Long-term functional stability of sacrospinous ligament-fixation repair of pelvic organ prolapse.

The objective of this study was to evaluate the variation over 5 years of functional discomfort associated with pelvic organ prolapse (POP) repaired by sacrospinous ligament fixation (SLF). A total of 178 women who had undergone SLF from 1992 to 2001. In 2002 and 2008, patients were sent a questionnaire including the pelvic floor distress inventory (PFDI-20); 79 responded and comparison of those data served to evaluate subjective signs at 5 years. This population was divided into two groups: ≤60 and >60 years old, and their 2002-2008 differences were compared. The outcomes were satisfaction, functional results and sexuality. Mean follow-up was 115 (72-173) months. Our results showed the long-term stability of SLF functional outcomes for women >60 years. However, for those≤60 years, functional outcomes and satisfaction had declined at 5 years.

Ovarian-sparing surgery for ovarian teratoma in children.

BACKGROUND: Ovarian teratoma (OT) is the most common ovarian neoplasm in children. Oophorectomy has been the standard treatment but may impair fertility. The aim of this study was to investigate the feasibility and outcome of ovarian-sparing surgery (OSS) for OT. PROCEDURE: We retrospectively studied all children treated for OT at a pediatric teaching hospital in Paris, France, between March 1992 and July 2006. OSS was performed when deemed technically feasible in patients who had no lymphadenopathy by preoperative imaging or surgical exploration, normal tumor marker levels, and calcifications on radiographs. RESULTS: We identified 30 patients, including 29 with unilateral OT and 1 with synchronous bilateral OT. Emergent surgery was performed in five patients, among whom four had ovarian torsion requiring oophorectomy and one underwent OSS. Of the 26 OTs in the 25 remaining patients, 10 were managed with OSS and 16 with oophorectomy. Subsequently, ultrasound monitoring detected OT development in the contralateral ovary in 4 (14%) patients, after a median of 3 years (range, 1-14 years); OSS was performed in all four cases. The patient with bilateral synchronous OT, managed by OSS initially, underwent unilateral oophorectomy 3 years later for a recurrence. Overall OSS was performed for 15 (42%) OTs. CONCLUSIONS: Our results suggest recommendations for preserving fertility whenever possible without compromising the oncological prognosis. In particular, OSS should be reserved for patients who meet all criteria for localized mature teratoma. Long-term follow-up is crucial.

[Para-arortic lymhadenectomy and pelvic gynecological cancers: Extraperitoneal or transperitoneal laparoscopy?] / Curage lombo-aortique et cancers gynécologiques pelviens : cœlioscopie rétroperitonéale ou transpéritonéale ?

INTRODUCTION: Para-aortic lymphadenectomy plays a fundamental role in the surgical management of pelvic gynecological cancers. Two laparoscopic approaches exist: the transperitoneal (TP) and the extraperitoneal (EP). The aim of this study was to compare these 2 approaches in terms of surgical outcomes, specially the number of removed lymph nodes according to the surgical technique, and morbidity. MATERIALS AND METHOD: A single-center retrospective study was carried out at the Lariboisiere University Hospital between January 2011 and March 2020 including all patients who underwent para-aortic lymphadenectomy for the management of a pelvic gynecological cancer (cervix, endometrium, ovary). Univariate and multivariate analysis (logistic regression) were performed to compare the TP and the EP groups. RESULTS: 143 patients were included: 74 in the TP group and 69 in the RP group. The total duration of surgery was 220.8minutes in the TP group and 166.4minutes in the EP group (P<0.001 in multivariate analysis). No significant difference between groups were found in the average total number of lymph nodes removed but there was a statistically significant difference in the average latero-aortic number of lymph nodes removed: 8.5 lymph nodes in the TP group and 11.3 lymph nodes in the group RP (P<0.001 in multivariate analysis). There was no difference between groups in peri and postoperative morbidity. CONCLUSION: EP para-aortic lymphadenectomy reduces duration of surgery and increases the average latero-aortic number of lymph nodes removed with same morbidity compared to TP para-aortic lymphadenectomy, this confirming its preferred indication in endometrial and in cervical cancers.

[The eastern Paris perinatal network (2008-2010). Defining the target population and assessing health needs]. / Le réseau périnatal de l'Est parisien (2008-2010). Définition de la population concernée pour évaluer les besoins à couvrir par le réseau.

BACKGROUND: Since the 1990s, governmental plans in France have imposed the regionalization of perinatal care to improve both safety and quality of care. The Eastern Paris Perinatal Network is under construction in health area 75-2, which includes the 11th, 12th, 13th and 20th arrondissements of Paris. A major issue is ensuring that the network can meet the needs of its target population. The objective is to define the network's target population of mothers and newborns. METHODS: We designed a matrix to help assess these needs and identify the data required to define the network's population. Four principal data sources were analyzed: the National Statistics and Economic Studies Institute (Insee) data, annual health facility activity data, national medical informatics program data, and 8th-day health certificates. RESULTS: The network's target population varies according to the precise perinatal period and the planning stage. For the conception period, it includes the general population and specifically all women of childbearing age (15-49 years). The health area included 672,000 inhabitants in 2006, 29% of them are women of childbearing age. The proportion of people born outside France and who are of foreign nationality ranges, according to arrondissement, from 13.2 to 20.0%; the mean for the Paris metropolitan area is 14.7%. Approximately 16,500 women gave birth in 2007, at nine obstetric facility sites in the health area (five level I, three level II, and one type III); only 41.46% of them resided in the health area. Approximately 2500 women living in the health area gave birth at a facility outside the area. The population likely to be covered by the network is thus estimated at approximately 19,000 women. CONCLUSION: A network must simultaneously take into account the local resident population and the population using its health care system. In an urban area such as Paris, where the health care supply is dense, it is essential for policy planning process to define the contours of the target population of a health network.

[Bladder endometriosis and barrenness: diagnostic and treatment strategy]. / Endométriose vésicale et infertilité: modalités de prise en charge diagnostique et thérapeutique.

Deep infiltrating endometriosis is a well-known female disease responsible for chronic pelvic pain, urinary dysfunction, infertility, and altered quality of life. Endometriosis and infertility are complex entities and the optimal choice of management of both of them remains obscure. Mechanism of development of the disease has to be understood to optimize patients care. The link between barrenness and endometriosis is well known, but there is no direct link between bladder lesion and infertility. Bladder endometriosis is a deeply infiltrating endometriosis lesion. Its management is first diagnostic and then remedial. In case of ineffectiveness of medical strategy, surgical treatment is indicated. However, for patient suffering from symptomatic isolated bladder endometriosis, surgical management can be offered in first intention. Isolated bladder injuries due to endometriosis are mostly treated by conservative laparoscopic surgery, after a complete evaluation of endometriosis disease and barrenness by clinical exam and imaging techniques.

Low pressure gynecological laparoscopy (7mmHg) with AirSeal® System versus a standard insufflation (15mmHg): A pilot study in 60 patients.

OBJECTIVES: To evaluate feasibility of performing benign gynecologic pathology low pressure (7mmHg) laparoscopy (LPL) with AirSeal® system and to study benefits in terms of postoperative pain, when compared to a standard insufflation group (15mmHg). MATERIALS AND METHODS: In this prospective randomized pilot study, 60 patients had laparoscopy for gynecologic benign pathology: 30 with 7mmHg and AirSeal system, and 30 with 15mmHg standard insufflator. The primary endpoint was incidence of shoulder pain. A postoperative questionnaire was completed by each patient to assess shoulder pain (Numeric Rating Scale [NRS], from 0 to 10) at H4, H8, H24, and consumption of morphinics was notified. During each procedure, anesthesia parameters were collected (peak airway pressure, systolic blood pressure, end tidal CO2). RESULTS: Laparoscopy was performed on 30 patients in AirSeal®-LP group without need to increase pressure above 7mmHg, and no complication was reported. Incidence of shoulder pain was significantly lower in the AirSeal®-LP group (23.3% vs. 73.3%, P<0.001). NRS shoulder pain was significantly lower in AirSeal® LP group at hour 4, 8 and 24. Maximal values of ETCO2, systolic blood pressure, and peak airway pressure were significantly lower in AirSeal®-LP group. CONCLUSION: LP (7mmHg) laparoscopy with AirSeal® platform allows laparoscopic surgery with less postoperative shoulder pain. These results could facilitate the development of ambulatory laparoscopy.

Good prognosis of postpartum lower limb sensorimotor deficit: a combined clinical, electrophysiological, and radiological follow-up.

Postpartum lower limb motor and/or sensory deficit is an uncommon obstetrical complication. We aimed to identify its incidence, etiology, and precipitating factors, as well as the neurological prognosis by retrospectively analyzing the successive neurological evaluations, electrophysiological, and MRI data from all the consecutive patients with postpartum motor and/or sensory deficits of the lower limbs referred from the Lariboisière Obstetrical Department to the Lariboisière Neurophysiology Department, from January 2012 to June 2016, as well as data concerning labor and morphological characteristics of mother and baby. Thirteen patients (0.11% of the parturient women in the Lariboisière hospital) were included. Eight (62%) had lumbosacral plexopathy. Symptoms followed a first vaginal delivery in 10/13 patients (77%), in patients who were mostly overweight (mean patient BMI before pregnancy 25.6 ± 3.2 kg/m2). Labor duration was slightly longer than average (mean labor duration 8.9 ± 2.9 h). No other potentially precipitating factor was identified. Recovery was good in all patients, 7/11 (64%) made a rapid full recovery (mean recovery time 5 ± 2.5 weeks excluding one patient who had a normal neurological examination at 2 weeks but still complained of foot weakness that fully recovered in 1 year), and a minority (4/11, 36%) still complained of minor symptoms at time of follow-up, but showed marked improvement. New mothers presenting postpartum lower limb nerve injury should, therefore, be reassured.

[Apoptosis of granulosa cells as a predictive marker of in vitro fertilization success?]. / L'apoptose des cellules de la granulosa peut-elle être considérée comme un marqueur prédictif du succès de la fécondation in vitro?

During in vitro fertilization (IVF) morphological criteria are the only means usable today to select embryos before their uterine transfer in order to obtain pregnancy with the best chances of success. Since several years many attempts have been made to find more functional means. Quantification of apoptosis of granulosa cells has been proposed for this purpose. The aim of this review is to take stock of our knowledge on apoptosis and its mechanisms in granulosa cells and to analyse how quantification of these apoptotic cells could be a reliable and predictive marker of success for an attempt of an IVF in terms of pregnancy.

[Contribution of three dimensional imaging techniques in the visualization of the fetal uterus]. / Contribution de l'imagerie tridimensionnelle échographique à la visualisation de l'utérus foetal.

The prenatal diagnosis of ambiguous genitalia requires a complete examination of the fetal anatomy to rule out any other congenital defects and the analysis of the fetal genotype. In addition any additional information on the anatomy of the internal genitalia, i.e. the presence or absence of fetal uterus, may be relevant to the prenatal evaluation of female pseudo-hermaphroditism. The recent development of 3D and 4D ultrasound technology may be relevant to a more clearly identification of the fetal uterus. Volume contrast imaging (VCI) provides high contrast images by the realization of thick slices of the region of interest (ROI) thereby providing a clearer picture of the fetal uterus. The multiplanar mode may also facilitate the differentiation of the fetal uterus from the other intra-pelvic organs by offering images in three perpendicular planes. Finally, the tomographic ultrasound imaging (TUI) mode offers the ability to display on a single panel numerous 2-dimensional sections, as obtained using computed tomography imaging.

[Screening and timing for the delivery of fetuses with intrauterine growth restriction of vascular origin]. / Dépistage et programmation de la naissance des foetus présentant un retard de croissance intra-utérin d'origine vasculaire.

The prenatal management of fetuses with intrauterine growth restriction (IUGR) has been a matter of perpetual evolving in obstetrics and has been the topic of numerous studies. The management of IUGR fetuses is currently available in tertiary centres using fetal heart monitoring, short term variability, or doppler investigation of the umbilical artery, ductus venosus and middle cerebral artery. The aim of the prenatal management is to detect anomalies that may predict severe fetal hypoxemia. On the other hand, any efforts should focus on the possibility to delay the time for delivery as gestational age at delivery together with birth weight appear to be essential parameters of the postnatal outcome.

[Contribution of fetal middle cerebral artery peak systolic velocity in the management of non-immune hydrops]. / Apport de la mesure du pic des vitesses systoliques dans l'artère cérébrale moyenne pour la discussion étiologique des anasarques foetaux.

Hydrops fetalis is associated with a wide variety of fetal and maternal disorders. Among these disorders, cases with anemia may benefit from a specific treatment. The authors report on two cases of hydrops fetalis with increased middle cerebral artery peak systolic velocity and discussed the contribution of this finding in the management of fetuses with hydrops.

Identification of genes overexpressed in tumors through preferential expression screening in trophoblasts.

Early trophoblastic cells share several features with neoplastic cells. Based on that observation, we attempted to identify genes overexpressed in tumors by analyzing genes preferentially expressed in trophoblasts. A subtracted library enriched in complementary DNA from early cytotrophoblasts was constructed, and the expression level of selected recombinants was analyzed on a large panel of normal and tumor tissues. The library was prepared using a polymerase chain reaction-based complementary DNA subtraction method with 6-week amenorrhea cytotrophoblast endoplasmic reticulum-bound RNA as target, and a mixture of complementary DNA prepared from terminal placenta and activated T-lymphocytes as driver. Two rounds of screening were performed to isolate clones preferentially expressed in early placenta. From a total number of recombinant clones estimated at 32,000 in the subtracted library, 594 inserts were analyzed by Southern blot and 21 sequences were isolated as corresponding to genes highly expressed in early placenta. Eleven encoded known molecules, such as carcinoembryonic antigen, human chorionic gonadotropin, and mitochondrial rRNAs. Ten sequences represented novel genes. Northern blot analysis confirmed that most of these genes were preferentially expressed in early trophoblast in comparison to terminal placenta. Three clones that gave detectable hybridization signals on total RNA were extensively studied and were found to be overexpressed in various tumors. Two of these clones, designated B9 and E4, were later identified as corresponding to genes coding for the putative ribosomal protein S18 and the bifunctional enzyme ADE2H1 involved in purine biosynthesis, respectively. Expression of the third clone, E9, was increased up to 10-fold in breast cancer tissues in comparison with normal counterparts. Present results confirm that many genes expressed in the trophoblast are overexpressed in malignant cells. This approach could provide a general targeted method for the identification of genes overexpressed in various neoplastic cell types.

[Diagnostic hysteroscopy and risk of peritoneal dissemination of tumor cells]. / Hystéroscopie diagnostique et risque de contamination péritonéale par les cellules tumorales.

Questions have been raised about the safety of diagnostic hysteroscopy preceding surgical treatment of endometrial carcinoma. Several studies showed that the risk of a positive cytology among patients presenting endometrial adenocarcinoma was increased after diagnostic hysteroscopy, suggesting a peritoneal dissemination of tumor cells due to the exploration. We studied this hypothesis on the basis of a systematic review of the scientific data. Five studies fulfilling inclusion criteria have been selected and have been introduced into a fixed model of meta-analysis. On a total of 756 studied patients, 79 presented a positive peritoneal cytology. The diagnostic hysteroscopy did not increase significantly the risk of abdominal dissemination of tumor cells, the peritoneal cytology being positive among 38 patients in the group having undergone this intervention vs 41 patients in the control group (OR = 1,64; 95% CI: 0,96-2,80). In conclusion, no formal evidence is currently available concerning the role of diagnostic hysteroscopy on the frequency of peritoneal dissemination of tumor cells, or on the vital prognosis of the patients presenting with endometrial carcinoma. From the data available, there is not any reason to avoid diagnostic hysteroscopy in the initial workup of endometrial cancer.

[Recording expulsive forces during childbirth using intercostal muscle electromyogram: a pilot study]. / Monitorage des efforts expulsifs pendant l'accouchement par l'électromyogramme des muscles intercostaux: étude pilote.

OBJECTIVE: The expulsive forces of childbirth can be included among the many potential risk factors implicated in the subsequent development of perineal disorders. The objective of this study was to devise a non-invasive way to measure abdominal pushing that would accurately represent the expulsive forces during childbirth. PATIENTS AND METHODS: By means of intravesical and intrauterine manometry, and electromyography (EMG) of intercostal muscles, we quantified these forces in 21 women during vaginal delivery. RESULTS: A mixed Ancova model showed the integral of intravesical pressure to be significantly associated (P<0.001) with the integral of intercostal muscle electrical activity during the first 6 uterine contractions during the phase of fetal expulsion. DISCUSSION AND CONCLUSION: Electromyography is a non-invasive measurement that can replace intravesical determinations to quantify these forces as it reflects the real intra-abdominal pressure.

[Assessment of a multidisciplinary care for 169 excised women with an initial reconstructive surgery project]. / Évaluation d'une prise en charge multidisciplinaire chez 169 patientes excisées demandeuses d'une chirurgie réparatrice.

OBJECTIVE: To assess the benefits of a multidisciplinary care among excised women with an initial surgery project and identify the reasons for discarding surgery. METHODS: Descriptive and retrospective study performed between the 1st of January 2006 and the 31st of December 2011 at the Armand Trousseau Hospital, Paris. All excised patients went through consultations with a mid-wife, a sexologist, a psychologist, a gynaecologist-obstetrician and, for some of them, underwent a clitoral reconstructive surgery. RESULTS: One hundred and sixty-nine patients were included: among them, 61 patients (36%) were operated and 108 patients (64%) have given spontaneously to surgery, 32% being reinforced by consultation. Ninety-one on 111 patients (82%) respondents were satisfied with their care pathway. The main motivation was to support identity for 39 patients operated (64%) while improving sex prevailed for 56 non-operated patients (52%). The study evidenced an improvement of the functional and sexual life quality after surgery: 17% experienced an orgasm versus 2% before surgery, 56% reported an increase in their libido and 41% a decrease in dyspareunia. CONCLUSION: Clitoral reconstructive surgery with multidisciplinary care tends to improve the functional and sexual life quality of excised patients, though it is not always necessary. Some of the patients discard their initial project of reconstructive surgery as in some of the cases, a multidisciplinary care only seems sufficient.

HIV-1 detection in cervicovaginal secretions during pregnancy.

OBJECTIVE: To assess the reproducibility of and factors associated with HIV detection in cervicovaginal secretions (CVS). DESIGN: Longitudinal study of 43 HIV-1-infected pregnant women in Paris. METHODS: HIV DNA was detected in peripheral blood mononuclear cells (PBMC) by Amplicor and gag nested polymerase chain reaction (PCR) assays. The HIV genotype was determined by heteroduplex mobility assay. Amplicor and gag nested PCR assays were performed on serial CVS samples for HIV DNA detection, and the HIV Monitor test was used for HIV RNA detection in plasma and CVS. RESULTS: A total of 144 CVS samples were collected from the women included in the study. HIV-1 DNA was detected in 36 (25%) of the 144 samples, from 16 (37.2%) of the 43 women. Results of HIV-1 DNA detection were concordant in the first two samples in 27 (84.4%) of the 32 women with at least two CVS samples. The last CVS sample collected in each woman was HIV-1 DNA-positive in 13 (30.2%) of the 43 women. Three factors were found to be independently associated with HIV-1 DNA detection in CVS: HIV-1 subtype B, absence of zidovudine therapy, and microbial cervicovaginal infection. HIV RNA was detected in CVS from 10 (23.3%) out of 43 women and correlated with DNA detection in the same sample and HIV RNA detection in plasma. CONCLUSIONS: DNA and RNA PCR can be used to detect HIV in cells and supernatants of CVS. These techniques may be useful in cohort studies to investigate HIV transmission and to evaluate the efficacy of antiretroviral drugs to reduce HIV excretion.

Frequent detection of HIV-1 in the gastric aspirates of neonates born to HIV-infected mothers.

OBJECTIVE: To evaluate the frequency and correlates of oral route exposure of infants born to HIV-1-infected women. METHODS: A multicenter study was performed within the prospective French Perinatal Cohort Study of mother-to-child HIV transmission. Oropharyngeal and gastric aspirates from 122 neonates were studied by reverse transcriptase (RT) polymerase chain reaction (PCR) for the presence of HIV-1, as well as for standard microbiology (Gram staining and culture). RESULTS: Aspirates from 101 neonates were analyzed by RT-PCR; 28% of these were positive for HIV RNA. Another 21 aspirates could not be tested because of PCR inhibition. The median concentration of HIV RNA in the positive aspirates was 126 copies/ml (range: 8-1270). Detection of HIV-1 in the aspirate was significantly related to high maternal plasma-viral load, presence of blood in the aspirate, positive Gram stain or culture, episiotomy or perineal lesions, and sexually transmitted infections during the pregnancy. Most of the mothers received zidovudine prophylaxis during pregnancy and delivery. Among the six infants who were infected with HIV, three had positive aspirates. Of the three assumed to have acquired the infection intrapartum, only one had an HIV RNA-positive aspirate. CONCLUSION: Exposure of the fetus to HIV via the oral route occurs frequently, even in the presence of zidovudine prophylaxis, and is likely to be one of the mechanisms of intrapartum transmission, but not the only one.

Antepartum transabdominal amnioinfusion to facilitate external cephalic version after initial failure.

Transabdominal amnioinfusion can be used to facilitate external cephalic version. Our technique involves filling the uterine cavity with 700 or 900 mL of 37C saline under continuous echographic monitoring. External cephalic version is done the next morning. We have used this procedure in six women, all of whom had previous unsuccessful attempts at external cephalic version. After amnioinfusion, all six patients were converted to cephalic presentation and delivered normally, without obstetric or neonatal complications.

Constriction of the fetal ductus arteriosus during prenatal betamethasone therapy.

BACKGROUND: Constriction of the fetal ductus arteriosus occurs with maternal indomethacin treatment and has been suggested with corticosteroid therapy as well. CASE: Fetal ductal constriction was diagnosed by Doppler echocardiography at 29 weeks' gestation after a third and fourth course of betamethasone was administered to a pregnant woman with placenta previa. Doppler echocardiography showed a patent ductus arteriosus 3 days after the treatment. CONCLUSION: The risk-benefit ratio of betamethasone should be assessed by large-scale studies when repeated courses or chronic maternal administration of betamethasone are required.