult psychiatry should be referred to specialized outpatient perinatal psychiatry services. Prevention involves raising awareness and training of all health professionals, networking, but also informing the general public.

Assessment of operator performance during oocyte retrievals: residents' learning curve and continuous monitoring of senior physicians.

BACKGROUND: The learning curve cumulative summation test (LC CUSUM test) allows to define an individualized learning curve and determine the moment when clinical proficiency is attained. After acquisition of the skills, the cumulative summation test (CUSUM test) allows to monitor the maintenance of the required level over time. The LC CUSUM test has been frequently used in the field of Obstetrics and Gynecology (Ob/Gyn) for several procedures, but only once for OR. METHODS: We performed a retrospective study at Angers university hospital between May 2017 and September 2018. Seven Ob/Gyn residents and 5 senior physicians were included, and all OR performed during that time (n = 690) were analyzed. The performance index assessed was the oocyte retrieval rate (ORR), defined as the ratio of oocytes retrieved to follicles aspirated. We used the LC CUSUM test to analyze the learning curves of residents, and the CUSUM test to monitor the performance of senior physicians. An ORR ≥50% in 60% of retrievals was defined as the threshold for clinical proficiency. RESULTS: Six hundred seventy-four oocyte retrieval (OR) were included: 315 were performed by residents, 220 by senior physicians, and 139 by both residents and physicians (mixed retrievals). Four residents (57%) reached the threshold after aspirating 82, 67, 53 and 46 ovaries, respectively. The mean number of ovaries aspirated in order to reach clinical proficiency was 62, and the mean number of weeks needed was 21. The duration of the learning period varied between 26 and 80 days. Two senior physicians (40%) remained proficient across the duration of the study, while two physicians (40%) had one statistically "suboptimal" OR, and one physician (20%) had two suboptimal retrievals. CONCLUSION: There is a large variability in the duration of the learning period and the number of procedures needed for a resident to master OR. Senior physicians maintain an adequate performance.

Should we perform subtotal hysterectomy associated with sacral colpopexy for genital prolapse to prevent the risk of endometrial cancer?

OBJECTIVE: In a menopausal woman scheduled for curative surgery for pelvic organ prolapse (POP) by sacral colpopexy (SC), the question of concomitant hysterectomy is frequently considered by the surgeon. The risk of endometrial cancer (EC) exists in this population, and increases with age and body mass index. The French college of gynecologists and obstetricians (CNGOF) decided to issue good practice guidelines on subtotal hysterectomy (SH) for postmenopausal women scheduled for SC for POP. METHODS: The CNGOF has decided to adopt the AGREE II and GRADE systems for grading scientific evidence. Each recommendation for practice was allocated a grade, which depends on the quality of evidence (QE) (clinical practice guidelines). RESULTS: The prevalence of occult endometrial cancer (EC) found on pathological analysis after SH in this context (concomitant SH associated with SC) is low (<1%) (QE: high). Few studies have assessed the value of preoperative uterine exploration. Performing SH during SC is associated with its own risks, which may diminish the potential "carcinological prevention benefit". Uterine morcellation, performed by laparoscopy or a robot-assisted procedure, is associated with a low risk (<0.6%) of dissemination of an unknown sarcoma/EC (QE: moderate) A risk of dissemination of parasitic myomas (<0.5%) is also possible (QE: moderate). CONCLUSION: It is not recommended to perform a subtotal hysterectomy associated with sacral colpopexy for the sole purpose of reducing the occurrence of endometrial cancer (Recommendation: STRONG [GRADE 1-]; the level of evidence was considered to be low and the risk-benefit balance was considered not to be favorable).

Impact of music therapy before first-trimester instrumental termination of pregnancy: a randomised controlled trial.

OBJECTIVES: To evaluate the impact of preoperative Music Therapy (MT) on pain in first-trimester termination of pregnancy (TOP) under local anaesthesia. DESIGN: Randomised controlled trial comparing women undergoing a first-trimester TOP under local anaesthesia with or without a preoperative MT session. SETTING: University Hospital of Angers from November 2016 to August 2017. POPULATION: Women who underwent first-trimester TOP under local anaesthesia. METHODS: Women allocated to the MT group underwent a preoperative 20-minute session of MT. MAIN OUTCOME MEASURES: Pain was assessed using a visual analogue scale (VAS) just before the procedure, during the procedure, at the end of the procedure and upon returning to the ward. RESULTS: A total of 159 women were randomised (80 in the MT group, and 79 in the control group). Two women were excluded from the control group and six from the MT group. Therefore, 77 women were analysed in the control group and 74 in the MT group. The intensity of pain was similar in the two groups just before the procedure (VAS 4.0 ± 2.9 versus 3.6 ± 2.5; P = 0.78), during the procedure (VAS 5.3 ± 2.5 versus 4.9 ± 2.9; P = 0.78), at the end of the procedure (VAS 2.7 ± 2.4 versus 2.6 ± 2.4; P = 0.43) and upon returning to the ward (VAS 1.8 ± 2.0 versus 1.5 ± 2.0; P = 0.84). The difference in pain between entering the department and returning to the room after the procedure was similar between the MT and control groups (difference in VAS 0.3 ± 2.5 versus 0.3 ± 2.4; P = 0.92). CONCLUSION: An MT session before a TOP under local anaesthesia procedure resulted in no improvement in patient perception of pain during a first-trimester TOP. TWEETABLE ABSTRACT: Music therapy before first-trimester termination of pregnancy under local anaesthesia did not improve the perception of pain.

Incidence and remission of urinary incontinence at midlife: a cohort study.

OBJECTIVE: Urinary incontinence (UI) is often considered to be an age-related disease that develops gradually as women grow older. Much remains to be learnt about factors that promote its incidence or its remission. Our objective was to assess its incidence and risk factors. DESIGN: Longitudinal cohort study. SETTING: French GAZEL cohort. POPULATION: A cohort of 4127 middle-aged women (aged 47-52 years at baseline) over an 18-year period (1990-2008). METHODS: UI was defined as 'difficulty retaining urine'. The question was asked at baseline and repeated every 3 years over an 18-year period. Two groups (UI incidence and remission) were analysed according to status at baseline (continent or incontinent). A multivariable analysis (Cox model) was used to estimate the risk factors for UI incidence and remission. MAIN OUTCOME MEASURES: Annual incidence and remission rates and risk factors for UI incidence and remission. RESULTS: The annual incidence and remission rates for UI were 3.3% and 6.2%, respectively. High educational level (hazard ratio [HR] = 1.28; 95% confidence interval [95% CI] = 1.05-1.55), parity, i.e. at least one baby versus no baby (HR = 1.64; 95% CI = 1.19-2.27), menopause (HR = 5.44; 95% CI = 4.47-6.63), weight gain, i.e. for each kilogram change in weight (HR = 1.00; 95% CI = 1.00-1.02), onset of depressive symptoms (HR = 1.31; 95% CI = 1.09-1.57) and impairment in health-related quality of life incidence (social isolation dimension [HR = 1.29; 95% CI = 1.04-1.60] and energy dimension [HR = 1.41; 95% CI = 1.17-1.70]) were associated with an increased probability of UI. The factors associated with persistent UI were age (HR = 0.58; 95% CI = 0.55-0.61), weight gain (HR = 0.99; 95% CI = 0.98-0.99) and transition to menopausal status (HR = 1.54; 95% CI = 1.19-1.99). CONCLUSIONS: Our study suggests that, in our population of middle-aged women, age, menopause, weight gain, onset of depression and impaired health-related quality of life may promote UI.

[Simulation training for French obstetrics and gynecology residents: A national survey in 2022]. / Formation initiale par la simulation pour les internes français de gynécologie et obstétrique : état des lieux en 2022.

OBJECTIVES: To evaluate the use of simulation among French Obstetrics and Gynecology residency programs. METHODS: A survey was conducted with all 28 French residency program directors. The questionnaire covered equipment and human resources, training programs, types of simulation tools and time spent. RESULTS: Of the cities hosting a residency program, 93% (26/28) responded regarding equipment and human resources, and 75% (21/28) responded regarding training program details. All respondents declared having at least one structure dedicated to simulation. A formal training program was reported by 81% (21/26) of cities. This training program was mandatory in 73% of the cases. There was a median number of seven senior trainers involved, three of whom had received a specific training in medical education. Most of declared simulation activities concerned technical skills in obstetrics and surgery. Simulations to practice breaking bad news were offered by 62% (13/21) of cities. The median number of half-days spent annually on simulation training was 55 (IQR: 38-83). CONCLUSION: Simulation training is now widely available among French residency programs. There remains heterogeneity between centers regarding equipment, time spent and content of simulation curricula. The French College of Teachers of Gynecology and Obstetrics has proposed a roadmap for the content of simulation-based training based on the results of this survey. An inventory of all existing "train the trainers" simulation programs in France is also provided.

Management of women with abnormal uterine bleeding: Clinical practice guidelines of the French National College of Gynaecologists and Obstetricians (CNGOF).

OBJECTIVE: To provide French guidelines for the management of women with abnormal uterine bleeding (AUB). DESIGN: A consensus committee of 26 experts was formed. A formal conflict-of-interest policy was developed at the beginning of the process and enforced throughout. The entire guidelines process was conducted independently of any industry funding (i.e. pharmaceutical or medical device companies). The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized. METHODS: The last guidelines from the Collège National des Gynécologues et Obstétriciens Français on the management of women with AUB were published in 2008. The literature seems now sufficient for an update. The committee studied questions within 7 fields (diagnosis; adolescents; idiopathic AUB; endometrial hyperplasia and polyps; type 0-2 fibroids; type 3 or higher fibroids; and adenomyosis). Each question was formulated in a PICO (Patients, Intervention, Comparison, Outcome) format and evidence profiles were compiled. The GRADE® methodology was applied to the literature review and the formulation of recommendations. RESULTS: The experts' synthesis work and the application of the GRADE method resulted in 36 recommendations. Among the formalized recommendations, 19 are strong and 17 weak. No response was found in the literature for 14 questions. We chose to abstain from recommendations rather than providing advice based solely on expert clinical experience. CONCLUSIONS: The 36 recommendations make it possible to specify the diagnostic and therapeutic strategies for various clinical situations practitioners encounter, from the simplest to the most complex.

Laparoscopic management of uterine arteriovenous malformation via occlusion of internal iliac arteries.

Uterine arteriovenous malformation (AVM) can be congenital or acquired. When acquired (e.g., fistula), it results from abnormal arteriovenous communication between one or more uterine arteries and a myometrial and/or endometrial venous plexus, without the interposition of a vascular nidus. Arteriovenous malformation is composed of a tortuous net of fragile low-resistant arteriovenous shunts. Other arteries can be involved in fistulas, including ovarian arteries or those from the round ligaments of the uterus, in particular in congenital AVMs, which develop from failure in embryologic differentiation that leads to multiple abnormal vascular connections. In these cases, extension to pelvic vessels other than uterine arteries is frequent. Acquired AVMs often result in trauma to the uterus such as dilation and curettage in 85% of cases, gestational trophoblastic disease, or endometrial carcinoma.

[Urinary incontinence and menopause]. / Incontinence urinaire et ménopause.

PURPOSE: The aim of this review was to examine the relationship between menopause and urinary incontinence (UI). MATERIAL: Our work is based on a review of the literature on the epidemiology of UI in women and the effects of hormone therapy on symptoms of urinary leakage. A search of the Medline database between January 2000 and April 2012 was performed by crossing the keywords "urinary incontinence, stress urinary incontinence (SUI), urge incontinence, over active bladder, menopause, estrogen therapy". RESULTS: Twenty-nine articles over the 482 articles were initialy selected. The UI was a common symptom during menopause, with a prevalence of 15 to 30% and an annual incidence of 5 to 10%. The association between UI and menopause was controversial. Indeed, although underpinned by pathophysiological mechanisms such as the sensitivity of tissues of the urogenital sinus to estrogen, the epidemiological data available were contradictory and should be interpreted, if possible, depending on the type of UI. Thus, it remained difficult to distinguish the effect of menopause of the aging. The effects of estrogen on IU differed depending on the route of administration and of the type of UI. Randomized trials showed that oral administration of estrogen after menopause increased the occurrence of UI or SUI. However a vaginal administration of estrogen improved urge urinary incontinence (UUI) and overactive bladder. CONCLUSION: The data of this review were consistent with the French and European guidelines.

[Acceptability and results of postpartum proctological consultation for women who have had an obstetric injury of the anal sphincter]. / Acceptabilité et résultats de la consultation proctologique du post-partum après une lésion obstétricale du sphincter anal.

OBJECTIVES: Early management of perineal disorders after obstetric anal sphincter injury (OASI) may improve the functional prognosis. The objective was to assess the acceptability of the consultation and to report on its results. METHODS: This unicentric retrospective study included 64 women who had LOSA 3 or 4 and who were offered a 3-month routine postpartum proctological consultation. The proposed diagnoses and recoveries were identified. RESULTS: Of the 5,070 women who gave birth vaginally, 64 women had LOSA (1.2%). 54 came to the clinic (84.3%). At the interview, 21 women had no complaints. A diagnosis of evacuation disorders or hemorrhoidal disease in particular was made in 10 women. A specific management was proposed to 16 women and a control consultation was proposed to 3 women. Of the 33 women with at least one symptom, 31 women were diagnosed and 27 women were offered specific management. A monitoring consultation was offered to 18 women. The main diagnoses were gas incontinence, dyschesia with or without abdominopererial asynchronism and decreased sphincter tone. The main measures undertaken were the extension of laxatives, the proposal of perineal massage and abdominal-perineal rehabilitation by biofeedback. CONCLUSION: Systematic proctological consultation was acceptable and allows for a specific management in the majority of cases. The assessment of its long-term impact remains to be defined.

[CNGOF clinical practice guidelines: Evaluation one year after revision of the methodology]. / Recommandations pour la pratique clinique du CNGOF : évaluation un an après révision de la méthodologie.

OBJECTIVES: To evaluate the revision of methodology of the clinical practice guidelines (CPG) of the French National College of Gynecologists and Obstetricians (CNGOF). METHOD: Three CPGs were organized in 2020 on the topics of severe preeclampsia, menorrhagia, and prophylactic surgery according to AGREE II (Apraisal of Guidelines for Research & Evaluation). Questions were presented in PICO (Population, Intervention, Comparison, Outcome) format and the grading of scientific evidence was based on the GRADE (Grading of Recommendation Assessment, Development and Evaluation) method. RESULTS: All three CPGs groups adhered to this new methodology. However, the presentation of the arguments, the formulation of the recommendations and the development of the GRADE tables were heterogeneous from one group to another. A homogenization of the presentation is proposed, as well as a guide to the critical analysis of the literature to help the experts to rate the evidence. CONCLUSION: Adherence to these quality criteria should make it easier to apply the recommendations at the national level and improve international recognition of the work done by the CNGOF.

Comparison of neonatal outcomes of cesarean sections performed under primary or secondary general anesthesia: a retrospective study.

BACKGROUND: The conversion of neuraxial anesthesia (NA) to general anesthesia (GA) during a cesarean section (CS) may be associated with a higher risk of neonatal morbidity by adding the undesirable effects of both these anesthesia techniques. We aimed to compare the neonatal morbidity of non-elective CS performed after conversion from NA to GA (secondary GA) vs. that after GA from the outset (primary GA). METHODS: We performed a monocentric retrospective study at the Angers University Hospital (France). All non-elective CSs performed under GA between January 2015 and December 2019 were included. The CSs were classified using a three-color coding system (green for non-urgent delivery, orange for urgent CS, and red for very urgent CS). The primary neonatal outcome was a composite of umbilical artery pH <7.10 or 5-min Apgar score <7. The crude and adjusted odds ratios (OR) for the risk of neonatal morbidity associated with secondary GA were estimated. RESULTS: We included 247 patients, of whom 101 (41.3%) had a secondary GA and 146 (58.7%) had primary GA. In the secondary GA group, 86.1% (87/101) had epidural anesthesia and 13.9% (14/101) had spinal anesthesia. Multivariate analysis showed no difference in neonatal morbidity between the two groups (adjusted odds ratio 1.18, 95% CI 0.56 to 2.51). CONCLUSIONS: Our study found insufficient evidence to identify a difference in neonatal outcomes between secondary compared with primary GA for CS, regardless of the level of emergency. However, our study is underpowered and additional studies are needed to confirm these data.

[Management of women with abnormal uterine bleeding: Clinical practice guidelines of the French National College of Gynecologists and Obstetricians (CNGOF)]. / Prise en charge des ménorragies : recommandations pour la pratique clinique du Collège national des gynécologues et obstétriciens français (CNGOF).

OBJECTIVE: To provide French guidelines for the management of women with abnormal uterine bleeding (AUB). DESIGN: A consensus committee of 26 experts was formed. A formal conflict-of-interest (COI) policy was developed at the beginning of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding (i.e. pharmaceutical, or medical devices). The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized. METHODS: The last guidelines from the Collège national des gynécologues et obstétriciens français (CNGOF) on the management of women with AUB was published in 2008. The literature seems now sufficient for an update. The committee studied questions within 7 fields (diagnosis; adolescent; idiopathic AUB; endometrial hyperplasia and polyps; fibroids type 0 to 2; fibroids type 3 and more; adenomyosis). Each question was formulated in a PICO (Patients, Intervention, Comparison, Outcome) format and the evidence profiles were produced. The literature review and recommendations were made according to the GRADE® methodology. RESULTS: The experts' synthesis work and the application of the GRADE method resulted in 36 recommendations. Among the formalized recommendations, 19 present a strong agreement and 17 a weak agreement. Fourteen questions did not find any response in the literature. We preferred to abstain from recommending instead of providing expert advice. CONCLUSIONS: The 36 recommendations made it possible to specify the diagnostic and therapeutic strategies of various clinical situations managed by the practitioner, from the simplest to the most complex.

Management of obstetrical injuries to the anal sphincter: A survey of French current practice and perceptions according to the specialties.

AIM OF THE STUDY: To conduct a survey of current practice in the management of obstetrical anal sphincter injuries (OASI) and to compare short, medium and long-term practices according to the specialty of the surgeon. PATIENTS AND METHODS: A 50-item questionnaire was addressed by mail to various specialists via the national learned societies. The questionnaire was addressed only to practitioners who currently managed OASI in their practice. RESULTS: Of the 135 healthcare professionals who responded, 57 were sub-specialists in ano-rectal surgery (42.2%) and 78 were obstetrical or gynecological specialists (OB-GYN) (57.8%). Management in the acute period after OASI was similar among the specialties and 50% of the practitioners did not perform suture repair of the internal sphincter. Furthermore, few gynecological specialists recommended systematic consultation with an ano-rectal specialist during acute management. In the medium term, ano-rectal specialists were more likely to explore gastro-intestinal symptoms, either clinically or through para-clinical studies. However, these studies did not systematically lead to interventional management in the absence of consensus, particularly for medium-term sphincter repair. In addition, 25% of practitioners recommended that patients undergo systematic delivery by caesarean section for further pregnancies after OASI. In the long term (>12 months), there were substantial differences in management of OASI not only between specialties but also within the same specialty. CONCLUSION: The various specialists should coordinate to propose multidisciplinary recommendations on the management of OASI.

In which cases should endometrial destruction be performed during an operative hysteroscopy? Clinical practice guidelines from the French College of Gynaecologists and Obstetricians (CNGOF).

OBJECTIVE: To provide guidelines from the French College of Obstetricians and Gynaecologists (CNGOF), based on the best evidence available, concerning the impact of endometrial destruction on bleeding and endometrial cancer risk reduction in patients candidates for operative hysteroscopy. METHODS: Recommendations were made according to AGREE II and the GRADE® (Grading of Recommendations Assessment, Development and Evaluation) systems to determine separately the quality of evidence (QE) and in the level of recommendation. RESULTS: In a retrospective study comparing the incidence of endometrial cancer in 4776 patients with menorrhagia treated with endometrial destruction vs 229 945 patients with a medical treatment. There was a non-significant reduced risk of developing endometrial cancer (HR, 0.45; 95% CI, 0.15-1.40; p = .17). In premenopausal women, five studies compared the incidence of endometrial cancer in patients treated with endometrial ablation/destruction (EA/D) to the incidence of endometrial cancer in a comparable population of women from national registers, all of which show reduced risk of endometrial cancer after endometrectomy. In case of menopausal metrorrhagia, the prevalence of endometrial cancer is 9%, by analogy with the results found in premenopausal patients, the combination of endometrial ablation during operative hysteroscopy seems justified. In a retrospective cohort of 177 non-menopausal patients treated with myomectomy for metrorrhagia and/or menorrhagia, a significantly better control of bleeding at 12 months was found when myomectomy was combined with endometrectomy using roller-ball (OR: 0.18 [95% Cl 0.05-0.63]; p = 0.003). CONCLUSION: In premenopausal women with heavy menstrual bleeding, when an operative hysteroscopy is performed, it is recommended to propose an endometrial ablation/destruction in order to prevent the risk of endometrial cancer, (QE3) and to prevent recurrence of bleeding (QE2). In menopausal women, it is probably recommended to also perform an endometrial ablation/destruction in case of operative hysteroscopy in order to prevent the risk of endometrial cancer (QE1).

Management and consequences of obstetrical anal sphincter injuries: Review.

Obstetrical anal sphincter injuries (OASI), formerly referred to as "complete" or "incomplete" perineal tears, are a frequent complication of childbirth. They can lead to intestinal consequences (anal incontinence, ano-genital fistula) or sexual consequences (dyspareunia, genital pain). The complexity of management of OASI lies in the multi-factorial nature of these consequences but also in the frequently lengthy interval before their appearance, often long after childbirth. Indeed, while 2.4% of women in childbirth develop OASI, up to 61% of them will present with anal incontinence15 to 25 years after childbirth. Immediate or delayed repair of the sphincter and perineum within a few hours of injury is therefore the rule, but there is no consensus on longer-term management. The patient must be educated on preventive actions (avoidance of pushing or straining, regularization of stool transit, muscle strengthening, etc.). Early detection of anal incontinence leads to prompt management, which is more effective. This review aims to synthesize the information necessary to provide clear and up-to-date patient information on OASI (risk factors and prevalence), the management of OASI, and the management of eventual complications in the setting of dedicated specialty consultations. Dedicated "post-OASI" consultations by a specialist in ano-perineal pathologies could therefore become a first step in the development of care for women, particularly by removing the "shameful" nature of the symptoms.

[Prolonged and post-term pregnancies: a regional survey of French clinical practices]. / Évaluation des pratiques professionnelles pour le suivi des grossesses prolongées dans un réseau de périnatalité.

OBJECTIVE: To assess professional practices of prolonged and post-term pregnancies in accordance to French guidelines. The secondary outcome was to evaluate neonatal and maternal morbidity during prolonged pregnancy. METHODS: Descriptive retrospective study was conducted in the 23 maternity hospitals of perinatal network between September and December 2018. The inclusion criterion was a birth term of≥41+0 weeks of gestation. Primary outcome was conformity to the national guidelines based on 10 items (conformity score≥80%). The secondary outcome was a composite criteria of neonatal morbidity (ventilation, resuscitation and/or Apgar score<7 at 5minutes) and maternal morbidity (obstetrical anal sphincter injury and/or postpartum hemorrhage). RESULTS: A total of 596 patients were included and the conformity was obtained in 65.3% of cases. Inconsistent criteria were amniotic fluid evaluation by the deepest vertical pocket (46.8%, n=279), and information of patients on prolonged pregnancy management (14.8%, n=88). Adverse perinatal outcome occurred for 40 newborns (6.0%) with shoulder dystocia (OR=5.2; CI 95%: 1.4-19.7) as a principal risk factor. Maternal morbidity outcome occurred in 70 cases (10.6%) primarily with increase in labour duration (OR=1.1 by hour of labour; CI 95%: 1.02-1.24) and prior caesarian section (OR=4.4; CI 95%: 1.8-11.0). CONCLUSIONS: Management of prolonged and post-term pregnancies matching with the French national guidelines. Points of improvement are amniotic fluid evaluation at term by a single deepest vertical pocket, and the information about induction of labour at term.

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

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