Normal delivery: physiologic support and medical interventions. Guidelines of the French National Authority for Health (HAS) with the collaboration of the French College of Gynecologists and Obstetricians (CNGOF) and the French College of Midwives (CNSF).

OBJECTIVE: To define for women at low obstetric risk methods of management that respect the rhythm and the spontaneous course of giving birth as well as each woman's preferences. METHODS: These clinical practice guidelines were developed through professional consensus based on an analysis of the literature and of the French and international guidelines available on this topic. RESULTS: Labor should be monitored with a partograph (professional consensus). Digital cervical examination should be offered every 4 h during the first stage of labor, hourly during the second. The choice between continuous (cardiotocography) or discontinuous (by cardiotocography or intermittent auscultation) monitoring should be left to the woman (professional consensus). In the active phase of the first stage of labor, dilation speed is considered abnormal if it is less than 1 cm/4 h between 5 and 7 cm or less than 1 cm/2 h after 7 cm. In those cases, an amniotomy is recommended if the membranes are intact, and the administration of oxytocin if the membranes are already broken and uterine contractions are judged insufficient (professional consensus). It is recommended that pushing not begin when full dilation has been reached; rather, the fetus should be allowed to descend (grade A). Umbilical cord clamping should be delayed beyond the first 30 s in newborns who do not require resuscitation (grade C). CONCLUSION: The establishment of these clinical practice guidelines should enable women at low obstetric risk to receive better care in conditions of optimal safety while supporting physiologic birth.

Clinical practice guidelines for contraception by the French National College of Gynecologists and Obstetricians (CNGOF).

The French College of Obstetrics and Gynecology (CNGOF) has released its first comprehensive recommendations for clinical practices in contraception, to provide physicians with an updated synthesis of the available data as a basis for their practice. The organizing committee and the working group adopted the objective methodological principles defined by the French Authority for Health (HAS) and selected 12 themes relevant to medical professionals' clinical practices concerning contraception. The available literature was screened through December 2017 and served as the basis of 12 texts, reviewed by experts and physicians from public and private practices, with experience in this field. These texts enabled us to develop evidence based, graded recommendations. Male and female sterilization, as well as the use of hormonal treatments not authorized for contraception ("off-label") were excluded from the scope of our review. Specific practical recommendations are provided for the management of contraception prescription, patient information concerning effectiveness, risks, and benefits of the different methods, patient follow-up, intrauterine contraception, emergency contraception, local and natural methods, contraception in teenagers, in women after 40, for women at high thromboembolism or cardiovascular risk, and for those at of primary cancer or relapse. The short- and mid-term future of contraception depends mainly on improving the use of currently available methods. This includes reinforced information for users and increased access to contraception for women, regardless of their social and clinical contexts. The objective of these guidelines is to aid in enabling this improvement.

Is the resulting phenotype of an embryo with balanced X-autosome translocation, obtained by means of preimplantation genetic diagnosis, linked to the X inactivation pattern?

OBJECTIVE: To examine if a balanced female embryo with X-autosome translocation could, during its subsequent development, express an abnormal phenotype. DESIGN: Preimplantation genetic diagnosis (PGD) analysis on two female carriers with maternal inherited X-autosome translocations. SETTING: Infertility center and genetic laboratory in a public hospital. PATIENT(S): Two female patients carriers undergoing PGD for a balanced X-autosome translocations: patient 1 with 46,X,t(X;2)(q27;p15) and patient 2 with 46,X,t(X;22)(q28;q12.3). INTERVENTION(S): PGD for balanced X-autosome translocations. MAIN OUTCOME MEASURE(S): PGD outcomes, fluorescence in situ hybridization in biopsied embryos and meiotic segregation patterns analysis of embryos providing from X-autosome translocation carriers. RESULT(S): Controlled ovarian stimulation facilitated retrieval of a correct number of oocytes. One balanced embryo per patient was transferred and one developed, but the patient miscarried after 6 weeks of amenorrhea. In X-autosome translocation carriers, balanced Y-bearing embryos are most often phenotypically normal and viable. An ambiguous phenotype exists in balanced X-bearing embryos owing to the X inactivation mechanism. In 46,XX embryos issued from an alternate segregation, der(X) may be inactivated and partially spread transcriptional silencing into a translocated autosomal segment. Thus, the structural unbalanced genotype could be turned into a viable functional balanced one. It is relevant that a discontinuous silencing is observed with a partial and unpredictable inactivation of autosomal regions. Consequently, the resulting phenotype remains a mystery and is considered to be at risk of being an abnormal phenotype in the field of PGD. CONCLUSION(S): It is necessary to be cautious regarding to PGD management for this type of translocation, particularly in transferred female embryos.

Four countries, four ways of discussing low-risk pregnancy and normal delivery: in France, Germany, The Netherlands, and the United Kingdom.

The 2012 "4 countries meeting" of the French, Dutch, British and German Societies of Gynaecology and Obstetrics (CNGOF, NVOG, RCOG, DGGG) was dedicated to the topic "Low-risk pregnancy and normal delivery". The objective was to compare how each country organises prenatal care and normal delivery. The discussion is outlined in the article and provides new opportunities to learn from each other's strengths in order to provide the highest level of care regardless of social, demographic, educational and clinical differences.

Analysis using fish of sperm and embryos from two carriers of rare rob(13;21) and rob(15;22) robertsonian translocation undergoing PGD.

The majority of fluorescence in situ hybridization (FISH) studies on the meiotic segregation of Robertsonian translocations focus on the most common types, rob(13; 14) and rob(14; 21). Here we report the first study for carriers of rare Robertsonian translocations rob(13; 21) and rob(15; 22) combining analysis of meiotic segregation in sperm and blastomeres following pre-implantation genetic diagnosis (PGD). Dual-colour FISH was applied to nuclei from spermatozoa and blastomeres from PGD embryos using two subterminal contig probes for each translocation, and a second round with probes for chromosomes 16 and 18. Patient 1 had a rob(13; 21) and patient 2 had a rob(15; 22), and 86.3% and 87.5% of gametes respectively were consistent with meiotic segregation resulting in a normal or balanced chromosome complement. Analysis of embryos showed that for patient 1 and 2 respectively, 25% and 46% were balanced, and of the unbalanced embryos, 50% and 31% were mosaic or chaotic. Our patients with a rob(13; 21) and rob(15; 22) were found to have a similar meiotic segregation pattern to that for male carriers of the common Robertsonian translocations. The observed rate in unbalanced embryos being mosaic or chaotic may result in an increased risk of chromosomal abnormalities. Our results may help to improve the genetic counseling for carriers of rare Robertsonian translocations.

Long-term efficacy and safety of a monophasic combined oral contraceptive containing 0.02 mg ethinylestradiol and 2 mg chlormadinone acetate administered in a 24/4-day regimen.

OBJECTIVE: This study was conducted to assess the long-term efficacy and safety of a low-dose monophasic combined oral contraceptive (COC) containing 0.02 mg ethinylestradiol (EE) and 2 mg chlormadinone acetate (CMA) in a novel regimen administered daily for 24 days followed by a 4-day placebo interval. STUDY DESIGN: In this multicenter, uncontrolled, Phase III trial, 1665 subjects took the COC 0.02 mg EE/2 mg CMA for up to 21 cycles. The overall Pearl Index was the primary end point; cycle control, safety, effect on acne and seborrhea, and changes in body weight and libido were secondary end points. RESULTS: Contraceptive efficacy was analyzed for 1653 subjects completing 21,495 cycles. Six pregnancies occurred during trial duration with one attributable to method failure. The overall Pearl Index for the first year of use was 0.33 (95% confidence interval, 0.09-0.85). The mean number of bleeding/spotting days during six 90-day reference periods (RPs) decreased from 17.0 (RP 1) to 11.7 (RP 6), and the number of bleeding episodes per RP decreased from 3.8 (RP 1) to 2.7 (RP 6). Among subjects who presented with acne at the baseline visit, a decrease of papules/pustules and comedones was observed during the course of the trial. The most common "at least possibly related" adverse events were headache, breast discomfort and nausea. The tolerability and well-being was reported as being excellent or good in the majority of trial subjects (84.6% and 80.2%, respectively). CONCLUSIONS: The low-dose COC 0.02 mg EE/2 mg CMA administered daily for 24 days followed by a 4-day placebo interval provides high contraceptive efficacy combined with an adequate cycle control and safety profile, beneficial effects on acne, and is well tolerated.

Endometriosis and in vitro fertilisation: a review.

This review aims to evaluate whether severe endometriosis has an impact on the outcome of in vitro fertilisation (IVF), whether IVF is associated with specific complications in this context, whether a specific ovarian stimulation protocol is most appropriate, whether the endometrial condition progresses following ovarian stimulation, and whether endometrial cysts pose a specific problem for IVF. In patients with severe endometriosis, IVF represents an effective treatment option for infertility, as a complement to surgery. The prognostic parameters of IVF are identical to those of other patients. However, the risks related to the severity of endometriosis, particularly the risk of ovarian deficiency, need to be considered. Because of this issue, to which endometriosis-related pain often adds, IVF treatment should be initiated as early as possible, using appropriate protocols and after having fully informed the patient about the specific oocytes retrieval-related risks.

Oocyte recovery post human follicular fluid centrifugation in modified natural cycle and achieving embryo.

This case reports a successful live birth by intracytoplasmic sperm injection (ICSI) following human follicular fluid (HFF) centrifugation for oocyte retrieval in the modified natural cycle of a poor responder patient. A 37-year-old patient presenting with a severe ovarian defect underwent a modified natural cycle with HFF centrifugation prior to ICSI. As there was only one oocyte under direct binocular observation, HFF was centrifuged and a second oocyte was collected. ICSI was performed on both oocytes. Embryo quality and outcome were not compromised by HFF centrifugation. A live birth was achieved in April 2008. In a modified natural cycle, HFF centrifugation avoided loss of oocytes, optimized the IVF treatment, and achieved the development of two embryos.

Optimal timing of ultrasonographic and Doppler evaluation of uterine receptivity to implantation.

In IVF programmes, transvaginal ultrasonography is used as a non-invasive method to evaluate uterine receptivity. The aim of this study was to determine when to perform this investigation in order to optimize prediction of the likelihood of pregnancy. Over 9 months, 124 patients undergoing IVF or intracytoplasmic sperm injection were studied. The ultrasonographic evaluation included endometrial thickness, endometrial pattern, uterine artery pulsatility index, protodiastolic notch, end-diastolic blood flow, and endometrial-subendometrial blood flow distribution pattern. All patients underwent ultrasonographic investigation on the days of human chorionic gonadotrophin (HCG) administration, oocyte retrieval, and embryo transfer. Statistical analysis was done using recursive-partitioning analysis. The pregnancy and implantation rates per transfer were 33 and 19.8% respectively. In terms of single parameters, women with an end-diastolic blood flow, an endometrial-subendometrial blood flow and a multilayered endometrium were more likely to be pregnant than women without one or more of these signs. The most effective combination for evaluation of uterine receptivity was end-diastolic blood flow, endometrial pattern and endometrial thickness. Sensitivity and specificity of this combination were around 81%, positive predictive value was 68.2%, and negative predictive value 89.7%. The best sensitivity and specificity were obtained on the day of HCG administration: respectively 81.1 and 81.3%.

Comparative protein expression profiling in human cumulus cells in relation to oocyte fertilization and ovarian stimulation protocol.

Comparative profiling was performed on proteins synthesized in human cumulus cells (CC) from individual oocytes recovered after two different ovarian stimulation protocols for classical IVF (cIVF). Using high-resolution two-dimensional protein electrophoresis after metabolic labelling with [35S]-methionine, protein expression was profiled in CC of metaphase II oocytes obtained after two different ovarian stimulation protocols (rFSH versus human menopausal gonadotrophin). Analysis was done on CC from two cIVF cycles in the same patient and then extended to CC from individual oocytes from two groups of patients. CC from single oocytes have robust levels of protein expression into 600-800 protein spots. Comparison of CC protein expression from oocytes obtained from the same patient but after two different stimulation protocols shows that the type of hormonal treatment influences CC protein expression. In contrast, CC from oocytes obtained under the same stimulation protocol but with different fertilization outcome show a high profile similarity with differences in only a few spots. Comparison of two groups of patients indicates that dissimilarities in protein pattern between patients become very high, even when comparing the same stimulation protocol and oocyte fertilization outcome. Thus protein expression profiling of human CC may provide a correlation between the synthesis of specific cumulus proteins and maturity and fecundity.

Extracorporeal membrane oxygenation therapy for circulatory arrest due to postpartum hemorrhage.

BACKGROUND: Cardiac arrest after postpartum hemorrhage may not respond to advanced life support. Various resuscitation methods have been proposed, including sternotomy and direct cardiac massage. Extracorporeal membrane oxygenation (ECMO) might be an alternative. CASE: We report the case of a woman who suffered atonic uterine hemorrhage perioperatively after cesarean delivery of twins. During initial conservative treatment using prostaglandin analog (sulprostone), cardiac decompensation developed and was followed by cardiopulmonary arrest. Circulatory failure remained unresponsive after 2 hours of resuscitation, when ECMO was initiated. The ensuing recovery was favorable. CONCLUSION: Aggressive mechanical circulatory support, such as ECMO, should be considered in a case of potentially reversible cardiocirculatory failure in a young obstetric patient.

Obesity does not adversely affect results in patients who are undergoing in vitro fertilization and embryo transfer.

OBJECTIVE: To examine the outcome of in vitro fertilization according to the body mass index of infertile patients. STUDY DESIGN: Between September 2003 and May 2005, 573 patients underwent 789 in vitro fertilization cycles or ICSI because of male factor, tubal factor, and unexplained infertility were retrospectively included from our IVF database. The patients were classified in four groups: BMI<20 kg/m2 (264 cycles), 20< or = BMI<25 (394 cycles), 25< or = BMI < 30 (83 cycles), and BMI> or = 30 (48 cycles). All patients had a long protocol for IVF with a combination of the GnRH agonist and recombinant FSH. RESULTS: All parameters of ovarian response were comparable except the total required r-FSH dose. This dose was statistically higher in the group of BMI> or = 30 compared to the other groups (p = 0.0003). All parameters of IVF outcome were comparable, including the cancellation rate, the implantation rate, and pregnancy rates. CONCLUSION: Obese patients require a higher r-FSH dose to achieve follicular maturation than normal weight patients. Obesity does not affect negatively results of in vitro fertilization.

Equivalence of the 3-month and 28-day formulations of triptorelin with regard to achievement and maintenance of medical castration in women with endometriosis.

OBJECTIVE: The present study aims at demonstrating the equivalence of the 28-day and 3-month formulations of triptorelin SR (sustained release) in terms of percentage of patients achieving castration levels of estradiol (<==50 pg/mL) 84 days after treatment initiation. DESIGN: A phase II, prospective, randomized, multicenter, open study was conducted in two parallel groups of women with endometriosis. SETTING: Academic hospitals. PATIENT(S): Seventy-two women with endometriosis. were treated with a single intramuscular injection of 3-month triptorelin SR, and 74 patients were treated with one intramuscular injection of 28-day triptorelin SR every 28 days for 3 months. INTERVENTION(S): As part of two parallel treatment groups, 72 women were given a single intramuscular injection of 3-month triptorelin SR, and 74 women were given one intramuscular injection of 28-day triptorelin SR every 28 days for 3 months. MAIN OUTCOME MEASURE(S): Percentage of patients achieving castration levels of estradiol at the end of the treatment period. RESULT(S): Patients participated in the study until resumption of menses. Ninety-seven percent of patients given the 3-month formulation and 94% of those given the 28-day formulation were in a state of medical castration on day 84. The mean time to achieve castration was shorter for the 3-month formulation, and the duration of castration was significantly longer. The FSH and LH parameters were comparable, though not always identical. CONCLUSION(S): The pharmacodynamic effects of the Decapeptyl SR 3-month formulation are equivalent to those of the 28-day formulation. The 3-month formulation provides the added advantage of a longer maintenance of medical castration in women who have endometriosis.

Amenorrhoea revealing an arteriovenous uterine malformation, and recovery of menses after embolization.

A case is reported of secondary amenorrhoea related to an arteriovenous malformation (AVM) successfully treated with embolization, with a recovery of menstrual cycles. A 28-year-old woman presented with secondary amenorrhoea as the only clinical symptom. Although she had an eugonadic status, there was no genital withdrawal bleeding upon cessation of an oral contraceptive. Pelvic transvaginal ultrasonography revealed a pelvic mass but magnetic resonance imaging (MRI) clearly showed an AVM. Classical angiography was performed with endovascular embolization. Partial thrombosis of the lesion was assessed by magnetic resonance angiography. Recovery of menses occurred 2 months later. It is speculated that blood stolen from the endometrium by the uterine AVM could have been responsible for the amenorrhoea. It is a very unusual cause, and it can be successfully treated with embolization.

Pfannenstiel versus Maylard incision for cesarean delivery: A randomized controlled trial.

OBJECTIVE: To compare the Pfannenstiel incision with transverse muscle-cutting Maylard incision in women who had cesarean delivery. METHODS: Patients were assigned randomly to a Pfannenstiel or Maylard incision. Postoperative treatment was similar for each group. Surgical characteristics, complications, postoperative pain (visual analog scale, analgesic use), and related quality of life (1- and 3-month self-administered questionnaires) were analyzed. Abdominal wall muscle recovery was compared objectively by dynamometer. RESULTS: Fifty-four women had a Pfannenstiel incision and 43 had the Maylard incision. There were no differences in intraoperative characteristics, postoperative morbidity, or pain. Women's responses to the Nottingham Health Profile questionnaire at 1 and 3 months postoperatively and clinical and isokinetic testing for abdominal wall strength were similar between the two groups. CONCLUSION: Transecting the rectus muscle was no more deleterious than the Pfannenstiel incision. There was no difference in objectively measured abdominal wall strength.

Integrated summary of Ortho Evra/Evra contraceptive patch adhesion in varied climates and conditions.

OBJECTIVE: To assess the adhesive reliability of the contraceptive patch (Ortho Evra/Evra). DESIGN: Pooled data of 3,319 women from three contraceptive studies of up to 13 treatment cycles; a subset of 325 women of the pooled data from warm and humid climates; and 30 women from a three-period, crossover exercise study. SETTING: 184 centers. PATIENT(S): 3,349 healthy women. INTERVENTION(S): In the contraceptive studies, each treatment cycle consisted of three consecutive 7-day patches (21 days) followed by one patch-free week. During each treatment period in the exercise study, women wore the patch for 7 days and participated in one of six activities (normal activity, excluding bathing; sauna; whirlpool; treadmill; cool-water immersion; or a combination of activities) each day at a supervised health center. MAIN OUTCOME MEASURE(S): Patch adhesion. RESULT(S): In the contraceptive studies, 4.7% of patches were replaced because they fell off (1.8% [1,297 of 70,552 patches]) or became partly detached (2.9% [2,050 of 70,552 patches]); patch replacement rates in centers from a warm, humid climate were 1.7% (85 of 4,877 patches) and 2.6% (128 of 4,877 patches), respectively. Only one of 87 patches (1.1%) completely detached in the exercise study. CONCLUSION(S): The reliability of adhesion of the contraceptive patch is excellent and consistent across all studies; only 1.8% and 2.9% of patches required replacement due to complete or partial detachment, respectively. Heat, humidity, and exercise do not affect adhesion.