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.

Early screening for gestational diabetes mellitus is not associated with improved pregnancy outcomes: an observational study including 9795 women.

AIMS: In addition to screening for hyperglycaemia during pregnancy after 24 weeks of gestation (WG), the current guidelines also suggest screening in early pregnancy and referring women with early gestational diabetes mellitus (eGDM) or overt diabetes (OD) for immediate care. Our aim was to evaluate this strategy. METHODS: This study evaluated, at our hospital (2012-2016), whether the incidence of a predefined composite outcome (preeclampsia, large-for-gestational-age infant, shoulder dystocia) and secondary outcomes was different when women were screened only after 22WG ('late screening only') or before 22WG and treated for eGDM or OD if present, with repeat screening after 22WG if absent ('early ± late screening'). RESULTS: Early ± late screening (n = 4605, 47.0%) increased between 2012 and 2016 (P < 0.0001) and was associated with more risk factors for GDM than late screening only. Glycaemic status differed in both groups (early ± late screening: eGDM 10.3%, GDM 12.1%, OD 0.9% vs. late screening only: GDM 16.8%, OD 1.2%; P < 0.001), with a higher rate of insulin therapy (8.9% vs. 6.0%; P < 0.001) and less gestational weight gain (11.1 ± 5.4 kg vs. 11.4 ± 5.5 kg; P = 0.013) in the early ± late screening group. Rates of those meeting the composite criterion were similar in both groups [11.6% vs. 12.0%, respectively; odds ratio (OR): 1.040, 95% confidence interval (CI): 0.920-1.176; P = 0.53] and remained comparable after adjusting for Propensity Scores (OR: 1.046, 95% CI: 0.924-1.185; P = 0.4790). Rates for secondary outcomes were also similar in both groups. CONCLUSION: While a strategy including early measurement of fasting plasma glucose during pregnancy increases the incidence and care of hyperglycaemia during pregnancy, it may not significantly improve pregnancy outcomes.

[Cornual pregnancy: Management and subsequent fertility]. / Grossesse extra-utérine cornuale : prise en charge, fertilité ultérieure et devenir obstétrical.

OBJECTIVE: Cornual pregnancy is a rare entity, representing 2% of ectopic pregnancies. Its management is poorly codified and often guided by the clinical situation. The aim of our study was to describe the management of cornual pregnancies, subsequent fertility, and obstetric outcomes according to the management. METHODS: Observational retrospective unicentric study. Nineteen patients hospitalized for cornual pregnancy between 2006 and 2015 were included. The data was collected with medical records and a phone standardized questionnaire. Patients were managed according to hemodynamic status by either systemic or local methotrexate injection or surgical corneal resection. RESULTS: Among the 19 patients, 32% (6) were treated by systemic injection (one failure treated by surgical treatment) and 68% (13) underwent surgical treatment by cornual resection. The median HCG rate decrease was 33 days (16-62). Among the twelve patients with a desire for a new pregnancy, 7 (58%) became pregnant without assisted reproductive technology (2 following medical treatment and 5 following surgical resection). Histological analysis of uterine horn showed proximal fallopian tube lesions in 76.9% of case (chronic salpingitis, endosalpingiosis and adenomyosis). CONCLUSION: Cornual pregnancies are at high risk of hemorrhagic rupture. Ectopic recidive may occur. Fertility and obstetrical outcomes following cornual pregnancy are not affected whatever the initial treatment. Other studies are needed to aid clinical management according to HCG level and ultrasound features.

Improving postpartum glucose screening after gestational diabetes mellitus: a cohort study to evaluate the multicentre IMPACT initiative.

AIMS: To evaluate a mobilization campaign, the IMPACT initiative, which included multidisciplinary meetings, provision of information and a systematic prescription of an oral glucose tolerance test to improve the rate of glucose screening in women with gestational diabetes mellitus in the four largest maternity units in our area, starting in March 2011. METHODS: We retrospectively compared the level of self-reported screening during the first 6 months postpartum of women who gave birth after having been diagnosed with gestational diabetes before (January 2009 to December 2010) and after the IMPACT campaign (April 2011 to February 2012). RESULTS: We included 961 women (589 in the period before and 372 in the period after the campaign was initiated) with a mean ± SD age of 33.2 ± 5.3 years and BMI of 27.8 ± 5.3 kg/m². Multivariate analysis, stratified using a propensity score in order to limit bias caused by imbalance between both periods, showed that the postpartum screening rate was higher after the campaign began (48.9 vs 33.3%, odds ratio 1.7, 95% CI 1.1-2.5; P = 0.019) and higher in women who received insulin treatment during pregnancy (odds ratio 2.3, 95% CI 1.5-3.6; P < 0.001), consumed fruit and vegetables daily (odds ratio 1.6, 95% CI 1.1-2.4; P = 0.035) and did not smoke (smoking vs non-smoking: odds ratio 0.3, 95% CI 0.1-0.7; P = 0.01). There was no interaction between the campaign effect and these particular conditions. The proportion of oral glucose tolerance tests performed in women who underwent screening increased from 6.3 to 33.0%. CONCLUSIONS: The IMPACT campaign increased postpartum screening, and the use the oral glucose tolerance test in particular. The effect of this initiative might be reinforced in women who are non-daily consumers of fruit and vegetables, smokers and those who do not receive insulin treatment during pregnancy.

[Obstetric and neonatal outcomes of adolescent pregnancies: a cohort study in a hospital in Seine-Saint-Denis France]. / Devenir obstétrical et néonatal des grossesses chez les adolescentes : cohorte de patientes en Seine-Saint-Denis.

OBJECTIVES: The aim of this study was to describe the characteristics, monitoring, obstetrical complications, childbirth and neonatal outcomes of pregnancies among minors in a cohort of adolescents from Seine-Saint-Denis (France). PATIENTS AND METHODS: This is a retrospective, cohort, comparative study, conducted from January 1, 1996 to July 31, 2011, made from the database of Jean-Verdier hospital in Seine-Saint-Denis. Three groups were established: patients aged less than 16 years old, patients aged over 16 years old and under 18 years old compared to a group consisting of older primiparas from 18 to 25 years old. The criteria considered were the characteristics of pregnancy, terms of delivery, neonatal outcome and conduct of post-partum. RESULTS: Minor patients were statistically more likely to be single, student, smoking and anemia compared to young adults. The obstetrical care was lower for minor compared to the control group with a number of consultations and ultrasounds lower (P < 0.001). Obstetrical complications were similar in the three groups outside of preterm labor. Adolescentes under 16 years old had a higher preterm delivery risk in multivariate analysis (RR = 0.33 CI 95% [0.12; 0.90] P = 0.03). Adolescents had fewer cesarean and instrumental deliveries (P < 0.05). DISCUSSION AND CONCLUSION: Teenage pregnancy remains an important managing issue for maternities, particularly from a social standpoint. On the medical side, one preterm delivery appears to be more common among these adolescents.

Factors associated with screening for glucose abnormalities after gestational diabetes mellitus: baseline cohort of the interventional IMPACT study.

INTRODUCTION: Although it is important to screen women who have had gestational diabetes mellitus (GDM) for abnormal post-partum glucose levels, such testing is rarely performed. The aim of this study was to use data from the first observational phase of the IMPACT study to determine rates of screening within 6 months of delivery in a multiethnic cohort, focusing in particular on the effects of social deprivation and the risk of future diabetes. PATIENTS AND METHODS: To investigate the frequency of post-partum screening, charts were analyzed, and all women attending four centres located in a deprived area who had had GDM between January 2009 and December 2010 were contacted by phone. The Evaluation of Precarity and Inequalities in Health Examination Centres (EPICES) deprivation index and Finnish Diabetes Risk Score (FINDRISK) questionnaire were also evaluated. RESULTS: Data were evaluable for 589 of the 719 women contacted (mean age: 33.4 ± 5.2 years; mean body mass index: 27.6 ± 5.4 kg/m(2)), and 196 (33.3%) reported having been screened. On multivariate analysis, factors associated with a lack of screening were smoking [odds ratio (OR): 0.42 (0.20-0.90), P<0.05], low consumption of fruit and vegetables [OR: 0.58 (0.39-0.82), P<0.01] and heavier offspring birth weight (P<0.05), although there were no differences in FINDRISK and EPICES scores between screened and unscreened women. CONCLUSION: One-third of women who had had GDM reported having been screened for dysglycaemia at 6 months post-partum. However, it is expected that the interventional phase of the IMPACT study will increase screening rates, especially in women with the risk factors associated with lower screening rates during this observational phase.

[A piece of needle of a cesarean section found 45 years later]. / Un bout d'aiguille de césarienne retrouvé 45 ans plus tard.

We report the case of a patient who had a caesarian section 45 years ago in whom was discovered a piece of needle during assessment of an endometrial cancer. This piece of needle, close to the small bowel, was found inside a hysterotomy scar but no complication occurred during all this time.

Universal rather than selective screening for gestational diabetes mellitus may improve fetal outcomes.

AIM: The benefit of treating gestational diabetes mellitus (GDM) has recently been shown. The aim of this study was to compare offspring and maternal health benefits from selective or universal screening for GDM. METHODS: The incidence of outcomes was compared in three series of pregnant women: 1) the 159 consecutive women with GDM out of the 1909 women who delivered between October 2000 and September 2001: during this period screening for GDM was based on risk factors (risk factor-GDM); 2) the 265 consecutive women with GDM out of the 2111 women who delivered during the year 2002: during this period screening for GDM was universal (universal-GDM); 3) 1255 women with no GDM during year 2002 (controls). RESULTS: After adjustment for age, pregravid body mass index, parity, and ethnicity, the risk of large for gestational age (Odds ratio 2.19[95% confidence interval 1.36-3.54], P < 10(-3)), delivery before 37 weeks of gestation (OR 2.44 [95CI 1.32-4.51], P = 0.004), jaundice (OR 3.31[95CI 1.58-6.93], P = 0.002), hospitalization in the department of pediatrics (OR 2.35 [95CI 1.53-3.61], P < 10(-3)) was higher in the GDM-risk factor group than in the control group, whereas it was similar in the universal-GDM group and the control group. Compared with the control group, the risk of anticipated delivery and hospital stay > 4 days after delivery was increased in the GDM-risk factor group (OR 2.69[1.88-3.84], P < 10(-3); and OR 2.6 [1.82-3.71], P < 10(-3) respectively) and the universal-GDM group (OR 1.54 [1.15-2.07] P = 0.004; and OR 1.49 [1.13-1.97], P = 0.005 respectively). CONCLUSION: This observational study suggests that universal rather than selective screening for GDM may improve outcomes. Universal screening might reduce delay of diagnosis and care.

[Comparison of two routine screening strategies for gestational diabetes mellitus: the experience of Jean-Verdier Hospital]. / Comparaison de deux politiques de dépistage du diabète gestationnel: expérience de l'hôpital Jean-Verdier.

OBJECTIVE: Screening strategies for gestational diabetes mellitus are controversial. Thus, we sought to determine the benefits of universal screening. PATIENTS AND METHODS: Prospective study with 2121 women involved but 1610 really screened (75.9%). According to WHO's recommendations, the strategy implemented was one-step, universal screening with a 75g oral glucose tolerance test. Screening was performed between 24 and 28 weeks of gestation or earlier if risk factors were identified. Results were compared to previous year (2001) then only a selective screening was done. RESULTS: Application of universal screening increased the prevalence of gestational diabetes mellitus (8.39% to 15.65%). Out of the 252 patients with gestational diabetes, 66 did not display any identified risk factor (26.19%). Some new risk factors have been identified: age>30, Asian, Indian or Pakistan ethnies. If these new risk factors were applied, this super selective screening would have a sensibility of 96%. DISCUSSION AND CONCLUSION: Universal screening seems to be the most appropriate routine screening strategy because it is difficult to know exactly the specific risk factors of a population to do a super selective screening.

[Endometrial ossification: about one case]. / Métaplasie ostéoïde de l'endomètre : à propos d'un cas.

The ossification of the endometrium is a rare disease. The common feature in most reported cases is previous history of abortion with retention of foetal bones. However, the physiopathology is unknown. Clinical presentation may include secondary infertility as well as chronic inflammation of endometrium. About one recent observation and with help of publications, we will discuss physiopathology, symptomatology and therapeutics of this disease.

Doppler ultrasonography and implantation: a critical review.

Active perifollicular angiogenesis in ovaries and endometrium is linked with the quality of oocytes and endometrial receptivity, and consequently with the outcome of implantation. Studies evaluating ovarian velocimetry in relation to implantation and pregnancy rates bring essentially into play velocity values or non-quantitative parameters, whose reproducibility is low and which are hardly usable in daily practice. Conversely, the assessment of uterine artery flow by Doppler examination is easy and reproducible, and high impedance at the end of the follicular phase is a good predictive indicator of poor endometrial receptivity. In early pregnancy, Doppler investigation must not be used routinely because its safety is still under discussion; however, the available data show that impedance in the uterine and spiral arteries does not show any significant difference between normal and abnormal pregnancies (missed abortions or anembryonic pregnancies), and the significance of easily detectable intervillous flow is hotly debated, raising fundamental points.

Uteroplacental circulation development: Doppler assessment and clinical importance.

In the first weeks of pregnancy, columns of endovascular cytotrophoblastic plugs develop in the lumen of spiral arteries. Morphologic data show that these plugs become loosened as soon as the end of the second month and the intervillous circulation of maternal blood is likely to be established progressively between the 8th and 12th weeks. The disorganization of the musculo-elastic layers of these vessels provokes a dramatic decrease in vascular tone in the uteroplacental circulation. These modifications appear to govern the establishment of a low-pressure blood flow in the placenta, and hence determine the quality of uteroplacental circulation and normal fetal growth. Placental bed biopsies in women with pre-eclampsia and in a proportion of pregnancies with intrauterine growth retardation have shown that these physiologic changes were absent in the myometrial segments of spiral arteries. Recently, colour Doppler was used to assess intervillous and spiral artery flow in early pregnancy, confirming in vivo free intervillous flow at 12 weeks and a progressive significant decrease in spiral artery resistance with advancing gestation during the first trimester. However, certain data at an earlier gestational age are still contradictory. Particularly, the exact nature of the contents of the intervillous space before 8 weeks, and whether or not this fluid can be considered maternal blood, remains controversial.

[Demons-Meigs syndrome: apropos of 1 case]. / Le syndrome de Demons-Meigs: à propos d'un cas.

A 33-year-old patient presented with ascites and a right abdominal mass. Ultrasound and scannography showed it was probably a solid ovarian tumor measuring 175 mm x 115 mm. Serum Ca 125 was 752 UI/mL and ACE was normal. Surgical exploration revealed 3.2 liters ascites without any suspect peritoneal implant and a bulky ovarian fibrothecoma. The patient recovered quickly and serum Ca 125 was 43 UI/mL one month post-operatively. In this case report of Meigs' syndrome serum CA 125 level was particularly high. Preoperative diagnostic difficulties are discussed.

Myometrial maturation and labour.

The increased expression of contraction-associated proteins, including oxytocin receptors, connexin-43, and prostaglandin F2alpha receptors, in term pregnant myometrium is classically considered to be the concrete expression of myometrial activation. However, the decrease in prostaglandin E2 receptor subtype EP2 on one hand and the down-regulation of the nitric oxide (NO) pathway and various vasorelaxing peptides on the other hand probably also play a key role in the loss of quiescence, and, with the above-mentioned activation, in the maturation of the myometrium. Decidual activation and production of interleukin-1, tumour necrosis factor-alpha and epidermal growth factor enhance prostaglandin production in both the amnion and chorion, and also in the myometrium. A substantial increase of eicosanoids concentration in myometrial tissue is probably an important condition for the success of the ultimate step of myometrial stimulation and the onset of labour. During labour, prostaglandins and oxytocin seem to act in synergy, perhaps along with endothelin-1, to trigger contractility through an increase in intracellular Ca2+ concentration. An overall view of these phenomena in which myometrial cells are the common targets of uterorelaxant and uterotonic agents appears essential for a rational use of tocolytic therapies and labour inductors.

Characterization of first trimester human fetal placental vessels using immunocytochemical markers.

Cell differentiation markers on placental villi from the first trimester of human pregnancy have been studied by indirect immunofluorescence. Fluorescence labelling with antibodies against CD34 and CD31 was conspicuous in the vascular cells. The vascular paracellular clefts were labelled by anti-cadherin-5. A few vascular cells exhibited a positive reaction for von Willebrand factor, high-molecular-weight melanoma-associated-antibody and alpha-sm-actin compared to term pregnancy, indicating changes in protein expression during vascular differentiation. The poor anti-collagen IV reaction and the absence of a sm-myosin fluorescent signal observed around the vessels confirned the immaturity of the vessels. In contrast, strong reactions have previously been obtained with the latter antibodies in similar locations using term placental villi. A labelling was observed for antibodies against alpha3 and alpha5 integrins in these immature placental vessels suggesting cell-matrix interactions with specific domains of laminin or fibronectin. The vascular cells were also stained by anti-CD26. Surprisingly, the fetal vascular cells exhibited immunostainings in common with the villous cytotrophoblast (CD26) or the syncytiotrophoblast (cadherin-5) and cell islands cytotrophoblast (CD31, cadherin-5, alpha3 and alpha5 integrin subunits). These observations suggested a two step process for fetal vasculogenesis in the villi: i/ the formation of peripheral vessels induced by growth factors or cytokines derived from the nearby trophoblast, ii/ the development of muscular vessels due to growth factors or cytokines production induced by circulatory changes.

[Neonatal myasthenia gravis]. / Myasthénie et grossesse: l'atteinte du nouveau-né peut être révélatrice.

BACKGROUND: Myasthenia gravis, an autoimmune disease of young women, is due to the dysfunction of neuromuscular transmission. The newborn of a myasthenic mother inconstantly presents a transitory neonatal myasthenic syndrome. Maternal aggravation, or even myasthenic crisis with respiratory failure, can occur in the first three months post-partum. CASE REPORT: Mrs. S., para two without appreciable medical history, delivered normally a boy weighing 4 kg with an Apgar score of 10/10. At 3 h of life the newborn was admitted to the neonatal care unit for grunting and axial hypotonia. Diagnoses of maternal-fetal infection and fetal distress were excluded. The dissociated pattern of neurological disorders (refusal to drink, axial hypotonia, hypomimia, but good contact and normal alertness) led to search for neuromuscular causes or poison. Myasthenia gravis was then considered and confirmed by maternal electromyography, allowing the diagnosis of transient neonatal myasthenia gravis and early diagnosis and treatment of the maternal myasthenic crisis in a specialized care unit. The outcome of both mother and child was favorable under treatment. CONCLUSION: Lack of maternal myasthenia gravis history should not result in excluding the diagnosis of transitory neonatal myasthenia gravis when evocative neonatal neurological signs are present. The symptomatology in the newborn may indeed reveal maternal myasthenia gravis, allowing an early diagnosis in both the mother and the newborn.

Virological and biological characteristics of cervical intraepithelial neoplasia grade I with marked koilocytotic atypia.

The aim of this study was to evaluate virologic and biological significance of marked koilocytotic atypia observed in some cases of grade I cervical intraepithelial neoplasia (CIN I). Thirty-one CIN I cervical biopsy specimens with marked koilocytotic atypia, defined by the presence of meganuclei in the superficial epithelial layers, were compared to 37 CIN I biopsy specimens with usual koilocytes for (1) the human papillomavirus (HPV) type and signal pattern as detected by nonisotopic in situ hybridization (ISH); (2) the proliferation index assessed by Ki 67 immunostaining and (3) the p53 labeling pattern. Interobserver agreement for meganuclei was excellent (k = 0.9). Twenty-five out of 68 biopsies (37%) were positive by ISH for the 6 of 11 HPV probe, 30 (44%) for the 16-18 probe, and 7 (10%) for the 31/33 HPV probe, 6 (9%) were negative for ISH. The presence of meganuclei was strongly related to high and intermediate risk HPV type (P = 0.0001). The sensitivity and specificity of meganuclei for the detection of high or intermediate risk HPV in CINI were 73 and 87%, respectively. Loss of p53 immunostaining in the lower third of the epithelium was also related to the presence of meganuclei (P < .05), but the MIB-1 index and ISH labeling pattern were not. In conclusion, marked koilocytotic atypia in CIN I is a reliable and sensitive marker for infection by high or intermediate-risk HPV, and might be a guide to therapy.