Analysis of the obstetrician's posture and movements during a simulated forceps delivery.

BACKGROUND: The objective of this study was to identify and qualify, by means of a three-dimensional kinematic analysis, the postures and movements of obstetricians during a simulated forceps birth, and then to study the association of the obstetricians' experience with the technique adopted. METHOD: Fifty-seven volunteer obstetricians, 20 from the Limoges and 37 from the Poitiers University hospitals, were included in this multi-centric study. They were classified into 3 groups: beginners, intermediates, and experts, beginners having performed fewer than 10 forceps deliveries in real conditions, intermediates between 10 and 100, and experts more than 100. The posture and movements of the obstetricians were recorded between December 2020 and March 2021 using an optoelectronic motion capture system during simulated forceps births. Joint angles qualifying these postures and movements were analysed between the three phases of the foetal traction. These phases were defined by the passage of a virtual point associated with the forceps blade through two anatomical planes: the mid-pelvis and the pelvic outlet. Then, a consolidated ascending hierarchical classification (AHC) was applied to these data in order to objectify the existence of groups of similar behaviours. RESULTS: The AHC distinguished four different postures adopted when crossing the first plane and three different traction techniques. 48% of the beginners adopted one of the two raised posture, 22% being raised without trunk flexion and 26% raised with trunk flexion. Conversely, 58% of the experts positioned themselves in a "chevalier servant" posture (going down on one knee) and 25% in a "squatting" posture before initiating traction. The results also show that the joint movement amplitude tends to reduce with the level of expertise. CONCLUSION: Forceps delivery was performed in different ways, with the experienced obstetricians favouring postures that enabled observation at the level of the maternal perineum and techniques reducing movement amplitude. The first perspective of this work is to relate these different techniques to the traction force generated. The results of these studies have the potential to contribute to the training of obstetricians in forceps delivery, and to improve the safety of women and newborns.

A new approach to assessing the obstetrician's posture and movement during an instrumental forceps delivery.

INTRODUCTION: The number of deliveries by forceps decreases significantly in favour of the vacuum. Now, when the use of forceps is necessary, physicians less experimented with this procedure are likely to induce serious and preventable perineal or foetal injuries. Training therefore becomes essential. However, there are no clear recommendations on the technique to perform a delivery by forceps, namely the body posture and gesture to adopt. Our goal is then to provide a protocol that can help to determine if there is an optimal technique to perform a delivery by forceps. METHOD: We will include voluntary participants whose level of experience and type of practice differ. We will propose to record their postures and gestures using an optoelectronic motion analysis system during a forceps delivery simulated on a mannequin. We will also measure the traction force produced by the subject on the forceps using force platforms and technical markers placed on the forceps. We will then perform a principal component analysis to look for similar motion patterns. EXPECTED RESULTS: We plan to analyse about fifty participants (25 seniors and 25 juniors). Our hypothesis is that the realism of the simulation will be deemed satisfactory by the participants, that the experimental conditions will not modify their gestures, and that the degree of experience will result in different techniques. CONCLUSION: A better knowledge on the posture and gesture to adopt to realise a forceps delivery should improve the safety of women and new-borns. The results of this study could also be a valuable contribution for the training of obstetricians.

Active or passive maternal smoking increases the risk of low birth weight or preterm delivery: Benefits of cessation and tobacco control policies.

In France, maternal smoking, active or passive, remains one of the highest in Europe. At the same time, there is an increase in the number of low birth weight (<2500 g) and premature (<37 weeks of amenorrhea) newborns. The objective of this narrative review is to examine the impact of active or passive maternal smoking on birth weight or prematurity rates, and to consider the benefits of policies to stop or control smoking. This is a narrative review that analyzes and discusses the major articles published over the past 20 years regarding the role of active or passive maternal smoking on the risk of low birth weight or preterm delivery. Articles were selected using the following keywords: maternal smoking, low birth weight, preterm birth, smoking cessation, passive smoking, exhaled carbon monoxide, tobacco control policies. Active smoking is associated, in a dose-response relationship, with increased risks of low birth weight and preterm delivery. Passive smoking, mainly related to the presence of a smoking spouse, increases the risk of low birth weight and preterm birth. Our review confirmed also the benefits of smoking cessation, even in the third trimester, in reducing the risk of small for gestation age or fetal growth restriction and preterm birth. Several studies of tobacco control policies have been shown to be effective in significantly reducing maternal smoking. There is sufficient evidence to infer a causal link between active or passive maternal smoking and low birth weight or preterm delivery. This causal link is compelling and sufficient to justify intensifying efforts to promote rapid progress in tobacco control policies, with the vision of a tobacco-free generation, and smoking cessation with best practices during preconception or pregnancy.

Follow-up of increased nuchal translucency: Results of a study of 398 cases.

INTRODUCTION: Increased fetal nuchal translucency is associated with chromosomal as well as morphological abnormalities. The psychomotor development of children from these pregnancies is still unclear. The main objective of our study was to evaluate pregnancy outcomes and the post-natal progress of fetuses with increased nuchal translucency. We also compared the features of patients and fetuses according to their nuchal translucency measurement (above 3.5 mm or not). METHODS: Retrospective single-center study in 398 patients in a level 3 maternity unit in France. Mothers whose fetus had a nuchal translucency higher than the 95 th percentile between 2009 and 2018 were included. All patients who had a child with a normal karyotype were prospectively given a questionnaire to evaluate their child's psychomotor development. RESULTS: 37.4% (130/348) of fetuses had a chromosomal abnormality and 2.3% (5/218) had a normal karyotype but a pathogenic copy number variant diagnosed by array- CGH. 28.7% (77/268) of fetus without diagnosed chromosomal abnormalities, presented a morphological abnormality with predominant cardiac malformations. Fetuses with a nuchal translucency ≥ 3.5 mm, had more chromosomal abnormalities (p<0.0001) and were at higher risk of hypotrophy (p=0.005) and birth by cesarean (p=0.04). Among the liveborn children, 70% (166/238) were healthy without morphological or chromosomal abnormalities. Lastly, 17% (17/102) of these children had psychomotor disorder. CONCLUSION: According to our results, parents should be warned of the increased risk of hypotrophy and delivery by cesarean section for fetuses with a nuchal translucency ≥ 3.5 mm. We recommend prolonged specialized pediatric follow-up for children who have been carriers of increased nuchal translucency.

Fetal growth restriction, low birth weight, and preterm birth: Effects of active or passive smoking evaluated by maternal expired CO at delivery, impacts of cessation at different trimesters.

INTRODUCTION: The objectives of this study were to evaluate the effect of cessation of active smoking during the 1st, 2nd, and 3rd trimesters of pregnancy on the risk of reduced birth weight and prematurity using an exhaled carbon monoxide biomarker with a cut-off value ≥3 ppm as well as the effects of passive smoking. METHODS: This was a multicenter prospective cohort study involving pregnant smokers and non-smokers. Pregnant smokers were identified at the first prenatal visit before 15 weeks of amenorrhea by the number of cigarettes smoked per day and by the carbon monoxide breath test. Women were classified into 6 groups: non-smokers, passive smokers, first trimester cessation, second trimester cessation, third trimester cessation, and smoking throughout pregnancy. Smoking cessation was defined if the pregnant woman reported quitting smoking and if she achieved an exhaled CO level of <3 ppm. The association between smoking cessation and fetal growth restriction or prematurity was assessed by multivariate logistic regression. Passive smoking was defined for non-smoking women on declarative smoking status and exhaled CO ≥3 ppm. The association between passive smoking and fetal growth restriction or prematurity was assessed by multivariate logistic regression. RESULTS: The number of patients included was 5244. The incidence of fetal growth restriction below the 10th percentile was 10.6%, 12.1%, 8.5%, 9.1%, 21.1%, and 22.9%, respectively, for the non-smoking, passive smoking, first, second, third trimester cessation, and full-pregnancy smoking, groups. The risk of FGR compared to non-smokers was OR=2.3 (95% CI: 1.18-4.30, p=0.014) for patients who quit smoking in the third trimester, OR=2.5 (95% CI: 2.03-3.12, p<0.001) for women who smoked throughout pregnancy. After logistic regression, FGR (AOR=1.9; 95% CI: 0.96-3.82) for women who quit smoking in the 3rd trimester (AOR=1.8; 95% CI: 1.38-2.31, p<0.001). The risk of FGR <5th percentile was AOR=1.96 (95% CI: 1.36-2.48, p<0.001). CONCLUSIONS: Active or passive smoking during pregnancy is associated with an increased risk of intrauterine growth restriction and low birth weight. Cessation in the 1st and 2nd trimester reduces the risk of intrauterine growth restriction or low birth weight. Passive smoking has a deleterious impact on fetal development, intermediate to that of active smoking.

Comparative study of dinoprostone and misoprostol for induction of labor in patients with premature rupture of membranes after 35 weeks.

The modalities of induction of labor in the event of premature rupture of membranes are controversial. The main purpose of this study was to compare the modalities of delivery after the use of dinoprostone or misoprostol for labor induction in the preterm rupture of membranes after 35 weeks in women with an unfavorable cervix. We then studied maternal and fetal morbidity for the two drugs. Retrospective, single-center, comparative cohort study in a level 3 maternity unit in France from 2009 to 2018 comparing vaginal administration of misoprostol 50 µg every six hours (maximum 150 µg) and administration of dinoprostone 10 mg, a slow-release vaginal insert, for 24 h (maximum 20 mg), for labor induction in the preterm rupture of membranes after 35 weeks in women with an unfavorable cervix (Bishop score < 6). We included 904 patients, 656 in the misoprostol group and 248 in the dinoprostone group. Vaginal delivery rate was significantly higher in the dinoprostone group (89% vs. 82%, p = 0.016). There were more cesarean sections for abnormal fetal heart rate in the misoprostol group (p = 0.005). The time interval from induction to the beginning of the active phase of labor and the duration of labor were shorter in the misoprostol group than in the dinoprostone group (437 min vs. 719 min, p < 0.001 and 335 min vs. 381 min, p = 0.0023, respectively). Maternal and neonatal outcomes were not significantly different in the two groups. Vaginal dinoprostone used for labor induction in preterm rupture of membranes seems to be more effective for vaginal delivery than vaginal misoprostol (50 µg).

Uterine Factor Infertility, a Systematic Review.

Uterine factor infertility (UFI) is defined as a condition resulting from either a complete lack of a uterus or a non-functioning uterus due to many causes. The exact prevalence of UFI is currently unknown, while treatments to achieve pregnancy are very limited. To evaluate the prevalence of this condition within its different causes, we carried out a worldwide systematic review on UFI. We performed research on the prevalence of UFI and its various causes throughout the world, according to the PRISMA criteria. A total of 188 studies were included in qualitative synthesis. UFI accounted for 2.1 to 16.7% of the causes of female infertility. We tried to evaluate the proportion of the different causes of UFI: uterine agenesia, hysterectomies, uterine malformations, uterine irradiation, adenomyosis, synechiae and Asherman syndrome, uterine myomas and uterine polyps. However, the data available in countries and studies were highly heterogenous. This present systematic review underlines the lack of a consensual definition of UFI. A national register of patients with UFI based on a consensual definition of Absolute Uterine Factor Infertility and Non-Absolute Uterine Factor Infertility would be helpful for women, whose desire for pregnancy has reached a dead end.

Impact of induction of labor in fetal macrosomia: comparative series from 256 cases.

INTRODUCTION: The management of fetal macrosomia remains controversial. A protocol for induction of labor in the case of a suspected macrosomic fetus has been in place in our maternity hospital since 2016. We studied the impact of this protocol by analyzing the mode of delivery. We then studied its safety in terms of maternal and fetal morbidity and mortality and the risk factors of macrosomia. METHODS: Retrospective, comparative, single-center study including 256 patients between 2016 and 2020 in a type 3 maternity hospital in France. We compared 114 patients induced at 39 weeks of gestation (fetal weight ≥ 95th p; group 1) with 142 patients who after 37 weeks of gestation delivered a macrosomic newborn (≥ 95th p according to Audipog; group 2) not diagnosed antenatally. RESULTS: The rate of vaginal delivery in the group 1 was 78.9% vs 83.8% in group 2 (p = 0.318). The rate of neonatal acidosis in group 1 was statistically lower than in group 2 (5.2% vs 16.9%; p = 0.004). The other maternal and neonatal outcomes were not significantly different in the two groups. A previous macrosomic newborn appeared to be a risk factor for macrosomia (p = 0.02). CONCLUSION: The establishment of a protocol for the induction of labor in the case of macrosomia in our maternity hospital did not increase the rate of vaginal delivery, but has a neonatal benefit, by significantly reducing neonatal acidosis.

Comparison of maternal and neonatal outcomes after forceps or spatulas-assisted delivery.

OBJECTIVE: The aim of this study was to compare the perinatal outcomes associated with spatulas or forceps assisted delivery. STUDY DESIGN: This is a bicentric retrospective cohort study including all assisted deliveries in cephalic presentation after 37 weeks of gestation, performed on singleton pregnancy with forceps and with spatulas in two tertiary centers. The main outcome was the rate of episiotomy. Secondary outcomes included obstetric anal sphincter injuries (OASIS), maternal outcomes and neonatal parameters. RESULTS: Out of 37 002 deliveries, the overall rate of assisted delivery was 11.4 %, and 1 041 (2.8 %) assisted deliveries with forceps and 2 462 (6.7 %) spatulas deliveries were included. The rate of episiotomy was 90.3 % after forceps-assisted delivery and 70.9 % for spatulas (p < 0.001). The rate of OASIS was 7.2 % and 5.6 % respectively (p = 0.06). A slight but significant decrease in neonatal trauma after spatulas was observed. CONCLUSION: In this retrospective cohort study, the episiotomy rate was higher with forceps assisted deliveries than with spatulas. Both instruments have low neonatal morbidity and are similar regarding OASIS.

Mobile phone use during pregnancy: Which association with fetal growth?

INTRODUCTION: Few studies have investigated the effect of electromagnetic waves on the human fetus whereas nowadays mobile phone use is ubiquitous. The aim of this study was to evaluate the association between mobile phone use by pregnant women and fetal development during pregnancy in the general population. MATERIAL AND METHODS: Data came from the NéHaVi cohort ("prospective follow-up, from intrauterine development to the age of 18 years, for children born in Haute-Vienne"), a prospective, longitudinal, multicenter (three maternity units in Haute-Vienne) observational cohort focusing on children born between April 2014 and April 2017. Main objective was to investigate the association of mobile phone use on fetal growth. Univariate and multivariate models were generated adjusted for the socioprofessional category variables of the mother, and other variables likely to influence fetal growth. RESULTS: For the analysis 1378 medical charts were considered from which 1368 mothers (99.3 %) used their mobile phones during pregnancy. Mean phone time was 29.8 min (range: 0.0-240.0 min) per day. After adjustment, newborns whose mothers used their mobile phones for more than 30 min/day were significantly more likely to have an AUDIPOG score ≤ 10th percentile than those whose mothers used their mobile phones for less than 5 min/day during pregnancy (aOR = 1.54 [1.03; 2.31], p = 0.0374). For women using their cell phones 5-15 min and 15-30 min, there wasn't a significant association with an AUDIPOG score ≤ 10th, respectively aOR = 0.98 [0.58; 1.65] and aOR = 1.68 [0.99; 2.82]. CONCLUSION: Using a mobile phone for calls for more than 30 min per day during pregnancy may have a negative impact on fetal growth. A prospective study should be performed to further evaluate this potential link.

Off-label prescribing during pregnancy in France: the NéHaVi cohort
.

OBJECTIVE: To describe the off-label medication use in a cohort of pregnant women. MATERIAL AND METHODS: We performed a multicenter prospective longitudinal observational study in the Haute-Vienne department (France) called the NéHaVi cohort ("Né en Haute-Vienne" meaning "born in Haute-Vienne"). Women who had given birth to a viable baby in one of three maternity wards in the Haute-Vienne were included in the study after giving their informed consent. Data on the progress and outcome of pregnancies, childbirth, and drug or toxic exposure during pregnancy were collected. Drugs were classified, according to the labeling of the summary of product characteristics (SmPC) regarding the use in pregnancy, as follows: on-label, off-label at risk, and off-label contra-indicated. RESULTS: During their pregnancy, the 397 included women gave birth to 400 viable babies (209 boys, 191 girls, 3 sets of twins). All women had used at least 1 health product: 3,533 (92%) drugs, 298 (7.5%) homeopathic products, and 18 (0.5%) herb derivatives. The mean number of different drugs taken was 8.9 ± 5.3 (min 1, max 31). All pregnant women used at least 1 drug either with a license or considered as safe to take during pregnancy. Among the 2,538 (71.6%) on-label drugs, the most frequently used were analgesics (n = 611, 24.1%) (acetaminophen (n = 566)), antianemia preparations (n = 528, 20.8%), drugs for functional gastrointestinal disorder (n = 269, 10.6%), vitamins (n = 192, 7.5%), drugs for acid-related disorders (n = 148, 5.8%), and antibacterials (n = 118, 4.6%). In total, 321 (80.9%, 95% CI: 77.0 - 84.7) pregnant women used at least 1 off-label drug; and more precisely, 285 (71.8%, 95% CI: 67.4 - 76.2) used at least 1 off-label high-risk drug, and 189 (47.6%, 95% CI: 42.7 - 52.5) at least 1 contra-indicated drug. Among the 995 off-label drugs (28.2%), 760 (21.5%) were considered high-risk, including vasoprotectives (n = 156, 20.5%) (treatment of hemorrhoids (n = 147)), antithrombotic agents (n = 91, 11.6%) (heparins (n = 88)), and calcium channel blockers (n = 88, 11.6%). Lastly, 235 (6.7%) off-label drugs used were contraindicated medications (non-steroidal anti-inflammatory drugs during the 3rd trimester (n = 231)). Five babies were born with malformations not related to the drugs used during pregnancy. CONCLUSION: We showed for the first time the magnitude of off-label prescription during pregnancy in France. Women and health professionals should be made more aware of the potential drug-induced risk during pregnancy. Drug adverse effects during pregnancy should be evaluated through an improved notification in pharmacovigilance and appropriate pharmacoepidemiologic studies in order to change SmPC labelings as early as possible, when necessary.

Description of an initiation program to robotic in vivo gynecological surgery for junior surgeons.

INTRODUCTION: Most gynecological residents or junior surgeons do not practice nor experience robotic surgery due to lack of access during residency or poor knowledge about this growing surgical technology. This study evaluated the feasibility and safety of a 3-half-day experiencing and training session for robot-assisted gynecological surgery designed for residents and fellows. MATERIEL AND METHODS: This is a prospective, single-center observational study about a training course aimed at residents or fellows at the university teaching hospital of Limoges (France). It spreads over three consecutive half-days: one dedicated to simulation exercises involving the Da Vinci Skills Simulator© and the other two, to practice in two robot-assisted procedures with dual-console equipment supervised by a senior surgeon (as it is usually performed in a university teaching hospital). Complications during surgery, patient's medical records as well as the participants' performances during in vivo suturing acts were gathered. Feedback on the session was obtained with a questionnaire at the end of the course. RESULTS: Twelve sessions involving 24 patients operated on by 34 trainees from 16 different teaching university hospitals across the country took place. No conversion to laparotomy nor any major peri- or post-operative complication was reported. Time for stitching decreased significantly (p=.016) between the first and the second in vivo surgery. Use of the dual console was found helpful and most attendees (96.8%) would recommend this training session. CONCLUSION: We showed this training course with both simulation and in vivo surgery was feasible, safe and was a well-liked initiation program for robotic surgery.

The Key Role of Warm and Cold Ischemia in Uterus Transplantation: A Review.

Introduction: Uterus transplantation (UTx) is a promising treatment for uterine infertility that has resulted in several births since 2014. Ischemia is a key step in organ transplantation because it may lead to changes jeopardizing graft viability. Method: We performed a systematic review of animal and human studies relating to uterine ischemia. Results: We retained 64 studies published since 2000. There were 35 studies in animals, 24 in humans, and five literature reviews. Modest preliminary results in large animals and humans are limited but encouraging. In small animals, pregnancies have been reported to occur after 24 h of cold ischemia (CI). In ewes, uterine contractions have been detected after 24 h of CI. Furthermore, it has been shown in animals that uterine tolerance to CI and to warm ischemia (WI) can be increased by pharmacological products. In women, mean CI time in studies of births from uteri obtained from live donors was between 2 h 47 min and 6 h 20 min from a deceased donor; with only one birth in this case. Muscle contractions have also been demonstrated in myometrial samples from women, after six or more hours of CI. Conclusion: The uterus seems to be able to tolerate a prolonged period of CI, of at least six hours. Studies of the ischemia tolerance of the uterus and ways to improve it are essential for the development of UTx, particularly for procedures using grafts from deceased donors.

Para-aortic Lymph Node Invasion in High-risk Endometrial Cancer: Performance of 18FDG PET-CT.

AIM: 18F-Fluorodeoxyglucose positron-emission tomography integrated with computed tomography (18FDG PET-CT) is a non-invasive examination that could be helpful for the management of endometrial cancer. This study investigated the performance of 18FDG PET-CT in assessing para-aortic (PA) lymph-node involvement in high-risk endometrial cancer. MATERIALS AND METHODS: This was a retrospective, single-center study carried out between 2009 and 2018. The inclusion criteria were high-risk and locally advanced type 1 or 2 endometrial cancer with 18FDG PET-CT before PA lymphadenectomy. RESULTS: During the study period, among 142 patients with high-risk endometrial cancer, 35 patients (24.6%) underwent 18FDG PET-CT followed by PA lymphadenectomy. In 25% of cases, PA lymphadenectomy was not performed due to the discovery of metastasis. 18FDG PET-CT had a sensitivity of 50%, a specificity of 100%, a positive predictive value of 100%, a negative predictive value of 75%, accuracy of 80% and an area under the curve of 0.75 for the evaluation of PA involvement. CONCLUSION: According to its high specificity in PA lymph-node evaluation, a positive PET scan might allow PA lymphadenectomy to be avoided.

Organizing a uterus transplantation programme: The designation of Uterus Transplantation Centres in France.

Absolute uterine factor infertility affects several thousand young women in France. The first healthy child delivered to a uterus transplant recipient took place in 2014, and uterus transplantation is developing rapidly in many countries. The French College of Gynaecologists and Obstetricians (CNGOF) formed a uterus transplantation committee (CETUF) in 2015 to advance this technology in France. The CETUF sets out the criteria for the designation of Uterus Transplantation Centres. The objectives, requirements, operation and responsibilities of these centres have been described. Their responsibilities for organizing geographical coverage, continuity of care, communication, training, research and evaluation have been defined. This document will serve as a guide for the authorities concerned, to ensure that the means are provided to adequately manage patients with absolute uterine factor infertility who require uterus transplantation.

Assessment of Ki67 and uPA/PAI-1 expression in intermediate-risk early stage breast cancers.

BACKGROUND: The objective of this study was to compare the efficacy of biomarkers in assessing the risk of breast cancer recurrence in patients with node-negative or micrometastatic grade II breast cancer. Specifically, we compared risk assessments based on the St. Gallen clinicopathological criteria, Ki67 expression and urokinase plasminogen activator (uPA)/plasminogen activator inhibitor-1 (PAI-1) expression. METHODS: This retrospective study included 347 patients with breast cancer followed at Limoges University Hospital. The optimal cut-off for high Ki67 expression (Ki67hi) was established as 20%. The threshold for uPA and PAI-1 positivity was 3 ng/mg and 14 ng/mg, respectively. RESULTS: Ki67 expression was lower in uPA/PAI-1-negative than in uPA/PAI-1-positive tumours (227 tumours; P = 0.04). The addition of Ki67 status to the St. Gallen criteria resulted in a 28% increase in the rate of identification of high-risk tumours with a potential indication for chemotherapy (P < 0.001). When considering uPA/PAI-1 levels together with the St Gallen criteria (including Ki67 expression), the number of cases identified as having a high recurrence risk with a potential indication for adjuvant chemotherapy increased by 20% (P < 0.001). Adjuvant chemotherapy was 9% less likely to be recommended by a multidisciplinary board when using the current criteria compared with using a combination of the St. Gallen criteria and Ki67 and uPA/PAI-1 status (P = 0.03). CONCLUSIONS: Taken together, our data show discordance among markers in identifying the risk of recurrence, even though each marker may prove to be independently valid.

Which Donor for Uterus Transplants: Brain-Dead Donor or Living Donor? A Systematic Review.

BACKGROUND: The aim of this systematic review was to evaluate and compare the pros and cons of using living donors or brain-dead donors in uterus transplantation programs, 2 years after the first worldwide live birth after uterus transplantation. METHODS: The Medline database and the Central Cochrane Library were used to locate uterine transplantation studies carried out in human or nonhuman primates. All types of articles (case reports, original studies, meta-analyses, reviews) in English or French were considered for inclusion. RESULTS: Overall, 92 articles were screened and 44 were retained for review. Proof of concept for human uterine transplantation was demonstrated in 2014 with a living donor. Compared with a brain-dead donor strategy, a living donor strategy offers greater possibilities for planning surgery and also decreases cold ischemia time, potentially translating into a higher success rate. However, this approach poses ethical problems, given that the donor is exposed to surgery risks but does not derive any direct benefit. A brain-dead donor strategy is more acceptable from an ethical viewpoint, but its feasibility is currently unproven, potentially owing to a lack of compatible donors, and is associated with a longer cold ischemia time and a potentially higher rejection rate. CONCLUSIONS: The systematic review demonstrates that uterine transplantation is a major surgical innovation for the treatment of absolute uterine factor infertility. Living and brain-dead donor strategies are not mutually exclusive and, in view of the current scarcity of uterine grafts and the anticipated future rise in demand, both will probably be necessary.

Uterus human leucocyte antigen expression in the perspective of transplantation.

AIM: To describe class I and II human leucocyte antigen (HLA) expression using different uterine tissues in the perspective of uterus transplantation. METHODS: Human uterine tissues were obtained from 12 women who had undergone hysterectomy for the treatment of benign disease. HLA class I and HLA-antigen D related (DR) expression were assessed via immunochemistry. HLA class I expression in the uterus was compared with expression in other organs and tissues, including kidney and myocardium samples. RESULTS: HLA class I expression was strong in the endometrial glands and mild in the myometrium. Staining of endometrial glands was similar to glomerular staining in the kidney. The myometrium seems to express HLA class I similarly to hepatocytes and myocardial cells. HLA class I expression in the uterus did not differ in younger or post-menopausal women. HLA-DR was expressed in the endometrial glands, but not in the myometrium. A lack of HLA-DR expression seemed to be correlated with cell proliferation. CONCLUSION: HLA expression in the endometrium and myometrium is different. The endometrium should be the major target of alloreactive response. As for other transplanted organs, assessment of HLA unacceptable antigens and multiple immunosuppressive treatments is necessary in uterus transplantation.