Comparative study of second-line labor induction methods in patients with unfavorable cervix after first-line low-dose oral misoprostol.

OBJECTIVE: The present study aimed to evaluate low-dose oral misoprostol induction, and compare different methods used in second-line induction in patients with a Bishop score less than 6. METHODS: This retrospective study analyzed the medical history and courses of pregnancy of all patients induced with first-line of low-dose oral misoprostol (50 µg every 4 h with a total of 200 µg/24 h) from April 2021 to June 2022 in a university hospital center, and reported outcomes according to the second-line method of induction. RESULTS: Among 437 labor inductions with low-dose oral misoprostol, 120 patients required a second-line induction. Predictive factors of first-line failure were higher body mass index (P = 0.011), absence of premature rupture of membranes (P = 0.021) and earlier term of pregnancy (P < 0.001). Regarding second methods of induction of labor, time from induction to delivery was shorter in the oxytocin group than the dinoprostone and misoprostol groups (24.0 vs. 41 and 51.0 h, respectively; P < 0.001), and was also significantly shorter in the dinoprostone than the misoprostol group (P = 0.048). Cesarean section rates did not differ between the three groups (P = 0.651). There were no clinically significant differences in adverse events between the groups. CONCLUSION: Normal body mass index, previous rupture of membranes and later term of induction of labor were the three favoring success factors during first-line oral misoprostol. In cases of a Bishop score <6, oxytocin may be the best option to reduce duration to delivery, with the same maternal-fetal outcomes, including a similar rate of vaginal delivery.

Eucapnic pH coupled with arterial cord pH improves hypoxic-ischemic encephalopathy prediction.

OBJECTIVE: To consider the classical use of "pH < 7.0 and/or a base deficiency ≥12 mmol/L" as markers of the risk of neonatal hypoxic-ischemic encephalopathy (HIE), recalling various criticisms of the use of these markers in favor of that of neonatal eucapnic pH, which appears to be a better marker of this risk. METHODS: Fifty-five cases of acidemia with pH < 7.00 were collected from a cohort from the Nice University Hospital with eight cases of HIE. We compared the receiver operating characteristics curves established from the positive likelihood ratio (+LR) for each case of: umbilical cord artery pH (pHa), neonatal eucapnic pH (pH euc-n) in isolation (not matched to pHa), and matched pHa to its own pH euc-n. RESULTS: The areas under the curve (AUC) are identical for pHa and pH euc-n, but AUC for the matched pair pHa-pH euc-n appears superior but non-significant because of the small number in our cohort. However, using the bootstrap method, the partial AUC for a sensitivity greater than 75% indicates the significant superiority (P < 0.01) of the matched pair pHa-pH euc-n approach. CONCLUSION: The originality of this study lies in the use of two methodologic approaches: (1) standardized partial analysis of the AUCs of the pHa curve and that of pHa matched to its own pH euc-n, and (2) bootstrap statistical technique, that allowed us to conclude (P < 0.01) that the combined use of pH measured at the cord coupled with its eucapnic correction is better for diagnosing metabolic acidosis and best predicting the risk of HIE.

Abortion medical management between 14-16 weeks' amenorrhea after French legislation deadline extension.

BACKGROUND: The National French Assembly promoted a law in 2022 allowing an extension of the period of abortion up to 16 week's amenorrhea. Medication protocols vary internationally, and there are no French data on medical management between 14- and 16-weeks' amenorrhea. OBJECTIVE: To assess effectiveness and feasibility of a medical management abortion between 14 and 16 weeks of amenorrhea. STUDY DESIGN: We retrospectively collected data from women undergoing medical abortion between 14 and 16 weeks' amenorrhea from April 2022 to April 2023 in Archet's University hospital, Nice, France. Medical protocol consisted in a single dose of oral mifepristone 600 mg and 36-48 h later, vaginal gemeprost 1 mg. Three hours after gemeprost, oral 400 µg of misoprostol were administered every three hours, to a maximum of three doses. Success was defined as fetal expulsion. RESULTS: Thirty women were enrolled in the study. Twenty-nine (96.7 %) patients aborted successfully. The median dose of misoprostol required was 800 µg (400 µg -1200 µg) and the median induction-to-abortion interval after first prostaglandin administration was 7 h (5.5-11.6). One patient (3.3 %) didn't expulse the fetus after 3 doses of misoprostol. Nine patients (30.0 %) had additional surgical aspiration for retained product of conception within 24 h. We encountered one post-abortum hemorrhage controlled only with surgical intra uterine aspiration. We did not need complementary hemostatic procedure and we reported no immediate or late complication. CONCLUSIONS: Medical abortion between 14 and 16 weeks of amenorrhea provides a noninvasive and effective management for a daycare mid trimester abortion in 96.7 % of cases, with a 36.7 % of risk of staying in hospital overnight and 30.0 % to have additional surgery for retained product of conception (RPOC).

Customizing Health Recommendations About Physical Activity During Pregnancy: A Qualitative Study Among Practitioners in France.

While studies have long shown the beneficial health effects of physical activity during pregnancy, such recommendations have been rarely analyzed in terms of how practitioners adapt such health messages to patients' social profiles. The present study sought to apprehend the logics underlying practitioner (non)recommendations of physical activity and exercise during pregnancy, and how these were associated with social distinctions made between patients. Semi-directive interviews were conducted with 20 midwives and 17 gynaecologists and obstetricians in south-eastern France. Based on thematic analyses, the results show how recommendations draw from both medical and social knowledge, mobilizing social representations regarding physical activity, (non)normative bodies and othered social categories of class, ethnicity or obesity. The othering processes reiterate gendered social hierarchies as well as moral orders surrounding normative bodies and health-enhancing behaviours. The findings demonstrate how social hierarchies and beliefs intertwine with public health discourses about the body and health-enhancing practices, suggesting directions for reducing their impact in contexts of medicine and health.

Multidisciplinary peer-led sexual and reproductive health education programme in France, a prospective controlled-study.

BACKGROUND: Sexual education is an international priority to promote sexual and reproductive health (SRH) and to reduce risky sexual behaviour. Experts recommend holistic and comprehensive SRH peer-led education. In 2018, the French government launched a new public peer-led health prevention programme called the "Service Sanitaire" (SeSa), consisting of health education provided by healthcare students (peer educators) to teenagers. For the first time in France, the impact of the programme was prospectively evaluated during its first year to examine whether the programme improved the SRH knowledge of healthcare students and teenagers. Risk perception and risky sexual behaviour among these populations were also evaluated. METHOD: A prospective multicentre controlled study was conducted from November 2018 to May 2019. SRH knowledge was compared before and after the SeSa programme, and the evolution of this knowledge was compared, with linear regression, between healthcare students part of the SRH SeSa programme and those who were part of another programme. The same analysis of knowledge was performed with respect to teenagers who received SRH interventions as part of the SeSa compared to teenagers who did not participate in a specific SRH education programme. Risk perception and risky behaviour were studied before and after the programme among healthcare students and teenagers. RESULTS: More than 70% of the targeted population participated in the study, with 747 healthcare students and 292 teenagers. SRH peer educators increased their knowledge score significantly more than other peer educators (a difference of 2.1 points/30 [95% CI 1.4-2.9] (p [between group] <  0.001)). Teenagers participating in the SeSa interventions also had a greater increase in their knowledge score than the other teenagers (+ 5.2/30 [95% CI 3.2-7.4] p [between group] < 0.001). There was no evidence of change in sexual risk behaviours for the healthcare student population. CONCLUSION: The "Service Sanitaire" programme significantly improved the sexual and reproductive health knowledge of peer-educator healthcare students and teenagers compared to a classic education programme. Longer and/or qualitative studies are needed to evaluate changes in sexual behaviour as well as positive impacts on sexuality.

Early postpartum discharge before 48 h: An exhaustive review.

PURPOSE: To describe the management of early discharge (less than 48 h after birth) attempts and investigate maternal and neonatal outcomes throw an exhaustive review. METHODS: This review was conducted according to PRISMA statement. The search was applied to PubMed and Google Scholar databases. Articles published before 2000 were not included to limit conclusions related to outdated medical practices. Eligibility assessment and analysis were performed independently by two reviewers. RESULTS: Of approximately 600 articles, 21 articles met the inclusion criteria, including 9 randomized trials. Fourteen studies were conducted in developed countries. Median primiparous rate was 40%. Home-visit, consultation and exclusive telephone follow-up were planned in 12, 4 and 3 studies respectively. Among the 100,311 patients of this review, mean rates of rehospitalization for maternal and neonatal causes were 1.9% [0.3-4.8] and 3.2% [0-10.1] respectively. Median breastfeeding rates at 2 weeks, 1 month and 3-6 months were 85% [73.2-100], 82% [62-91] and 63% [10-95] respectively. CONCLUSION: Length of stay after childbirth is not discriminating mother and newborn safety. The optimal length of stay would rather depend on the health of the mother and infant, the maternity discharge organization, the medical follow-up, and the subsequent support.

Preoperative high-dose-rate brachytherapy for high-risk early-stage cervical cancer: Long-term clinical outcome analysis.

OBJECTIVE: To report long-term oncological and toxicity outcomes after high-dose-rate brachytherapy (HDB) followed by oncologic surgery for patients with early-stage cervical cancer. METHODS AND MATERIALS: From 2005 to 2019, all patients treated with preoperative HDB at Antoine Lacassagne Cancer Center for early-stage (IB1-IB2-IIA - FIGO 2018) cervical cancer with local relapse risk factors were included. HDB was performed followed by hysterectomy. Oncological and toxicity outcomes were evaluated prospectively. RESULTS: We identified 61 patients, with a median follow-up of 84 months. Posthysterectomy complete pathological response was observed in 46 patients (75.4%). Six patients (9.8%) experienced recurrence, including 4 local relapses (6.6%), and 2 deaths (3.3%) due to cervical cancer. Five-year local, nodal and metastatic relapse-free survivals were 94% (95% CI 87-100%), 96% (95% CI 90-100%) and 93% (95% CI 86-100%) respectively. Five-year overall survival was 98% (95% CI 95-100%). No grade ≥ 3 acute toxicity was observed, and 3 patients (4.9%) experienced grade 2 acute toxicity. One patient presented grade 4 late digestive toxicity, and 6 patients had grade 2 late toxicity. Only 1 patient still had grade 2 toxicity, after 9 years follow-up. CONCLUSIONS: To our knowledge, we are reporting the longest follow-up of a preoperative HDB cohort. With similar oncological outcomes and less morbidity compared to primary surgery treatment followed more or less by adjuvant radiotherapy, HDB followed by hysterectomy could be a promising therapeutic option for early-stage cervical cancers with poor prognostic factors.

Immunosuppressive Tumor Microenvironment Status and Histological Grading of Endometrial Carcinoma.

The recent successes of new cancer immunotherapy approaches have led to investigate their relevance in the context of the Endometrial Carcinoma (EC). These therapies, that take the tumor-induced immunosuppressive microenvironment into account, target the tumor immune escape, in particular the inhibitory receptors involved in the regulation of the effector T cells' activity (immune checkpoints). The aim of this study was to identify, in ECs, differences in intergrades immune status that could contribute to the differences in tumor aggressiveness, and could also be used as theranostic tools. The immune status of tumors was assessed by quantitative real-time PCR. We analyzed the expression of specific genes associated to specific leukocytes subpopulations and the expression of reporting genes associated with the tumor escape/resistance. This study highlights significant differences in the EC intergrades immune status especially the tumor-infiltrating cell types and their activation status as well as in the molecular factors produced by the environment. The immune microenvironment of grade 1 ECs hints at a robust tumoricidal milieu while that of higher grades is more evocative of a tolerogenic milieu. This genes-based immunological monitoring of tumors that easily highlights significant intergrade differences relating to the density, composition and functional state of the leukocyte infiltrate, could give solid arguments for choosing the best therapeutic options, especially those targeting immune checkpoints. Moreover it could enable an easy adaptation of individual treatment approaches for each patient.

Magnetic resonance hysterosalpingography in diagnostic work-up of female infertility - comparison with conventional hysterosalpingography: a randomised study.

OBJECTIVE: To compare diagnostic accuracy of MR-hysterosalpingography (MR-HSG) and conventional hysterosalpingography (X-HSG) in the evaluation of female infertility. METHODS: Forty women received prospectively both X-HSG, the gold standard technique, and MR-HSG on the same day but the order in which they were conducted was randomised. A 1.5 Tesla MRI was performed with classical sequences for pelvic analysis and an additional 3D T1-weighted sequence with intra-uterine injection of gadolinium. Two radiologists independently interpreted X-HSG and MR-HSG according to randomisation, blinded to the other results. They both then performed a second interpretation of MR-HSG blinded to the first reading with a minimum time delay of 1 week. Diagnostic performance of MR-HSG for analysis of tubal and intracavity abnormalities was evaluated by calculating sensitivity (Se), specificity (Sp), positive predictive value (PPV) and negative predictive value (NPV). RESULTS: Twenty-six patients were included. Diagnostic performance of MR-HSG was: Se: 91.7% (95% CI 61.5-99.8); Sp: 92.9% (95% CI 66.1-99.8) ; PPV: 91.7% (95% CI 61.5-99.8); NPV: 92.9% (95% CI 66.1-99.8). Pain analysis showed a significant statistical difference between the two procedures: average VAS for X-HSG was 4.43 (95% CI 3.50-5.36) versus 3.46 (95% CI 2.62-4.31) for MR-HSG, p=0,01. Intra- and inter-rater agreements for detection of tubal or intracavity abnormalities were 0.92 (95% CI 0.78-1.00) and 0.76 (95% CI 0.52-1.00). CONCLUSION: MR-HSG is a well-tolerated technique demonstrating high accuracy in investigating tubal patency and intra-uterine abnormalities for diagnostic work-up of female infertility. KEY POINTS: • MR-hysterosalpingography is an innovative technique. • Hysterosalpingography can be used to investigate tubal patency and intracavity abnormalities. • Hysterosalpingography is a potential 'one-stop-shop' imaging technique for a single comprehensive examination of female infertility.

The Pubic Diastasis Measurement, a Key Element for the Diagnosis, Management, and Prognosis of the Bladder Exstrophy.

OBJECTIVE: To demonstrate the feasibility of measuring the fetal pubic diastasis (PD) distance on antenatal ultrasound in normal fetuses and to compare it to fetuses with bladder exstrophy. METHODS: Firstly, a prospective multicentric study was conducted to determine the feasibility of the PD ultrasound measurement during the second half of pregnancy. Secondly, data from a single center were used to develop a nomogram for PD values in normal fetuses. Thirdly, retrospective PD measurements were collected from fetuses with bladder exstrophy, diagnosed in seven French Multidisciplinary Centers for Prenatal Diagnosis (MCPDs). RESULTS: Operators from several MCPDs examined 868 fetuses and found that overall PD ultrasound measurement was feasible in 71% of cases and that the ossification of pubic points increased to be always visible from 27 weeks of gestation onward. Performed in a single center by a referring operator on 1,539 fetuses, the feasibility reached 94.74%. Both set of measurements were concordant (mean PD distance value of 5.42 ± 1.8 mm). Interestingly, all 23 fetuses with bladder exstrophy showed a significantly larger PD distance (mean 15.74 ± 3.9 mm). CONCLUSION: PD measurement in the fetus is feasible and reliable in the second half of gestation and can be used to support the antenatal diagnosis of bladder exstrophy with PD values exceeding 10 mm.

Predicting early death in older adults with cancer.

BACKGROUND: Predicting early death after a comprehensive geriatric assessment (CGA) is very difficult in clinical practice. The aim of this study was to develop a scoring system to estimate risk of death at 100 days in elderly cancer patients to assist the therapeutic decision. METHODS: This was a multicentric, prospective cohort study approved by an ethics committee. Elderly cancer patients aged older than 70 years were enrolled before the final therapeutic decision. A standardised CGA was made before the treatment decision at baseline. Within 100 days, event (death), oncologic and geriatric data were collected. Multivariate logistic regression was used to select the risk factors for the overall population. Score points were assigned to each risk factor using the ß coefficient. Internal validation was performed by a bootstrap method. Calibration was assessed with the Hosmer-Lemeshow goodness of fit test and accuracy with the mean c-statistic. FINDINGS: One thousand fifty patients (mean age: 82 years) joined the study from April 2012 to December 2014. The independent predictors were metastatic cancers (odds ratio [OR] 2.5; 95% confidence interval [CI], [1.7-3.5] p<0 .001); gait speed<0.8 m/s (OR 2.1; 95% CI [1.3-3.3] p=0.001); Mini Nutritional Assessment (MNA) < 17 (OR 8; 95% CI; [3.7-17.3] p<0.001), MNA ≤23.5 and ≥ 17 (OR 4.4; 95% CI, [2.1-9.1) p<0.001); performance status (PS) > 2 (OR 1.7; 95% CI, [1.1-2.6)] p=0.015) and cancers other than breast cancer (OR 4; 95% CI, [2.1-7.9] p<0.001). We attributed 4 points for MNA<17, 3 points for MNA between ≤23.5 and ≥ 17, 2 points for metastatic cancers, 1 point for gait speed <0.8 m/s, 1 point for PS > 2 and 3 points for cancers other than breast cancer. The risk of death at 100 days was 4% for 0 to 6 points, 24% for 7 to 8 points, 39% for 9 to 10 points and 67% for 11 points. INTERPRETATION: To our knowledge, this is the first score which estimates early death in elderly cancer patients. The system could assist in the treatment decision for elderly cancer patients.

Development and validation of an objective structured assessment of technical skill tool for the practice of breech presentation delivery.

OBJECTIVE: To develop and test the validity of an Objective Structured Assessment of Technical Skills (OSATS) tool for breech presentation delivery. MATERIALS AND METHODS: Monocentric prospective study conducted in the Department of Gynecology, Obstetrics, Fetal Medicine and Reproductive Medicine at the University Hospital of Nice. The study consisted of two parts, the development of the OSATS scoring system and its objective validation. Several experts in obstetrics from university hospital centers and private French hospitals were invited to participate in the development phase of the scoring system. For the validation phase, we formed a group of 20 novices and a group of 20 experts, who had to perform a breech presentation delivery on a simulator, according to a standardized scenario. Each participant was filmed and two experts would then evaluate their performance by viewing anonymized videos and using the OSATS score. RESULTS: The scores obtained by the expert group were significantly higher than those of the novice group, with a total score of 21.73/25 versus 6.95/25 (p < 0.0001), a task-specific score of 87.2/110 versus 44.3/110 (p < 0.0001) and an overall score of 108.93/135 versus 51.25/135 (p < 0.0001), respectively. CONCLUSION: The OSATS score developed in this study for breech presentation delivery is a reliable model to assess the competence level in procedural skills using a simulator.

A prospective study into the benefits of simulation training in teaching obstetric vaginal examination.

OBJECTIVE: To assess the benefits of incorporating simulations in obstetric vaginal-examination training. METHODS: A single-center, randomized, prospective study was conducted in a French University Hospital. Medical students without obstetric experience were assigned, by simple random sampling, to perform either 10 or 30 vaginal-examination training procedures using a simulator. A control group of students that had not performed any simulator training procedures was also enrolled. Medical students performed six vaginal examinations on patients who were in labor. The students reported the findings of the examinations in terms of five items (cervical length, position, consistency, dilation, and fetal presentation). The students' findings were then compared with those of experienced midwives (whose answers were considered to be the gold standard) who examined the same patients. RESULTS: A total of 66 students were included in the analyses. Students who had performed 10 simulated procedures demonstrated significantly greater accuracy in vaginal examination assessments in comparison with the control group (P<0.001). No significant difference was observed between the results for students that had performed 10 or 30 simulated procedures (P=0.44). CONCLUSION: Simulation training assisted novice students in improving their vaginal-examination skills before performing such procedures on real patients. Vaginal-examination simulations should be included in the training curriculum for students who will examine pregnant patients.

Postpubertal Persistent Hyperestrogenemia in McCune-Albright Syndrome: Unilateral Oophorectomy Improved Fertility but Detected an Unexpected Borderline Epithelial Ovarian Tumor.

BACKGROUND: McCune-Albright syndrome (MAS), due to a somatic mutation of the GNAS1 gene, begins usually in girls with peripheral precocious puberty. Ovarian autonomy may persist in adulthood with acyclic hyperestrogenemia, infertility, and a potential risk of estrogen-dependent cancer. CASE: A 22-year-old woman, with MAS, was referred for infertility with left macropolycystic ovary, hyperestrogenemia, and chronic anovulation unsuccessfully treated by controlled hyperstimulation. Once ovarian cyst punctures and cDNA analysis verified that GNAS1 mutation was restricted to the left ovary, unilateral ovariectomy was performed. It improved right ovarian function, allowed an in vitro fertilization-induced pregnancy, but revealed an unexpected borderline epithelial ovarian tumor. SUMMARY AND CONCLUSION: Several breast cancers have already been reported in young MAS patients but not a borderline epithelial ovarian tumor. In this context, we would recommend that persistent hyperestrogenemia in an adult be corrected and gynecological follow-up of the breasts, ovaries, and endometrium be implemented.

Hyperthermic intraperitoneal chemotherapy for the treatment of recurrent ovarian cancer in elderly women.

Our aim was to evaluate the morbidity and survival associated with combined cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) in the treatment of recurrent ovarian cancer for patients aged 70 years and older. We conducted a monocentric study in a French university hospital and collected data on 15 women aged ≥ 70 years, treated by cytoreduction and HIPEC for ovarian cancer relapse. The median overall survival was 35 months, with a median disease-free survival of 15.6 months. When a Peritoneal Cancer Index subgroup analysis was performed, a statistically significant difference in the disease-free survival could be observed for a Peritoneal Cancer Index ≤ 13 (p = 0.036). A trend towards improvement of disease-free survival was observed when the Completeness of Cytoreductive Score was equal to 0 (p = 0.0915).

[Gynecological cancers in elderly women]. / Cancers gynécologiques pelviens chez la femme âgée.

Pelvic gynaecological cancers are common in elderly women. Diagnosis and the decision to treat require multidisciplinary expertise. An oncologic, surgical and geriatric evaluation contributes to a split decision and personalised care. The care team is involved in the geriatric evaluation, information, education and patient monitoring throughout the treatment plan.

In vitro fertilization versus conversion to intrauterine insemination in Bologna-criteria poor responders: how to decide which option?

OBJECTIVE: To compare the continuation of in vitro fertilization (IVF) with the conversion to intrauterine insemination (IUI) in cases of suboptimal ovarian response in Bologna-criteria poor responders. DESIGN: Retrospective and multicenter comparative study. SETTING: Three academic fertility centers and a fertility private clinic. PATIENT(S): Analysis of 7,176 initiated IVF cycles from January 2010 to January 2013. The 461 cycles with poor ovarian response (fewer than three follicles ≥16 mm at hCG trigger) in patients with poor response according to the Bologna criteria were included. INTERVENTION(S): Decision to pursue IVF (n = 184), convert to IUI (n = 141), or cancel cycle (n = 136) when only one or two follicles were recruited. MAIN OUTCOME MEASURE(S): Live birth, ultrasound pregnancy, and early pregnancy rates were compared depending on whether they resulted from IVF or IUI and were stratified according to patient age and the number of mature follicles at trigger. RESULT(S): Live birth rates were significantly higher for IVF patients compared with IUI conversion when two follicles were present (11.6% IVF vs. 1.6% IUI), especially for patients <40 years of age (13.1% IVF vs. 2% in IUI). In case of a monofollicular recruitment, the pregnancy outcomes were similar. CONCLUSION(S): A therapeutic strategy could therefore be to pursue IVF for women demonstrating two follicles and to convert to IUI for cycles with only one follicle if the sperm and tubal parameters are favorable.

Development and validation of an objective structured assessment of technical skill tool for the practice of vertex presentation delivery.

OBJECTIVE: To develop and test the validity of an objective structured assessment of technical skill (OSATS) tool for vertex presentation delivery simulations. MATERIALS AND METHODS: Monocentric prospective study conducted in the Department of Gynecology, Obstetrics, Fetal Medicine and Reproductive Biology at the University Hospital of Nice. The study consisted of two parts, the development of the scoring system and then its validation. Experts in obstetrics from several academic institutions and private French hospitals were invited to participate in the development phase of the scoring system. For the validation phase, we formed a group of 20 novices and a group of 20 experts, who performed a childbirth simulation according to a standard scenario. Each participant was filmed and then two experts evaluated their performance with the OSATS score by viewing anonymized videos. RESULTS: The scores obtained by the expert group were significantly higher than those of the novice group, whether we compared the total score or each part of the score (task-specific or global) independently. We obtained a p value of 0.03 for the total score, p = 0.036 for the task-specific score, and p < 0.001 for the overall score. CONCLUSION: The OSATS score developed in this study for vertex presentation delivery is a reliable mean to assess the medical students' competence in procedural skills using a simulator.