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Wu DF, Zhang HX, He W, Liu X, Song HM, Yu TF. Experience in management of cesarean scar pregnancy and outcomes in a single center. J Int Med Res 2022; 50:3000605221123875. [PMID: 36262051 PMCID: PMC9585568 DOI: 10.1177/03000605221123875] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE This study aimed to describe our experience of managing cesarean scar pregnancy (CSP) and outcomes depending on ultrasound imaging features. METHODS A retrospective, cohort observational study was performed on 31 consecutive patients with CSP at 6 to 9 weeks of gestation from April 2015 to January 2021. All patients were evaluated for the residual myometrial thickness (RMT), growth direction of the gestational sac (GS), blood flow, and chorionic parenchyma using ultrasonography. Patients underwent curettage or methotrexate (MTX) combined with curettage in CSP depending on the age of the GS. Blood loss of >500 mL with curettage was considered major bleeding. RESULTS Twenty-five (80.6%) patients had successful treatment, and six (19.4%) patients had major bleeding. The incidence of major bleeding was significantly higher in patients with >7 weeks of gestation, types II and III CSP, mixed and exogenous types of the growth direction of the GS, an RMT < 2 mm, and multiple lacunae formation in thickened chorionic parenchyma. CONCLUSIONS The exogenous and mixed types of the GS, an RMT < 2 mm, and multiple lacunae in thickened chorionic parenchyma may be high-risk factors for major hemorrhage by curettage in CSP.
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Affiliation(s)
- Dong-fang Wu
- Department of Ultrasound, Beijing Fengtai Hospital, Capital Medical University, No. 99 Feng Tai South Road, Feng Tai District, Beijing 100071, China
| | - Hong-xia Zhang
- Department of Ultrasound, Beijing Tiantan Hospital, Capital Medical University, No. 119 4th South Ring West Road, Fengtai District, Beijing 100070, China,Hong-xia Zhang, Department of Ultrasound, Beijing Tiantan Hospital, Capital Medical University, No. 119 4th South Ring West Road, Fengtai District, Beijing 100070, China.
| | - Wen He
- Department of Ultrasound, Beijing Tiantan Hospital, Capital Medical University, No. 119 4th South Ring West Road, Fengtai District, Beijing 100070, China
| | - Xin Liu
- Department of Ultrasound, Beijing Tiantan Hospital, Capital Medical University, No. 119 4th South Ring West Road, Fengtai District, Beijing 100070, China
| | - Hai-man Song
- Department of Ultrasound, Beijing Tiantan Hospital, Capital Medical University, No. 119 4th South Ring West Road, Fengtai District, Beijing 100070, China
| | - Teng-fei Yu
- Department of Ultrasound, Beijing Tiantan Hospital, Capital Medical University, No. 119 4th South Ring West Road, Fengtai District, Beijing 100070, China
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2
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Wildblood C, Ding J, Aquilina J, Gbegbaje M. Live tubal ectopic pregnancy managed with localised injection of methotrexate into gestational sac. BMJ Case Rep 2022; 15:e245149. [PMID: 35228215 PMCID: PMC8886386 DOI: 10.1136/bcr-2021-245149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Ectopic pregnancy is a pregnancy outside the uterine cavity and is, in majority of cases, a non-viable pregnancy. There are multiple methods of managing patients with ectopic pregnancy including expectant, medical and surgical management. Live tubal ectopic pregnancies, also known as ectopic pregnancies present in the fallopian tube with fetal heartbeat still present, are most commonly treated via surgical route. This case outlines the presentation and an unusual method of management of a patient diagnosed with a live tubal ectopic pregnancy with extensive medical and surgical history.
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Affiliation(s)
| | - Jane Ding
- Department of Obstetrics and Gynaecology, Royal London Hospital, London, UK
| | - Joe Aquilina
- Department of Obstetrics and Gynaecology, Royal London Hospital, London, UK
| | - Mary Gbegbaje
- Department of Obstetrics and Gynaecology, Royal London Hospital, London, UK
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Maleki A, Khalid N, Rajesh Patel C, El-Mahdi E. The rising incidence of heterotopic pregnancy: Current perspectives and associations with in-vitro fertilization. Eur J Obstet Gynecol Reprod Biol 2021; 266:138-144. [PMID: 34653918 DOI: 10.1016/j.ejogrb.2021.09.031] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 07/18/2021] [Accepted: 09/26/2021] [Indexed: 12/27/2022]
Abstract
Heterotopic pregnancy is the simultaneous occurrence of an intrauterine and ectopic pregnancy. This study aims to review the current literature regarding heterotopic pregnancy with a focus on its diagnosis and associations with in-vitro fertilization (IVF). Studies have shown that ovarian hyperstimulation syndrome and multiple embryo transfer during IVF are associated with an increased risk of heterotopic pregnancy. Tubal abnormalities such as pelvic inflammatory disease and previous tubal or abdomino-pelvic surgery have also been identified as risk factors. Diagnosis is challenging as the falsely reassuring presence of an intrauterine fetus frequently delays early intervention. Treatment should be individualised, but is often prompt surgical intervention, and focuses on terminating the ectopic pregnancy while minimizing harm to the mother and intrauterine fetus.
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Affiliation(s)
- Aryan Maleki
- Queen Mary University of London, Barts and The London School of Medicine and Dentistry, London, UK
| | - Noorulain Khalid
- Queen Mary University of London, Barts and The London School of Medicine and Dentistry, London, UK
| | - Chandni Rajesh Patel
- Queen Mary University of London, Barts and The London School of Medicine and Dentistry, London, UK
| | - Essam El-Mahdi
- Department of Obstetrics and Gynaecology, Newham University Hospital, Barts Health NHS Trust, London, UK
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Wang Y, Niu Z, Tao L, Yang Y, Ma C, Li R. Early intervention for heterotopic caesarean scar pregnancy to preserve intrauterine pregnancy may improve outcomes: a retrospective cohort study. Reprod Biomed Online 2020; 41:290-299. [PMID: 32553465 DOI: 10.1016/j.rbmo.2020.03.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 03/19/2020] [Accepted: 03/24/2020] [Indexed: 02/07/2023]
Abstract
RESEARCH QUESTION What is the best intervention time and method for patients who are diagnosed with heterotopic caesarean scar pregnancy (HCSP) wishing to preserve intrauterine pregnancy. DESIGN Four patients diagnosed with HCSP from January 2014 to May 2019 were enrolled. Because HCSP is rare, data on 27 published cases were extracted to augment the analysis. Clinical characteristics and medical documents related to fetal reduction and subsequent maternal-neonate outcomes were analysed. RESULTS The intervention time was significantly earlier in the full-term birth group (6.76 ± 1.05 weeks) compared with pre-term birth group (8.02 ± 1.55 weeks; P = 0.042). The cumulative full-term delivery rate was 91.48% when the intervention was at 6 weeks' gestation and decreased to 42.02% at 8 weeks. The maternal-neonate outcome was similar among the selective fetal reduction and surgical removal groups as was delivery time (34.68 ± 3.12 versus 34.80 ± 6.64 weeks; P = 0.955). In the four cases undergoing selective fetal reduction, the residual mass grew by 1.16-7.07 times compared with the area before reduction. The maximum size of the residual mass was observed at 12-13 weeks and 22-25 weeks. CONCLUSIONS Most patients with HCSP who choose to keep intrauterine pregnancy will be able to carry the fetus to term. Selective fetal reduction would be the first intervention of choice and should take place immediately after diagnosis. The residual mass after reduction could continue to grow throughout the whole pregnancy, although this should not be considered as an indication for termination. With good supervision and careful management, the pregnancy could be maintained and carried to term.
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Affiliation(s)
- Yang Wang
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing 100191, China; National Clinical Research Center for Obstetrics and Gynecology, Beijing 100191, China; Key Laboratory of Assisted Reproduction (Peking University), Ministry of Education, Beijing 100191, China; Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Beijing 100191, China
| | - Ziru Niu
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing 100191, China; National Clinical Research Center for Obstetrics and Gynecology, Beijing 100191, China; Key Laboratory of Assisted Reproduction (Peking University), Ministry of Education, Beijing 100191, China; Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Beijing 100191, China
| | - Liyuan Tao
- Research Center of Clinical Epidemiology, Peking University Third hospital, Beijing 100191, China
| | - Yan Yang
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing 100191, China; National Clinical Research Center for Obstetrics and Gynecology, Beijing 100191, China; Key Laboratory of Assisted Reproduction (Peking University), Ministry of Education, Beijing 100191, China; Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Beijing 100191, China
| | - Caihong Ma
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing 100191, China; National Clinical Research Center for Obstetrics and Gynecology, Beijing 100191, China; Key Laboratory of Assisted Reproduction (Peking University), Ministry of Education, Beijing 100191, China; Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Beijing 100191, China
| | - Rong Li
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing 100191, China; National Clinical Research Center for Obstetrics and Gynecology, Beijing 100191, China; Key Laboratory of Assisted Reproduction (Peking University), Ministry of Education, Beijing 100191, China; Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Beijing 100191, China.
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Bi Y, She Y, Tian Z, Wei Z, Huang Q, Liao S, Ye Y, Qin A, Yang Y. Efficacy and safety of laparoscopy versus local injection with absolute ethanol in the management of tubal ectopic pregnancy. Eur J Obstet Gynecol Reprod Biol X 2019; 3:100032. [PMID: 31403121 PMCID: PMC6687442 DOI: 10.1016/j.eurox.2019.100032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 04/22/2019] [Accepted: 04/28/2019] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To compare the efficacy and safety between laparoscopy and local injection with absolute ethanol (AE) for treating tubal ectopic pregnancy (EP). STUDY DESIGN Retrospective cohort study of ectopic pregnancies in the fallopian tube from two tertiary hospitals between January 2015 and December 2017. Clinical information such as presenting symptoms, reproductive history, possible risk factors, initial diagnosis, serum beta-human chor-ionic gonadotropin (β-HCG) level, transvaginal ultrasonography findings, methods of treatment and outcomes were reviewed and analyzed. RESULTS A total of 119 patients were identified for this study. The diagnosis was based on clinical manifestations, ultrasonography scan and dynamic serum β-HCG. 71.4% of women (85/119) had at least one risk factor for ectopic pregnancy, with the most common risk factors being a history of induced labor, uterine curettage, spontaneous abortion or tubal pregnancy. 64 patients were managed by laparoscopic surgery (Group A) and 2 subjects were failure and followed by a systemic methotrexate (MTX) prescription. The other 55 patients had local injection with absolute ethanol, of which 9 cases failed, followed by a second local injection and intramuscular MTX. The HCG decrease rate post absolute ethanol injection was a value predictive factor for prognosis. Moreover, the pregnancy rate one-year post treatment in local injection subjects (10/55, 18.2%) was higher than that of surgical subjects (5/64, 7.8%). CONCLUSION Local injection of absolute ethanol and laparoscopic surgery for tubal ectopic pregnancy are both effective and relatively safe, but laparoscopic surgery has better efficacy and shorten hospitalization day. Local injection may be less invasiveness and thus beneficial to fertility preservation.
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Affiliation(s)
- Yin Bi
- Center of Reproductive Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Yuanping She
- Department of Obstetrics and Gynecology, The Affiliated Hospital of Guilin Medical University, Guilin, People’s Republic of China
| | - Zhengping Tian
- Center of Reproductive Medicine, The Affiliated Hospital of Guilin Medical University, Guilin, People’s Republic of China
| | - Zhiyao Wei
- Center of Reproductive Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Qiuyan Huang
- Center of Reproductive Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Shengbin Liao
- Center of Reproductive Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Yuan Ye
- Department of Obstetrics and Gynecology, The Affiliated Hospital of Guilin Medical University, Guilin, People’s Republic of China
| | - Aiping Qin
- Center of Reproductive Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Yihua Yang
- Center of Reproductive Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
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Bilateral Tubal Pregnancy without Known Risk Factor. Case Rep Obstet Gynecol 2017; 2017:4356036. [PMID: 29181210 PMCID: PMC5664235 DOI: 10.1155/2017/4356036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 09/13/2017] [Indexed: 11/17/2022] Open
Abstract
Spontaneous bilateral ectopic gestation is very rare. The authors report a case diagnosed and taken care of at Yalgado Ouedraogo Teaching Hospital, Ouagadougou. It was a 30-year-old patient with no known pathological history. She had presented at the obstetric emergencies with a state of hypovolemic shock by haemoperitoneum with digestive disorders, pelvic pain, vaginal bleeding, and a mention of delayed menstruation. The ultrasound coupled with the urinary immunological pregnancy test confirmed the diagnosis of ruptured ectopic pregnancy and a bilateral form was suspected. A laparotomy in emergency confirmed the diagnosis of bilateral ectopic gestation with a right ampullary unruptured pregnancy and a left isthmic ruptured gestation. A bilateral salpingectomy was performed and counseling was made for the use of medical help of procreation in case of future need of pregnancy.
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Hoffmann S, Abele H, Bachmann C. Spontaneous Bilateral Tubal Ectopic Pregnancy: Incidental Finding During Laparoscopy - Brief Report and Review of Literature. Geburtshilfe Frauenheilkd 2016; 76:413-416. [PMID: 27134298 DOI: 10.1055/s-0041-110394] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Objective: Bilateral tubal ectopic pregnancies are rare; the reported incidence is only 1 in 200 000 pregnancies. Detecting bilateral tubal ectopic pregnancy is urgent because of the associated morbidity and mortality. The appropriate fertility-preserving surgery must also be considered, as preservation of both tubes is presumed to offer better fertility prospects. Case Report: A 39-year-old gravida 2, para 1 presented with vaginal bleeding at 8 + 4 weeks of gestation. An approximately 18 mm adnexal mass in the right fallopian tube was detected on ultrasound. Laparoscopy was performed because ectopic pregnancy was suspected. This suspicion was confirmed during laparoscopy; the right fallopian tube was found to contain a mass measuring 20 mm in the isthmic part. Ultrasound of the left fallopian tube also showed a mass in the ampullary region (diameter: 10 mm), also suspicious for ectopic pregnancy. Bilateral salpingotomy was performed laparoscopically. Pathological examination confirmed the diagnosis. Conclusions for Practice: Although ectopic tubal pregnancy is seen more often after assisted reproductive techniques, bilateral spontaneous ectopic pregnancies must also be considered in other cases. Laparoscopic surgery is effective to confirm the diagnosis and treat heterotopic pregnancies. Further studies will be needed to confirm whether unilateral or bilateral conservative fertility-preserving surgery is more appropriate.
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Affiliation(s)
- S Hoffmann
- Department of Obstetrics and Gynecology, Tübingen University Hospital, Tübingen
| | - H Abele
- Department of Obstetrics and Gynecology, Tübingen University Hospital, Tübingen
| | - C Bachmann
- Department of Obstetrics and Gynecology, Tübingen University Hospital, Tübingen
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Li JB, Kong LZ, Yang JB, Niu G, Fan L, Huang JZ, Chen SQ. Management of Heterotopic Pregnancy: Experience From 1 Tertiary Medical Center. Medicine (Baltimore) 2016; 95:e2570. [PMID: 26844463 PMCID: PMC4748880 DOI: 10.1097/md.0000000000002570] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
The objective of this study is to summarize the experiences of our department in the management of heterotopic pregnancy (HP) and to analyze the influence of different treatment modality on the viable intrauterine pregnancy.There were 64 patients diagnosed as HP in the Department of Gynecology and Obstetrics in our hospital between January 2003 and June 2014, 52 HP patients with viable intrauterine pregnancy were included and analyzed in our study. Interventions included expectant management, surgical management and transabdominal sonographic guided transvaginal aspiration of ectopic gestational embryo (embryo aspiration) management.Main outcome measures are maternal outcome and pregnancy outcome.In expectant management group, 4 patients suffered rupture of ectopic pregnancy, 6 patients transferred to surgical management, 1 patient suffered a fever of 40.4°C, the abortion rate was 5% (1/20). In surgical management group, emergency surgery was performed in 9 patients with unstable hemodynamics and 3 patients with stable hemodynamics, 1 patient suffered uterine rupture 5 weeks later and dead fetus was demonstrated, 1 patient suffered urinary retention postoperative, the abortion rate was 14.8% (4/27). In embryo aspiration management group, 1 patient needed another embryo aspiration, all patients were eventful and no abortion was observed.In our retrospective study, transabdominal sonographic guided aspiration of ectopic gestational embryo has the best maternal outcome and the lowest abortion rate, surgical management group shows the highest abortion rate, and expectant management presents the worst maternal outcome.
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Affiliation(s)
- Jin-Bo Li
- From the Department of Gynecology and Obstetrics, The First Affiliated Hospital of Sun Yat-Sen University, Guangdong, Guangzhou, P.R. China
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États des lieux et expertise de l’usage hors AMM du méthotrexate en gynécologie–obstétrique : travail du CNGOF. ACTA ACUST UNITED AC 2015; 44:230-6. [DOI: 10.1016/j.jgyn.2014.12.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Accepted: 12/01/2014] [Indexed: 12/27/2022]
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10
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Misme H, Agostini A, Dubernard G, Tourette C. [Indications for methotrexate in gynecology outside the first-line treatment of ectopic tubal pregnancies]. J Gynecol Obstet Hum Reprod 2015; 44:220-229. [PMID: 25666162 DOI: 10.1016/j.jgyn.2014.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Accepted: 12/02/2014] [Indexed: 06/04/2023]
Abstract
The objective of this work is to discuss the indications for methotrexate in gynecology outside the first-line treatment of tubal ectopic pregnancy. In tubal ectopic pregnancy, the prophylactic use of systemic methotrexate can be discussed when performing laparoscopic salpingotomy. In case of failure of salpingotomy, administration seems justified especially if it avoids re-intervention. The combination of methotrexate with other therapies such as mifepristone, potassium chloride or gefitinib is not recommended in the treatment of ectopic pregnancy. For non-tubal ectopic pregnancy, the intramuscular or local administration of methotrexate is an acceptable treatment for uncomplicated interstitial pregnancies. For uncomplicated cervical or cesarean scar pregnancies, the local administration of methotrexate should be considered as a first-line treatment. For ovarian pregnancies, methotrexate should not be a first-line treatment, surgical treatment remains the standard. Asymptomatic women presenting with a pregnancy of unknown location and plateauing serum hCG concentration<2000 UI/L can be managed expectantly: it is recommended to take an additional quantitative hCG serum level after 48 hours. Thus, methotrexate is not recommended in the first intention. Other gynecological indications were discussed: methotrexate is not recommended in the management of first-trimester miscarriages or in the management of placenta accreta.
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Affiliation(s)
- H Misme
- Service de gynécologie-obstétrique de l'hôpital de la Croix-Rousse, hospices civils de Lyon, 103, Grand rue de la Croix-rousse, 69004 Lyon, France.
| | - A Agostini
- Service de gynécologie-obstétrique, CHU de La Conception, 147, boulevard Baille, 13385 Marseille cedex 05, France
| | - G Dubernard
- Service de gynécologie-obstétrique de l'hôpital de la Croix-Rousse, hospices civils de Lyon, 103, Grand rue de la Croix-rousse, 69004 Lyon, France
| | - C Tourette
- Service de gynécologie-obstétrique, CHU de La Conception, 147, boulevard Baille, 13385 Marseille cedex 05, France.
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