[Retrospective validation of a model to predict the outcome of pregnancies of unknown location]. / Évaluation rétrospective d'un algorithme d'aide à la décision concernant les grossesses de localisation indéterminée.

OBJECTIVE: The prediction model M6 classifies pregnancy of unknown location (PUL) into a low-risk or a high-risk group in developing ectopic pregnancy (EP). The aim of this study was to validate the two-step M6 model's ability to classify PUL in French women. MATERIAL AND METHODS: All women with a diagnosis of PUL over a year were included in this single center retrospective study. Patients with a diagnosis of EP at the first consultation of with incomplete data were excluded. For each patient, the M6 model calculator was used to classified them into "high risk of EP" and "low risk of EP" group. The reference standard was the final diagnostic: failed PUL (FPUL), intrauterine pregnancy (IUP) of EP. The statistical measures of the test's performance were calculated. RESULTS: Over the period, 255 women's consulted for a PUL, 197 has been included in the study. Final diagnosis were: 94 FPUL (94/197; 47.7%), 74 IUP (74/197; 37.6%) et 29 EP (29/197; 14.7%). The first step of the M6 model classified 16 women in the FPUL group of which 15 (15/16; 93.7%) correctly. The second step of the M6 model classified 181 women: 90 (90/181; 49.7%) in the "high risk of EP" group of which 63 (63/90; 70%) were FPUL/IUP and 27 (27/90; 30%) were EP. 91 (91/181; 50.3%) was classified in the "low risk of EP" group of which 90 (90/91; 98.9%) were FPUL/IUP and 1 (1/91; 1.1%) were EP. EP were correctly classified with sensitivity of 96.4%, negative predictive value of 98.9%, specificity of 58.8% and positive predictive value of 30.0%. CONCLUSIONS: The prediction model of PUL M6 classified EP in "high risk of EP group" with a sensitivity of 96.4%. It classified 50.3% of PUL in a "low risk of EP" group with a negative predictive value of 98.9%.

[Endometriosis and miscarriage: Systematic review]. / Endométriose et fausse couche spontanée. Méta-analyse et revue systématique de la littérature.

OBJECTIVES: In spontaneous pregnancies, endometriosis appears to be a risk factor of miscarriage. The aim of this study is to evaluate the association between endometriosis and miscarriage in spontaneous pregnancy. METHODS: We searched the Cochrane Library, Medline of eligible studies from inception to December 2016, without any restriction. We selected studies that compared endometriosis-affected pregnant women to disease-free pregnant women. To ensure the quality of the methodology, the PRISMA criteria have been met at all stages of the development of this meta-analysis. The primary adverse pregnancy outcomes studied was miscarriage. Three reviewers independently extracted the studies' characteristics and outcome data. RESULTS: Of 225 identified abstracts, 4 primary studies met our inclusion criteria by comparing spontaneous pregnant patients with endometriosis to disease-free women. Miscarriage rate was higher in the endometriosis group (OR 1.77 [CI 95% 1.13-2.78]). CONCLUSION: In spontaneous pregnancies, endometriosis appears to be a risk factor of miscarriages (almost 80% increased risk). Further prospective studies are needed to confirm these results in order to establish the exact impact of endometriosis on spontaneous pregnancy course.

[Complications of termination of pregnancy]. / Complications de l'interruption volontaire de grossesse.

The legalization of abortion in France allowed to disappear almost maternal deaths caused by induced abortions. Nevertheless, the practice of abortion in a medical framework is encumbered with a number of immediate complications. Similarly, the late consequences of the practice of surgical abortion have generated an abundant literature, which it is important to analyse, both to meet the legitimate concerns of patients as to prevent any spread of false ideas under the influence of movements opposed to abortion.

[Misoprostol: off-label use in the first trimester of pregnancy (spontaneous abortion, and voluntary medical termination of pregnancy)]. / Misoprostol: utilisation hors AMM au premier trimestre de la grossesse (fausses couches spontanées, interruptions médicales et volontaires de grossesse).

OBJECTIVE: State of knowledge about misoprostol's use out of its marketing authorization during the first trimester of pregnancy, in early miscarriage or to induce abortion or medical termination of pregnancy. METHODS: French and English publications were searched using PubMed, Cochrane Library and international learned societies recommendations. RESULTS: Cervical ripening prior to surgical uterine evacuation during the first trimester of pregnancy facilitates cervical dilatation and reduces operative time and uterine retention risk. Misoprostol, mifepristone and osmotic cervical dilators are equally efficient. Concerning first trimester miscarriage, surgical uterine evacuation remains the most effective and the quickest method of treatment (EL 1). Depending on the clinical situation, medical treatment using misoprostol (missed miscarriage) or expectative attitude (incomplete miscarriage) does not increase the risk of complications, neither haemorrhagic nor infectious (EL 1). However, these alternatives generally require longer outpatient follow-up, which leads to more consultations, prolonged bleeding and not planned surgical procedures (EL 1). Concerning missed miscarriage, a vaginal dose of 800 µg of misoprostol, possibly repeated 24 to 48 hours later, seems to offer the best efficiency/tolerance ratio (EL 2). Concerning early abortion, medical method is a safe and efficient alternative to surgery (EL 2). Success rates are inversely proportional to gestational age (EL 2). According to the modalities of its marketing authorization, 400 µg of misoprostol can only be given by oral route, for less than 7 weeks of amenorrhea (WA) pregnancies and after 36 to 48 hours following 600 mg of mifepristone (EL 1). However, 200mg of mifepristone is as efficient as 600 mg (EL 1). Beyond 7WA, misoprostol buccal dissolution (sublingual or prejugal) or vaginal administration are more efficient and better tolerated than oral ingestion (EL 1). Between 7 and 9WA, the best protocol in terms of efficiency and tolerance is the association of 200mg of mifepristone followed 24 to 48 hours later by 800 µg of vaginal, sublingual or buccal misoprostol (EL 1). An additional dose of 400 µg can be given 3 hours later if necessary (EL 3). In case of buccal administration, the dose of 400 µg seems to offer the same efficiency with a better tolerance but further evaluation is needed (EL 2). Between 9 and 12WA, medical treatment is less efficient than surgery and its tolerance is lower (EL 2). However, a protocol of 200mg of mifepristone followed 36 to 48 hours later by 800 µg of vaginal or sublingual misoprostol, plus an additional 400 µg dose every 3-4 hours (until 4-5 doses maximum) seems safe and efficient (EL 5). CONCLUSION: Misoprostol use during the first trimester of pregnancy is a safe and efficient alternative to surgery as long as detailed protocols adjusted to each clinical situation are respected.