[Fertility-sparing management of endometrial cancer and atypical hyperplasia]. / Traitement conservateur des hyperplasies atypiques et cancers de l'endomètre et préservation de la fertilité.

The fertility sparing management of endometrial cancer and atypical hyperplasia concern women in childbearing age with stage 1, grade 1, endometrioid adenocarcinoma confined to endometrium or atypical hyperplasia (simple or complex). These pathologies affecting more frequently postmenopausal women, the number of people involved is relatively low. The main risk factor is hyperestrogenism and these patients often present a history of infertility with a desire for pregnancy. The recommendations for this conservative management are scarce and unclear. The national observatory in the gynecology and obstetrics department of Bichat hospital gives expert advice to help doctors and patients concerned. We present a type of conservative management based on the expertise of the national observatory. Rigorous pre-therapeutic assessment must first be made to avoid missing a more advanced lesion. Hormone therapy is then started to obtain complete remission. In case of remission, fast achieving pregnancy is advised, and the use of assisted reproductive therapy is possible if necessary. Monitoring by hysteroscopy and histological examination is essential during the treatment. Hysterectomy is the last time the conservative management. It is motivated by the risk of recurrence and progression. The probability of remission after conservative treatment is estimated at 78.0 % at 12 months, the probability of recurrence at 29.2 % at 24 months, and the risk of progression at 15 % (stage 1A with myometrial invasion or more on the hysterectomy specimen). In terms of fertility, 32 % of women get at least one pregnancy.

[An update on adenomyosis and implantation]. / Adénomyose et implantation : mise au point.

Adenomyosis is an enigmatic disease whose impact on implantation and fertility outcome is still controversial. A negative effect on IVF outcome was already observed, but it is mainly explained by an increase in early spontaneous miscarriages. We reviewed scientific data in order to bring relevant information about adenomyosis and endometrial receptivity for patient counselling and to precise if screening of adenomyosis is indicated before IVF treatment.

Ulipristal acetate for uterine fibroid-related symptoms.

Uterine fibroids are the most common benign uterine tumors in women of reproductive age. Although most women are asymptomatic (80%), fibroids, according to their type and location, can cause several symptoms and impact quality of life. To date, no medical treatment is able to eliminate fibroids. Ulipristal acetate (UPA) is an orally active synthetic selective progesterone receptor modulator (SPRM) characterized by a tissue-specific progesterone antagonist effect that reduces the proliferation of leiomyoma cells and induces apoptosis. It was licensed in Europe for preoperative fibroid treatment in 2012. Its pharmacological and pharmacodynamic characteristics, its efficacy and good tolerance make UPA a new important tool in the management of uterine fibroids.

Can rectal endoscopic sonography be used to predict infiltration depth in patients with deep infiltrating endometriosis of the rectum?

OBJECTIVES: To evaluate the diagnostic accuracy of rectal endoscopic sonography (RES) in the prediction of the infiltration depth of rectal endometriosis and to ascertain whether RES could be used to choose between segmental bowel resection and a more conservative approach, such as shaving or discoid resection. METHODS: In this retrospective study, 38 consecutive patients with symptomatic deep infiltrating endometriosis of the rectum who underwent laparoscopic colorectal resection were included. RES results for infiltration depth of rectal endometriosis were compared with results of pathological examination. The sensitivity, specificity, positive and negative predictive values (PPV and NPV, respectively), positive and negative likelihood ratios (LRs) and test accuracy were calculated for the presence of infiltration of the muscularis layers and submucosal/mucosal layers, as demonstrated by RES and confirmed by histopathological analysis. RESULTS: For the detection of muscularis layer infiltration by endometriosis, the PPV of RES was 100%, whereas for the detection of submucosal/mucosal layer involvement, the sensitivity was 89%, specificity was 26%, PPV was 55%, NPV was 71%, test accuracy was 58% and positive and negative LRs were 1.21 and 0.40, respectively. CONCLUSIONS: RES is a valuable tool for detecting rectal endometriosis as endometriotic infiltration of the muscularis layer can be predicted accurately. However, RES is less accurate in detecting submucosal/mucosal layer involvement and cannot, therefore, be used to choose between bowel resection and a more conservative approach.

[Routine screening for CMV during pregnancy: practices assessment in Île-de-France]. / Dépistage systématique du CMV pendant la grossesse : évaluation des pratiques en Île-de-France.

OBJECTIFS: Congenital infection with cytomegalovirus (CMV) is the leading cause of materno-fetal viral infection in industrialized countries. It covers up to 1% of neonates with risk of sequelae. The recommendations of the National agency for accreditation and evaluation in health from 2004 does not support routine screening for CMV during pregnancy. Some maternity hospitals still practice this screening and the purpose of this work is to present an overview of this practice in Île-de-France. PATIENTS AND METHODS: We present a descriptive cross-sectional survey among 99 maternity hospitals of Île-de-France between July 30, 2011 to January 15, 2012. Data were collected using a questionnaire in most cases during a telephone interview. Ninety-one questionnaires were collected. The primary endpoint was the achievement or otherwise of this screening. RESULTS: Of the 91 maternity hospitals surveyed, 13 (14.3%) still were conducting this screening in 2012. This practice was a minority and unrelated to the status (public/private), obstetric-pediatric type or activity. DISCUSSION & CONCLUSION: According to recent literature data, this diagnosis should be proposed only in case clinical or ultrasound signs. Screening could be included as part of research protocol for a better understanding of this pathology. It is not recommended in France and pending the development of an effective vaccine, informing pregnant women about preventive measures appear to be the most effective measure. This will involve a wide dissemination of recommendations to general practitioners in first line in support of women in early pregnancy.

Foetal serum but not urinary ß2-microglobulin correlates with histological injury to the kidney.

In a context of foetal obstructive uropathies, biochemical markers can be helpful to assess the renal function, but most studies to date have focused on their correlation with ultrasound findings and neonatal outcome. Our aim was to evaluate foetal ß2-microglobulin as an index of histological injury to the kidney. ß2-microglobulin was measured in serum and/or urine from 27 foetuses with bilateral obstructive uropathy, and compared to the findings of kidney examination following the termination of pregnancy. In serum, increased ß2-microglobulin levels correlated to a decreased number of glomeruli, a reduction in the blastema and the presence of primitive ducts reflecting renal hypoplasia and dysplasia. However, elevated ß2-microglobulin levels in the urine correlated only to a decreased number of glomeruli.

Accuracy of a nomogram for prediction of lymph-node metastasis detected with conventional histopathology and ultrastaging in endometrial cancer.

BACKGROUND: We developed a nomogram based on five clinical and pathological characteristics to predict lymph-node (LN) metastasis with a high concordance probability in endometrial cancer. Sentinel LN (SLN) biopsy has been suggested as a compromise between systematic lymphadenectomy and no dissection in patients with low-risk endometrial cancer. METHODS: Patients with stage I-II endometrial cancer had pelvic SLN and systematic pelvic-node dissection. All LNs were histopathologically examined, and the SLNs were examined by immunohistochemistry. We compared the accuracy of the nomogram at predicting LN detected with conventional histopathology (macrometastasis) and ultrastaging procedure using SLN (micrometastasis). RESULTS: Thirty-eight of the 187 patients (20%) had pelvic LN metastases, 20 had macrometastases and 18 had micrometastases. For the prediction of macrometastases, the nomogram showed good discrimination, with an area under the receiver operating characteristic curve (AUC) of 0.76, and was well calibrated (average error =2.1%). For the prediction of micro- and macrometastases, the nomogram showed poorer discrimination, with an AUC of 0.67, and was less well calibrated (average error =10.9%). CONCLUSION: Our nomogram is accurate at predicting LN macrometastases but less accurate at predicting micrometastases. Our results suggest that micrometastases are an 'intermediate state' between disease-free LN and macrometastasis.

[Inflammatory bowel diseases: gynecological and obstetrical considerations]. / Gynécologie, obstétrique et maladies inflammatoires chroniques de l'intestin.

Inflammatory bowel diseases (IBD), including Crohn's disease and ulcerative colitis, are invalidating inflammatory affections, which evolve by relapse interrupted with clinical remission. Crohn's disease commonly affects young women in their reproductive years with a peak of incidence between 20 and 30. Infertility and sexual dysfunction are equivalent to that of the general population while they are increasing in patients with active IBD or after colorectal surgery. IBD are well controlled by medical treatments and the frequency of relapse during the pregnancy is similar to that of the non-pregnant IBD patients. The data concerning the risk of congenital malformations in IBD are contradictory. The risk of preterm delivery and low birth weight is significantly increased and correlated to the disease activity. When a medical treatment insures a quiescent disease before the pregnancy, it is advisable to continue it during the pregnancy because the benefits of controlled disease outweigh the risks of medication. IBD, possible perianal lesions and colorectal surgical interventions influence the mode of delivery, but the indication of caesarean section should primarily be governed by obstetric necessity. Preconceptional counseling seems desirable because of the risks during pregnancy, according to the disease activity, the surgical histories and the therapeutic agents.

[Anti-TNFα therapy and its implication in gynecology and obstetrics]. / Médicaments anti-TNFα (tumor necrosis factor α) en gynécologie et en obstétrique.

Anti-TNFα treatments have modified the medical care, the course and the quality of life of the patients with autoimmune rheumatic, cutaneous or bowel inflammatory diseases. On the other hand, these treatments may have potential severe side effects during pregnancy (congenital malformations, fetal infections). Actually, many pregnancies have been reported during anti-TNFα exposures, with good maternal and neonatal outcomes. The introduction or the discontinuation of these treatments will always have to be discussed with the specialist of the chronic disease and, ideally, during a preconceptional counselling. In gynecology, anti-TNFα drugs may offer a new safe and effective approach to treating patients with recurrent miscarriages or unexplained or failed in vitro fertilization cycles. On the other hand, these treatments significantly increase the risk for serious infections or viral reactivations and may promote gynaecological malignancies. An adapted gynaecological survey is necessary.

A benign metastasizing leiomyoma involving a nodule in the pulmonary artery: case and literature review.

Benign metastasizing leiomyoma (BML) is a rare disease defined as a primary benign uterine tumor with "metastatic" lesions preferentially occurring in the lung, pelvis and lymph nodes. There are few reports about local recurrence after initial surgery. We report a case of a BML with local recurrence and metastasis growing into the wall of the left pulmonary artery, diagnosed 11 years after initial hysterectomy. A 55-year-old woman complaining of abdominal discomfort, heaviness and asthenia was admitted to our hospital for investigation of a voluminous uterine mass with high vascularization and three pulmonary nodules. The resection of the mass by laparotomy was complicated by uncontrolled severe hemorrhage due to vascular proliferation, requiring multiple transfusions, packing the cavity and postoperative uterine artery embolization. Three months later the patient underwent a left upper lobe lobectomy with the aim of removing the largest pulmonary nodule, a nodule a located in the lingular branch of the left pulmonary artery. The comparison of hysterectomy and lobectomy pieces showed a similar aspect, leading thus to the diagnosis of BML. Awareness of this rare entity should potentially avoid under-diagnosis and difficulties due to hemorrhage during surgery.

[Evolution of surgical operations for female for stress urinary incontinence in gynaecology departments of Parisian public hospitals between 2002 and 2006]. / Evolution des interventions chirurgicales pour incontinence urinaire d'effort dans les services de chirurgie gynécologique de l'Assistance publique des Hôpitaux de Paris entre 2002 et 2006.

OBJECTIVE: To appreciate the evolution of the current surgical practice for female for stress urinary incontinence (SUI) in the gynaecologic surgery departments of Parisian public hospitals in three different periods of 12 months (2002-2003, 2003-2004, and 2006). PATIENTS AND METHODS: The 16 departments were surveyed by postal questionnaire about their surgical practice for the treatment of female SUI. The number, the type of operation, the type of suburethral tapes and their surgical routes were detailed. RESULTS: The participation rate in the survey was 87.5% (14/16) for the first two studied periods and 75% (12/16) for the last one. The number of SUI procedure decreases between the three periods (586, 505, and 263 procedures, respectively; p<0.001). Suburethral slings represent the technique of choice for SUI (86.2% in 2002-2003; 92.7% in 2003-2004, and 98.1% in 2006). Other practices are exceptional. The transobturator approach has widely progressed and became the preferred one in 2006 (31.1%; 64.5%; 95.4% in 2006; p<0.001). No transobturator route was privileged. TVT procedures have decreased between the three studied periods (48.3%, 36.5%, and 4.6% in 2006; p<0.001). TVT-O is the preferred sling in 2006 (120/258, 46.5% of suburethral tapes). DISCUSSION AND CONCLUSION: Suburethral tape placement is nowadays the main surgical treatment for female SUI amongst members in gynaecology departments in Parisian public hospitals. The transobturator approach is preferred.

[Bariatric surgery and obstetrics]. / Chirurgie bariatrique et obstétrique.

Obesity poses a significant risk to reproductive-aged women. Weight reduction before conception is the best way to increasing fertility and reduces obesity associated morbidity. When medical interventions fail, bariatric surgery is the most successful method of weight loss, effective increasing fertility and reducing obstetrical complications and maternal and neonatal morbidity comparing obese women. Gastric banding and gastric bypass are the most increasingly utilized treatment option in France and should be offered to morbidly obese women of childbearing age. This literature review provides information about different techniques of bariatric surgery and about the multidisciplinary management of these pregnancies (monitoring, micronutrient supplementation) to promote maternal and fetal wellbeing in concert with continuing postoperative weight control.

Prenatal evaluation of a scrotal mass using a high-frequency probe in the diagnosis of inguinoscrotal hernia.

Whereas inguinal hernia is a common pediatric disease, fetal inguinal hernia is rarely diagnosed because intra-abdominal pressure usually occurs only after birth. We report a case of prenatal diagnosis of a scrotal mass at 35 weeks' gestation. The initial differential diagnosis included hydrocele, testicular teratoma and testicular torsion, but inguinoscrotal hernia was considered the most likely diagnosis when further ultrasound imaging using a high-frequency probe demonstrated bowel loop movements around the mesenteric artery. This diagnosis was confirmed postnatally.

[Prevention of intrauterine adhesions after hysteroscopic surgery]. / Prévention des synéchies après hystéroscopie opératoire.

Intrauterine adhesions are the most frequent complications after hysteroscopic surgery in women of reproductive age. The prevalence of intrauterine adhesions after hysteroscopic surgery is correlated to intrauterine pathology (myoma, polyp, or adhesions). Few clinical trials have demonstrated the efficiency of barrier agents developed in order to prevent adhesions after operative hysteroscopy. Adhesion barriers are mechanic agent (intrauterine device), fluid agents (Seprafilm, Hyalobarrier) and postoperative systemic treatment (estroprogestative treatment). In this article, we evaluate the efficiency of these barrier agents for adhesion prevention in hysteroscopic surgery, undertaking a review of clinical trials published. The most frequent published studies evaluate the anatomic efficiency of antiadhesion agents after hysteroscopic surgery in order to evaluate the fertility. Data are still insufficient to evaluate them for clinical use. There is a need for other randomised controlled trials.

Ovarian malignant immature teratoma associated with pregnancy--a case report.

We report the case of a malignant immature teratoma diagnosed at 21 weeks of amenorrhea in a 36-year-old healthy woman. Ultrasound examination showed a multilocular cystic mass of 175 mm in diameter, situated on the left side of the uterus. A left ovariectomy was performed by laparotomy at 22 weeks of amenorrhea. Histologic examination revealed a malignant grade 2 immature teratoma, and the patient underwent three courses of chemotherapy with a good pregnancy outcome. A cesarean section was carried out at 39 weeks of amenorrhea, associated with a left salpingectomy on which the pathologist examination did not find any malignant cells. The newborn had a normal aspect, and the mother was considered to be in remission after two more courses of chemotherapy..

[Surgical management of peripartum hemorrhage: a retrospective study]. / Prise en charge chirurgicale des hémorragies de la délivrance: étude rétrospective.

OBJECTIVE: Peripartum haemorrhage is an obstetrical emergency and requests a life saving procedure. The purpose of this study is to describe our experience with the surgical management of peripartum haemorrhage. PATIENTS AND METHODS: We performed a retrospective study including 16 patients who necessitated a surgical management of peripartum haemorrhage (artery ligations, uterine compression and/or emergency peripartum hysterectomy) between 1985 and 2007. RESULTS: The incidence of surgical management of peripartum haemorrhage was 0.047%. Conservative surgical management consisted in uterine compression sutures in three cases. Artery ligations were performed without success in seven patients; only one case of isolated utero-ovarian artery ligations was effective. An emergency peripartum hysterectomy was necessary in 12 cases. Uterine atony was the principal etiologic factor (43.8% of cases). There were no significant perioperative complications. No maternal death was reported. DISCUSSION AND CONCLUSION: In cases of non life-saving procedure, medical treatment and uterine arteries embolisation are often sufficient. Uterine compression suturing techniques are interesting alternatives and uterine arteries ligations can always be performed before hysterectomy. In cases of failure of conservative treatment, the emergency peripartum hysterectomy must be performed. Then, the choice concerning the surgical technique for the management of peripartum haemorrhage may be adapted to the patient, the centre and the obstetrical team.