[Skills assessment for the practice of fetal ultrasound biometry: Prospective validation of the OSAUS METHOD score]. / Évaluation des compétences pour la pratique de la biométrie échographique fœtale : validation prospective du score OSAUS METHOD.

OBJECTIVES: To develop and validate a customized variant for fetal biometry of the generic OSAUS score (Objective Structured Assessment of Ultrasound Skills) METHODS: The 5-points OSAUS METHOD grid was elaborated by defining five target skills specific to fetal biometry for each thematic item of the generic score. The level of skills of 43 trainees was prospectively assessed during an ultrasound examination by using this grid. The results of the "novice" level group (experience<10 ultrasounds) were compared to those of the "intermediate" level group (experience≥10 ultrasounds) (I). The reached/non-reached skills ratio within the different items composing the score allowed the identification of priority areas of improvement (II). Previously published distribution and actual distribution of ratings according to the generic pass/fail score were compared (III). RESULTS: Median scores of "novices" (n=29) and "intermediates" (n=14) groups were statistically different, 1.87 (±0.75) and 3.31 (±0.83) (P=1.85-5), respectively and corresponded to the pre-existing experience (I). A lower ratio of reached skill allowed the identification of "documentation of the examination" item as a priority area of improvement for both groups (II). The relevance of the pass/fail score is consolidated, even if an overlap was observed between novices and intermediates groups (III). CONCLUSIONS: The relevancy and feasibility of using OSAUS scoring method for fetal biometry are supported. In addition, the possibility of comparisons with generic OSAUS remains.

Efficacy and safety of moxifloxacin in uncomplicated pelvic inflammatory disease: the MONALISA study.

OBJECTIVE: To evaluate the efficacy and safety of moxifloxacin versus levofloxacin plus metronidazole in uncomplicated pelvic inflammatory disease (uPID) in Asia. DESIGN: Prospective, randomised, double-blind, double-dummy, parallel-group study. SETTING: Multicentre, multinational study in the inpatient and/or outpatient setting. POPULATION: Women (aged ≥18 years) with uPID (defined as PID with no pelvic or tubo-ovarian abscess on pelvic ultrasonography and at laparoscopic examination) and not requiring intravenous treatment. METHODS: Women received a 14-day course of either oral moxifloxacin, 400 mg once daily, or oral levofloxacin, 500 mg once daily, plus oral metronidazole, 500 mg twice daily. Additionally, a single dose of ceftriaxone, 250 mg intramuscularly, was administered to women who had a positive screening test for Neisseria gonorrhoeae. MAIN OUTCOME MEASURES: The primary measure of efficacy was clinical response at test-of-cure (TOC) (7-14 days after the last dose of study drug) in the per-protocol population. Non-inferiority of moxifloxacin to the comparator regimen was demonstrated if lower limit of 95% CI was >-15%. Other measures were clinical response during therapy and at 4-week follow up, microbiological response at TOC, and safety. RESULTS: A total of 460 women were randomised to the study. For the primary measure of efficacy (clinical cure at TOC), moxifloxacin was noninferior to levofloxacin plus metronidazole (moxifloxacin: 152/194, 78.4%; comparator 155/190, 81.6%; 95% CI -10.7 to +4.9). The most commonly isolated pathogens at baseline included Neisseria gonorrhoeae, Chlamydia trachomatis, Escherichia coli, Staphylococcus aureus, Peptostreptococcus spp., Proteus mirabilis, Streptococcus agalactiae and Klebsiella pneumoniae. Bacteriological success rates were high and comparable between treatment arms (microbiologically valid populations, moxifloxacin 27/30, 90.0%; comparator 22/26, 84.6%; 95% CI -12.7 to +20.3). Both treatments were well tolerated. CONCLUSIONS: Moxifloxacin monotherapy, 400 mg once daily for 14 days, is an effective and well-tolerated oral treatment for women with uPID.

[Pelvic inflammatory diseases]. / Physiopathologie, diagnostic et prise en charge des infections génitales hautes.

Pelvic inflammatory diseases (PID) include salpingitis and endometritis. They usually result from the infection of upper genital tract by pathogens ascending from the cervix or the vagina. Since the clinical signs of uncomplicated forms are frequently mild or misleading, diagnosis require other exams such as microbiology (samples from the cervix and, if applicable, from the pelvis) and laparoscopy. Acute complications (pelvic abscesses, peritonitis) can occur, that call for both surgical drainage and antibiotics. Pelvic sequelae with permanent tubal alterations due to immuno-allergic reactions can also happen, that lead to chronic pelvic pain and infertility. Treatment consists in broad-spectrum antibiotics by oral route, combined with non steroid anti-inflammatory drugs. Atraumatic laparoscopic procedure can also be performed.

[Microbiological exams and screenings during pregnancy]. / La surveillance microbiologique de la femme enceinte: quels examens réaliser durant la grossesse?

Infections due to bacteria, virus or parasites are frequent during pregnancy and can have severe consequences. Moreover, the vaginal carriage of commensal bacteria or dramatic changes in the equilibrium of the vaginal flora can induce complications and cause fetal contaminations. With the help of the guidelines set up by the French Agency of Accreditation and Evaluation in Health (Anaes), the authors detail the microbiological exams and screening which take part in the management of different situations at risk.

Cowden disease in a young girl: gynecologic and immunologic overview in a case and in the literature.

There is an increased risk of cancer (mainly breast cancer) in patients with Cowden disease. Little is known of the etiopathogenic mechanisms of this condition, but immunologic abnormalities may be evoked. A young patient with Cowden disease was submitted for gynecologic examination and immunologic investigations. Although no neoplastic disorder had appeared, laboratory investigations disclosed abnormalities of the humoral and cellular immune compartments in the peripheral blood. This rare observation of gynecologic involvement in a very young girl with family antecedents of Cowden disease prompted a review of the gynecologic features and etiopathogenic bases of Cowden disease. The possible role of neoplasia such as breast cancer in this syndrome makes early diagnosis a criterion for good prognosis.

[Genital mycoplasmas]. / Mycoplasmes génitaux.

The mycoplasmas frequently isolated in genital tract, and potentially pathogenic, are M. hominis, U. urealyticum and M. genitalium. M. hominis and U. urealyticum are very frequent in the vaginal tract and they can be, according to circumstances, either commensal or pathogenic. M. hominis and/or U. urealyticum, have been considered as responsible for many types of genital infectious diseases (such as cervicitis, pelvis inflammatory disease), for infertility, obstetrical pathologies (premature delivery, premature rupture of membranes, chorio-amniotitis) and neonatal infections. Yet, most of the time, their actual responsibility has not been conclusively proven. Published data lack indisputable conclusions and in many fields, doubts still exist whether these mycoplasmas are pathogens or mere co-factors associated with genital infections. On the other hand, M. genitalium has been much less studied but it seems to be an unquestionable pathogen of genital tract; new studies will be necessary so that one has a better understanding of the pathologies it can induce.

[Immunohistology in assessment of the spread of cancer]. / L'immunohistologie dans le bilan d'extension des cancers.

The prognosis of cancers is conditioned by tumoral extension. We report a case of a squamous carcinoma of the vulva where pathological examination had been at fault. An immunohistological study performed with monoclonal antibodies revealed a lymph node micro-metastasis. This case emphasizes the importance of estimating the tumoral extension by simultaneous pathological and immunological examinations.

[Comparative study of ofloxacin+amoxicillin-clavulanic acid versus doxycycline+amoxicillin-clavulanic acid combination in the treatment of pelvic Chlamydia trachomatis infections]. / Etude comparative des associations ofloxacine+amoxicilline-acide clavulanique versus doxycycline+amoxicilline-acide clavulanique dans le traitement des infections génitales hautes à Chlamydia trachomatis.

OBJECTIVE: To evaluate the efficacy and safety of ofloxacin+coamoxiclav versus doxycycline-coamoxiclav in the treatment of chlamydial pelvic infections. DESIGN: An open, comparative, randomised, monocentric study. SUBJECTS: A hundred and eighteen patients (85 endometritis and 33 salpingitis) were included. Clinical, laparoscopic and bacteriological assessments were performed before treatment. 30.4% of salpingitis were considered as severe (COGIT score > 6). 25.4% of acute pelvic infections were only caused by Chlamydia trachomatis. TREATMENT: A hundred and eighteen patients were treated orally with 3 week combination ofloxacin (200 mg b.i.d.) + coamoxiclav (1 g b.i.d.) (n = 60) or with a 6 week coamoxiclav (1 g b.i.d.) + doxycycline (100 mg b.i.d.) (n = 58). RESULTS: Oral combination ofloxacin-coamoxiclav is as effective as oral combination doxycycline+coamoxyclav with respectively 96.7% versus 96.6% and 100% versus 98.4% satisfactory clinical et bacteriological results.

[Bacteria isolated in 1994-1995 in female upper genitalia infections and in male urethritis. Distribution and sensitivity to antibiotics]. / Bactéries isolées en 1994-1995 au cours des infections gynécologiques hautes et des uréthrites masculines. Distribution et sensibilité aux antibiotiques.

OBJECTIVE: Classify antibiotics according to their individual activity so as to identify those suitable for empiric therapy. METHODS: We studied bacterial strains isolated from patients with urethritis (n = 189) and upper genital tract infections (n = 163) between June 1994 and February 1995 in 3 hospital and 4 community laboratories. Upper genital tract infections were divided into two groups: proven infection on laparoscopy specimen (n = 79) and suspected infection with isolation of pathogen in cervical samples (n = 84). Pathogens isolated were: Chlamydia trachomatis in 36/12/15 cases respectively, Mycoplasma hominis in 12/20/13, Ureaplasma urealyticum in 55/30/15, Neisseria gonorrhoeae in 40/2/0, Haemophilus spp in 20/2/1, group B streptococci in 7/1/8, E. coli in 8/1/17 and miscellaneous in 11/8/15. The minimal inhibitory concentrations for all strains were determined in 4 laboratories for ofloxacin, erythromycin and doxycyclin against C. trachomatis, M. hominis and U. urealyticum, and for ofloxacin, erythromycin, doxycyclin, amoxicillin+clavulanate, cefotaxime and gentamicin against the other strains. The activity score (% susceptibility to each antibiotic weighted by the frequencies of each isolate in urethritis and upper genital tract infection based on recent French epidemiologic data) was calculated for each antibiotic. CONCLUSION: The antibiotics with the best empiric activity scores in urethritis were, in decreasing order: doxycyclin (90.4%), ofloxacin (88.1%), and erythromycin (50.2%). The most active combinations in upper genital tract infections were ofloxacin+amoxicillin (100%), doxycyclin+cefotaxime+metronidazole (95.9%) and doxycyclin+amoxicillin (95.3%).

[Materno-fetal morbidity of instrumental deliveries: forceps versus spatulas. About a series of 77 cases]. / Morbidité materno-fœtale des extractions instrumentales : forceps versus spatules. À propos d'une série de 77 cas.

OBJECTIVE: To compare the early feto-maternal morbidity after assisted vaginal delivery using forceps versus spatulas. PATIENTS AND METHODS: It is a retrospective comparative study conducted in a third level maternity carrying on cephalic instrumental non premature deliveries by forceps or spatulas, on singleton pregnancies. Forty assisted vaginal deliveries using forceps and 40 others using spatulas were registered, over a period of 4.5 months. Feto-maternal lesions were analyzed. RESULTS: Characteristics of the population of forceps and spatulas groups were alike (Body Mass Index: 25.9 versus 26.7kg/m(2), P=0.79; parity: 0.6 versus 0.4, P=0.20; fetal weight: 3306g versus 3295g, P=0.91). The characteristics of labor were also similar, except for the left transverse fetal position more important in spatulas group (10.8% - 4/37 - versus 0%; P=0.03). More fetus had no lesion in the spatulas group (85.7% - 30/35 - versus 60.5% - 23/38), P=0.02). The episiotomy rate was higher in the forceps group: 32/40 (80.0%) versus 13/37 (35.1%); P=0.0001. DISCUSSION AND CONCLUSION: These results are similar to those from the literature, which evoke a fetal protection by spatulas. However, this is biased by the fact that the two instruments are not always used in the same conditions. Besides, spatulas do not appear to be more deleterious to maternal perinea. Therefore, perpetuation and teaching the use of these two instruments seem essential.

[Post-rape pregnancy]. / La grossesse après viol.

A rape is a traumatizing circumstance for the victim. This aggression often has, regrettably, immediate repercussions, and then medium and long-term ones. Its complications are psychological, but also sometimes somatic, like pregnancy. Through an international literature review, and the study of the national legislation, we will summarize the main essential elements of the medical and forensic care of a pregnancy arising after a rape.

[Management of post-abortum infections]. / Prise en charge des infections du post-abortum.

In countries where induced abortions are legal and medically supervised, the frequency of post-abortion infections is low and maternal death is infrequent. Nevertheless, short and long term consequences of post-abortion infections must be addressed. Sexually transmitted pathogens are frequently in cause here. Risk factors include in particular young age (less than 24 years), low socioeconomic level, late pregnancy, nulliparity, and history of previous untreated pelvic inflammatory disease. Diagnosis is based on clinical criteria and an inflammatory syndrome occurring within 2 to 3 weeks after spontaneous or induced abortion. A pelvic ultrasound is recommended in order to ensure the uterus vacuity and to look for a possible pelvic abscess, and bacteriological samples must be performed. Management consists in a regimen combining two antibiotics intravenously, with the possible addition of intravenous heparin in case of pelvic thrombophlebitis. Antibiotics can be discontinued 48 h of a clinical improvement and further treatment by oral route brings no benefit. Intrauterine retention associated with post-abortion endometritis must be addressed either by medical or surgical method.

[Management of post-partum infections]. / Prise en charge des infections du post-partum.

Post-partum endometritis are frequent and account for the fifth cause of maternal death. This disease is preventable and effective treatments are available. Streptococcus agalactiae is the primary pathogen implicated. The clinical diagnosis is usually easy and involves pelvic pain, fever and abnormal lochia. Whenever antibiotic treatment provides no clinical improvement, or in case of doubt on the vacuity of the uterus, an ultrasound exam must be performed. Likewise, a CT scan or a MRI will be performed in case of persistent fever in search of a pelvic abscess requiring a drainage, or of a pelvic thrombophlebitis. Thromboplebitis requires heparin for the duration of antibiotic therapy, or oral anticoagulants for at least 3 months in case of pulmonary embolism or extension to the vena cava. The recommended antibiotic regimen combines clindamycin with gentamicin (once daily) intravenously. In case of contraindication or breastfeeding, other regimens may be prescribed. Adequate duration of treatment has not been evaluated and a switch to oral antibiotics after clinical improvement brings no benefit. Antibioprophylaxy (mostly cephalosporins) is recommended in cases of cesarean section (at skin incision), while it is debated in case of assisted delivery or of 3rd and 4th degree perineal tears.

[Contribution of robot-assisted surgery in the management of female infertility]. / Apport de la chirurgie robot-assistée dans la prise en charge de l'infertilité féminine.

Although considerable progresses were made in the field of medically assisted procreation, surgery keeps its place in the therapeutic armamentarium of female infertility. Indeed, its results are very interesting, both in its tubal, myometrial and endometriosis indications. Laparotomy is the first step in the development of any surgical technique. Laparoscopy brings benefits concerning recovery, but also in terms of fertility because of the reduction of postoperative adhesions. Nevertheless, comfort of the surgeon, so the ease of skills, are often altered, especially for complex operations such as those implicated in infertility treatment. Robot-assistance takes here all its interest. It allows indeed a quality in the realization of precise and complex skills, and results at least as interesting as standard laparoscopy can be provided. An overview of robot-assistance in surgery of female infertility is here presented. A review of world literature furnished multiple studies evaluating the tubal robotic surgery, and demonstrating its interesting results. Other indications could, according to us, emerge and be evaluated in this area, such as myomectomy and endometriosis surgery.

Pelvic arterial ligations for severe post-partum hemorrhage. Indications and techniques.

In cases of serious bleeding postpartum, resuscitation and surgical techniques are complementary and should be adapted to both the etiology and severity of bleeding. In extremely severe cases, the performance of a hysterectomy should not be delayed. For women with stable hemodynamic status, so-called "conservative" surgical techniques can instead be used. In this study, we describe and discuss the indications and feasibility of various techniques of vascular ligation. Uterine mattress suture compression techniques and abdomino-pelvic packing are also described. When conservative management is feasible, the first line approach should be bilateral distal ligation of the uterine arteries: this simple and low-risk technique is immediately effective in 80% of cases. If bleeding persists, uterine devascularization can be completed by a triple ligation as described by Tsirulnikov, with or without supplemental proximal ligation of the uterine arteries. This procedure should be performed in preference to the so-called "stepwise ligation sequence", which involves ligation of the ovarian pedicles and poses a risk of subsequent ovarian failure. Bilateral hypogastric artery ligation is also an effective and widely used first-line technique for experienced surgeons. This approach is technically challenging for less-experienced surgeons and is reserved for cases of failed triple ligation.