Cord blood collection and banking from a population with highly diverse geographic origins increase HLA diversity in the registry and do not lower the proportion of validated cord blood units: experience of the Marseille Cord Blood Bank.

Several Cord Blood (CB) Bank studies suggested that ethnicity impaired CB unit (CBU) qualification. The Bone Marrow Donors Worldwide registries present an over-representation of unrelated donors (UD) from Northwestern European descent. This raises the question of equality of access to hematopoietic stem cells transplant, especially in the Mediterranean zone, which has taken in many waves of immigration. The aim of our study is to address whether, in the Marseille CB Bank, CBU qualification rate is impaired by geographic origin. The study compared biological characteristics of 106 CBU disqualified for total nucleated cell (TNC) count (dCBU) and 136 qualified CBU in relation to registry enrichment and haplotype origin. A high proportion (>80%) of both dCBU and CBU had at least one non-European haplotype and enrich CB and UD registries to a higher extent than those with two European haplotypes (P<0.001). No difference was observed between TNC count and volume according to geographic origin. Our study shows that diverse Mediterranean origins do not have an impact on the CBU qualification rate. Partnership with Mediterranean birth clinics with highly trained staff is a reasonable option to increase the HLA diversity of CB Bank inventories and to improve the representation of minorities.

[Cervical ripening after previous cesarean section with Foley catheter: A prospective study of 41 patients]. / Maturation cervicale des utérus unicicatriciels par sonde de Foley : étude prospective de 41 patientes.

OBJECTIVES: Effectiveness of cervical ripening with Foley catheter for patients requiring labor induction with a previous cesarean section and unfavorable cervical conditions. PATIENTS AND METHODS: Prospective unicentric study conducted between 1 April 2011 and 31 October 2013 on 41 patients with medical indication for labor induction with a Bishop's score<7 and one previous cesarean section. Outcomes evaluated were mode of delivery, Bishop's score variations and maternal or neonatal complications. RESULTS: Cervical ripening was performed in 39 patients and 17 (43.5%) were delivered vaginally. A total of 24/39 (61.5%) patients were put into work and 10/39 (25.6%) came into work immediately after removal of the Foley catheter. The average score improvement Bishop was 2.7±0.6 points. No maternal or fetal complication was reported. CONCLUSION: Foley catheter is an interesting procedure in patients with previous cesarean section and unfavorable cervical conditions requiring labor induction.

[Comparative study of patients with placenta accreta with or without a history of cesarean section]. / Étude comparative des patientes présentant un placenta accreta avec ou sans antécédent de césarienne.

OBJECTIVE: To evaluate characteristics of placenta accreta (PA) in patients without previous cesarean section. MATERIAL AND METHODS: Retrospective cohort study from December 1993 to April 2010 in two departments of obstetrics in university hospitals, Marseille, France. Comparison of clinical characteristics, circumstances of diagnosis, maternal morbidity and treatment was performed between PA diagnosed in patients with (n=63) and without prior cesarean section (n=35). RESULTS: In group of patients without previous caesarean section, rate of placenta praevia, and antenatal diagnosis were lower (16/35 [46 %] vs. 44/63 [70 %], [P: 0.02]) and (4/35 [11 %] vs. 28/63 [44 %], [P<0.001]) and rate of pregnancies obtained by IVF was higher (5/35 [15 %] vs. 2/63 [3 %], [P=0.05]). In this group, no hysterectomy was performed but risk of uterus necrosis following embolization was increased (3/35 [8.6 %] patients vs. 0/63 patients [P: 0.02]). CONCLUSIONS: Patients without previous caesarean section have specific characteristics in terms of risk factor and of management.

Predictive value of hemoperitoneum for outcome of methotrexate treatment in ectopic pregnancy: an observational comparative study.

OBJECTIVE: To assess the predictive value of hemoperitoneum for the outcome of methotrexate (MTX) treatment of ectopic pregnancy (EP). METHODS: This observational prospective single-center study included women presenting with EP treated with MTX from November 2007 to November 2009. The percentage of women with hemoperitoneum at the beginning of MTX treatment was compared between two groups: those whose treatment was successful and those whose treatment failed. The rate of hemoperitoneum in each group and its value in predicting the outcome of MTX treatment of EP were assessed. RESULTS: MTX treatment was successful in 69 of 93 (74%) cases. The percentage of women with hemoperitoneum at the beginning of treatment was significantly higher in women in whom MTX treatment failed as compared to those in whom it was successful (15/24 (62.5%) vs 17/69 (24.6%); P = 0.001). The likelihood of requiring surgery following treatment with MTX was higher in women with hemoperitoneum (odds ratio, 5.1; 95% CI, 1.74-15.14). Study of the diagnostic performance of hemoperitoneum in predicting the need for surgical treatment after MTX treatment revealed a sensitivity of 0.63, a specificity of 0.76, a positive predictive value of 0.47 and a negative predictive value of 0.85. CONCLUSIONS: The presence of hemoperitoneum appears to be a risk factor for MTX treatment failure. It is important to inform women as fully as possible about the risk of such failure. Nonetheless, the predictive value of this sign is insufficient for either routinely excluding women with hemoperitoneum from MTX treatment or omitting post-treatment monitoring.

[Current and future use of surgical skills simulation in gynecologic resident education: a French national survey]. / Utilisation des simulateurs pour former les internes de chirurgie gynécologique en France : un état des lieux en 2013.

OBJECTIVES: Simulation is a promising method to enhance surgical education in gynecology. The purpose of this study was to provide baseline information on the current use of simulators across French academic schools. MATERIALS AND METHODS: Two questionnaires were created, one specifically for residents and one for professors. Main issues included the type of simulators used and the kind of use made for training purposes. Opinions and agreement about the use of simulators were also asked. RESULTS: Twenty-six percent of residents (258/998) and 24% of professors (29/122) answered the questionnaire. Sixty-five percent of residents (167/258) had experienced simulators. Laparoscopic pelvic-trainers (84%) and sessions on alive pigs (63%) were most commonly used. Residents reported access to simulators most commonly during introductory sessions (51%) and days of academic workshops (38%). Residents believed simulators very useful for training. Professors agreed that simulators should become a required part of residency training, but were less enthusiastic regarding simulation becoming a part of certification for practice. CONCLUSION: Surgical skills simulators are already experienced by a majority of French gynecologic residents. However, the use of these educational tools varies among surgical schools and remains occasional for the majority of residents. There was a strong agreement that simulation technology should be a component of training.

[Port-site metastasis after retroperitoneal lymphadenectomy for endometrial adenocarcinoma]. / Métastase orificielle sur site de trocart après lymphadénectomie rétropéritonéale pour un adénocarcinome endométrial.

Port-site metastasis is a rare but serious complication of laparoscopic surgery. The etiologies are poorly identified and multiple. We report the case of port-site metastasis after laparoscopic retroperitoneal lymphadenectomy for endometrial adenocarcinoma. In the literature, three cases of port-site metastasis after laparoscopic retroperitoneal lymphadenectomy are reported: two cases concerning cervical cancer and one case concerning a kidney cancer. To our knowledge, this is the only case about port site metastasis after laparoscopic retroperitoneal lymphadenectomy for endometrial adenocarcinoma.

[Prognostic value of early hCG changes after methotrexate injection for ectopic pregnancy]. / Valeur pronostique de la cinétique précoce du taux d'hCG après injection de méthotrexate pour grossesse extra-utérine.

OBJECTIVES: The purpose of this study was to evaluate the predictive value of early hCG changes on the risk of methotrexate (MTX) therapy failure for ectopic pregnancy. PATIENTS AND METHODS: This monocentric observational study compared the success of single-dose MTX therapy according to early hCG changes. Patients with a decrease of hCG value by at least 20% between day 1 and day 4 were followed up one month later only with an hCG concentration (group A, study protocol). The others patients were followed up with classic protocol, one time a week (group B). RESULTS: Of the 91 patients treated, there were 29 (31.9%) patients in the group A and 62 (68.1%) in the group B. The overall success rate of MTX treatment was 89%. The success rate of single-dose MTX therapy was significantly increased in group A (29/29 (100%) vs 30/62 (48.4%), P<0.001). The rate of patients requiring surgical treatment was significantly lower in group A (0/29 vs 10/62 (16%), P=0.02) (Table 1). CONCLUSION: The 20%-decrease cut-off between day 1 and day 4 appears to be a predictive factor to select patients with low failure rate after one MTX injection, allowing a less stringent follow-up.

[Pronostic risk assessment of delivery, in patients admitted for threatened preterm birth, in a tertiary care maternity center]. / Étude pronostique du risque d'accouchement, des patientes hospitalisées pour menace d'accouchement prématuré, dans une maternité de niveau III.

OBJECTIVES: To assess preterm birth rate, in patients admitted for threatened preterm birth (TPB) in a tertiary care maternity center and evaluate our diagnostic and therapeutic tools. MATERIALS AND METHODS: A retrospective cohort study, in a tertiary care maternity center (Marseille, France), reviewed all admissions for TPB from January 1 to December 31, 2009. RESULTS: We recorded 224 admissions for TPB (181 single pregnancies and 43 twin pregnancies), 43.8% of TPB admissions were from materno-fetal transfer. Preterm birth rate was 44.9% (n=89), 39% (n=66) for single pregnancy and 76.6% (n=23) for twins. The 15 mm threshold for transvaginal sonography cervical length (CL) was the most relevant to predict the risk of preterm delivery, 77.3% (85/110) of patients with CL>15 mm having full term delivery. CONCLUSION: For single pregnancy, most of the patients with cervical length>15 mm have full term delivery. It seems important to us to develop the use of more efficient predictive markers of risk-premature labor in order to improve the diagnosis and management of TPB.

[Cervical ripening at term with repeated administration of dinoprostone vaginal pessary]. / Maturation cervicale à terme par utilisation répétée du dispositif intravaginal de dinoprostone.

OBJECTIVES: To evaluate efficacy and safety of cervical ripening with repeated administration of dinoprostone slow release vaginal pessary (Propess®) in current practice. PATIENTS AND METHODS: An observational study of 111 women who underwent cervical ripening with two Propess® during the study period from 1st July 2007 to 31st October 2011. Modes of delivery, success of cervical ripening, failure of labor induction, maternal and neonatal morbidity were reported. RESULTS: The nulliparous rate was 75,7%. The main indications for induction of labor were post-term pregnancy in 34,3% (38/111) and premature rupture of membranes in 25,2% (28/111). The rate of vaginal delivery was 53,1% (59/111). Cesarean sections were performed for failure of labor induction in 27/52 (51,9%) and an abnormal fetal heart rate in 17/52 (32.7%). Indication for induction of labor, nulliparous patients (44 [84.6%] versus 40 [67.8%]; P=0.04), initial Bishop score (2.2±1.2 versus 2.9±1.2; P=0.04) before the cervical ripening and Bishop score before administration of second Propess® (3.3±1.4 versus 4.0±1.2; P=0.05) were significant risk factors of cesarean delivery. DISCUSSION AND CONCLUSION: In more than half of the cases, the cervical ripening by two Propess® is efficient and allows a vaginal delivery. This practice does not appear to increase the maternal or neonatal morbidity.

Molecular diagnosis of bacterial vaginosis: impact on IVF outcome.

Bacterial vaginosis can increase obstetrical complications such as miscarriage, premature rupture of membranes and preterm delivery. The aim of our study was first to assess BV prevalence for infertile patients treated by in vitro fertilisation (IVF) using both the Nugent score and polymerase chain reaction (PCR), and then to assess the impact of BV on the pregnancy rate after IVF. Vaginal samples were obtained from women followed for IVF in our Assisted Reproduction Technology (ART) Unit between August 2010 and April 2011. For each patient, two techniques were performed to diagnose BV: Gram staining to assess the Nugent score and a quantitative molecular analysis using a specific real-time PCR assay. Two groups were studied: normal flora (BV-) and BV (BV+). The primary outcome measure was the implantation rate. The secondary outcomes were clinical pregnancy rate, early and late miscarriage, premature rupture of membranes, preterm delivery, mode of delivery and birthweight. A total of 307 patients were included. PCR revealed a prevalence of BV of 9.45 %. Among women who performed vaginal douching, 22.2 % were BV+, whereas 7.9 % of patients who did not douche were BV+ (p = 0.028). The embryo implantation rate was decreased between the BV- and BV+ groups (36.3 % vs. 27.6 %, p = 0.418), but it was not significant. Obstetrical outcomes did not present significant statistical differences among the groups. Vaginal douching significantly enhanced BV in women treated with IVF. We also observed a non-significant decrease of embryo implantation rate and clinical pregnancy rate for women treated by IVF.

Fetal heart disease and interruption of pregnancy: factors influencing the parental decision-making process.

OBJECTIVE: To identify factors influencing parental decision when a fetal cardiac disease is diagnosed. METHOD: All pregnancies with fetal cardiac abnormalities diagnosed at three academic hospitals of Marseille, France, between 2004 and 2008, were retrospectively studied. The association between maternal and fetal variables (maternal age, parity, ethnicity, gestational age at diagnosis, nuchal translucency, fetal gender, chromosomal and extra cardiac abnormalities, and severity of the cardiopathy) and parental decision was tested using univariate and multivariate statistical methods RESULTS: One hundred eighty-eight cases of fetal cardiac disease were analysed, of which 63 were interrupted pregnancies (IP) and 125 continued pregnancies (CP). Four factors were important in the parental decision-making process: the severity of cardiac malformation, the ethnic origin of the parents, the gestational age at diagnosis and the chromosomal abnormalities. CONCLUSION: Counselling of parents following the diagnosis of a congenital heart disease should take into account that, in addition of the severity of the congenital heart disease (CHD), ethnicity, gestational age at diagnosis and chromosomal abnormalities influence parental decision regarding pregnancy continuation or interruption.

[Clinical and ultrasonographic factors affecting successful medical treatment of early pregnancy failure]. / Facteurs cliniques et échographiques influençant le succès du misoprostol pour grossesse arrêtée au premier trimestre.

OBJECTIVES: To assess clinical and echocardiographic factors impacting the effectiveness of misoprostol in early pregnancy failure. PATIENTS AND METHODS: An observational study was carried out within the gynaecological emergency service from 01/06/2000 to 15/05/2010. Patients had pregnancy failure in the first 12 weeks at ultrasonic examination. The patient received 4 misoprostol tablets (800 µg) intravaginally with clinical and ultrasound examination 24 hours later. The treatment was considered effective if the endometrial thickness was lower than 15 mm by ultrasound examination and absence of secondary endo-uterine aspiration. If the treatment was considered as a failure, an endo-uterine aspiration was carried out. Variables studied were clinical (patient age, date of the last menstrual period, gravidity, parity, history of miscarriage, endouterine aspiration, ectopic pregnancy, vaginal delivery, caesarean section) and ultrasound-based (presence or absence of an embryo, CRL, gestational sac diameter). RESULTS: Five hundred and one patients were included. The success rate was 336/501 (67.1%). After univariate analysis, the averages of parity (P=0.048) and caesarean section (P=0.002) were significantly higher in failure cases. The history of one or more caesarean section was a significant risk factor for failure (P=0.001). There was no significant difference for the other criteria. In multivariate analysis, the average number of caesarean sections (P=0.003) and the history of one or more caesarean section remained significant (P=0.002). DISCUSSION AND CONCLUSION: The ultrasound criteria and gestational age do not impact the effectiveness of misoprostol in the treatment of early pregnancy failure. The history of one or more caesarean section (s) significantly decreased the success rate. It has to be confirmed by other studies. This new data can be an aid to decision-making for the patient and the physician in case of early pregnancy failure.

[Surgical treatment of ectopic pregnancy by single port access with SILS® system: preliminary study]. / Traitement de la grossesse extra-utérine par accès endoscopique unique avec le système SILS® : expérience initiale.

AIM: To evaluate feasibility of surgical treatment for ectopic pregnancy with single laparoscopic access with SILS(®) system. PATIENTS AND METHODS: We conducted an open study from 1/7/2009 to 1/12/2010 in a single gynaecologic department. All procedures were performed by three operators. Procedures evaluated were corneal resection, salpingotomy, salpingectomy. Feasibility, per- and postoperative data were reported. RESULTS: We performed completely 31 over 32 (97%) surgical procedures with SILS(®) system (27 salpingectomies and five salpingotomies). In one case, conversion to conventional laparoscopy was required. No intra- or postoperative complications were reported. CONCLUSION: Laparoscopic surgery for ectopic pregnancy by single access seems feasible with SILS(®) system. Further study including larger number of patients and operators were necessary to confirm risks and advantages of this technique.

[Single laparoscopic access: initial experience]. / Chirurgie laparoscopique par accès unique : expérience initiale.

OBJECTIVE: To evaluate feasibility of single laparoscopic access with LESS(®) system. PATIENTS AND METHODS: We conducted an open study from 1/7/2009 to 1/10/2010 in a single gynaecologic department. All procedures were performed by four operators. Procedures evaluated were total hysterectomy, adnexectomy and ovarian cystectomy. Feasibility, per- and postoperative data were reported. RESULTS: We performed completely 24/25 (96 %) total hysterectomies by single laparoscopic access. Traditional laparoscopy and finally laparotomy was necessary for one patient. Bladder injury repaired by vaginal approach was reported in one patient. We performed 29 adnexectomies in 19 patients (nine unilaterals et 10 bilaterals) and six ovarian cystectomies in four patients (four unilaterals et two bilaterals). All procedures were performed successfully by single laparoscopic access. Parietal haematoma were reported in two patients. DISCUSSION AND CONCLUSION: Laparoscopic gynaecologic surgery by single access seems feasible with LESS(®) system for these procedures. Further study including larger number of patients and operators were necessary to confirm risks and advantages of this technique.

[Female fertility preservation: feasibility of emergency IVF for embryo freezing]. / Faisabilité de la congélation embryonnaire dans la préservation de la fertilité féminine.

With the improvement of the anticancerous treatments, the preservation of the feminine fertility before gonadotoxic treatment tends at present to stand out as a legal obligation, with a duty of information to patients. When emergency IVF can be performed, the cryopreservation of embryos is the best mastered method which offers most chances to patients to obtain a pregnancy after cancer remission thanks to the transfer of frozen embryos. This article proposes an overview about the indications, the feasibility and the ethical and practical limitations of IVF emergency for embryo freezing before gonadotoxic anticancerous treatment.

[Acute vulvar ulcer of Lipschütz: a misdiagnosis entity]. / Ulcère de Lipschütz, un diagnostic méconnu.

Acute vulvar ulcer or Lipschütz ulcer has been described in 1917 [1]. Clinical pattern is characterized by a prodromic period, with hyperthermia, malaise, headache, odynophagia, myalgia and cough before the apparition of vulvar localization. Vulvar ulcer is classically deep, painful, necrotic, with edema and adenopathy in an adolescent or young woman without any previous sexual contact. Epstein-Barr Virus is the first etiology, but some authors have suggested other infections. Differential diagnosis has to be made with other sexually transmitted pathology, Behçet disease and Crohn disease. Gynecologist and dermatologist should be aware of this diagnosis to avoid unconscionable treatment and reassure patient and family about sexual transmission.

[Initial results of a novel technique for sperm retrieval in male infertility due to refractory retrograde ejaculation]. / Résultats préliminaires d'une nouvelle technique de recueil du sperme vésical en présence d'éjaculation rétrograde réfractaire au traitement médical.

AIMS: To describe and evaluate a novel technique of spermatozoa retrieval from patients suffering from infertility secondary to refractory retrograde ejaculation. METHOD: Prospective study to compare mobility and vitality of spermatozoa obtained from urine (U) after oral modification of chemical parameter (PH, Osmolarity) versus from endovesical instillation of sterile spermatozoa culture medium before ejaculation (F). Patients were their own controls. Twelve month prospective follow-up was achieved to document the results of assisted procreation. RESULTS: Eight patients were included and mobility and vitality were improved in all patients after F technique was compared to U technique. With U technique, eight patients on eight had negative defrost test; after F technique, seven patients on eight had a positive defrost test and could therefore have access to assisted reproduction techniques. Four couples had five ICSI and obtained three pregnancies leading to five births. CONCLUSION: Endovesical instillation of sterile spermatozoa culture medium before ejaculation was a safe and effective technique to improve spermatozoa quality in male infertility related to refractory retrograde ejaculation.

[Combined screening for Down syndrome in Marseille multidisciplinary prenatal centers]. / Mise en place du dépistage combiné de la trisomie 21 au sein des centres pluridisciplinaires de diagnostic prénatal marseillais.

Combined screening for trisomy 21 (CS) is established since January 2010 in multidisciplinary centers for prenatal screening in Marseille. Our work investigates its implementation. To date, the false positive rate is 3.5% and the coverage of the SC after six months is 5.7% in our low-risk population.

[The spinal cord injured patient: semen quality and management by Assisted Reproductive Technology]. / Le blessé médullaire: quel sperme et quelle prise en charge en Assistance médicale à la procréation?

Men with spinal cord injury present a unique infertile population. Only 10 % of them can father children without medical assistance, owing to potential impairments in erection, ejaculation and semen quality. The algorithm typically followed is to retrieve semen by Penile Vibratory Stimulation, in case of failure by Electro Ejaculation. Most of these patients have normal sperm concentrations but abnormally low sperm motility and vitality in the ejaculate. The reasons for poor semen quality in spinal cord injured men are reviewed. If semen cannot be obtained by Electro Ejaculation, or if the ejaculate from Penile Vibratory Stimulation or Electro Ejaculation contains an insufficient quantity or quality of sperm for in vitro fertilization with intracytoplasmic sperm injection, then retrieval of sperm from reproductive tissues is attempted. Despite abnormal semen quality, successful pregnancies with sperm from spinal cord injured male partners have occurred by intravaginal insemination, intrauterine insemination, and in vitro fertilization with intracytoplasmic sperm injection. The prevailing pregnancy and fecundity rates in couples with a spinal cord injured male partner are reviewed.