Serious complications and recurrences after retropubic vs transobturator midurethral sling procedures for 2682 patients in the VIGI-MESH register

BACKGROUND

Midurethral slings are the gold standard for treating stress urinary incontinence, but their complications may raise concerns. Complications may differ by the approach used to place them.

OBJECTIVE

This study aimed to compare serious complications and reoperations for recurrence after midurethral sling procedures when using the retropubic vs the transobturator route for female stress urinary incontinence.

STUDY DESIGN

This analysis was of patients included in the French, multicenter VIGI-MESH register since February 2017 who received a midurethral sling for female stress urinary incontinence either by the retropubic or the transobturator route and excluded patients with single-incision slings. Follow-up continued until October 2021. Serious complications (Clavien-Dindo classification ≥ grade III) attributable to the midurethral sling and reoperations for recurrence were compared using Cox proportional hazard models including any associated surgery (hysterectomy or prolapse) and a frailty term to consider the center effect. Baseline differences were balanced by propensity score weighting. Analyses using the propensity score and Cox models were adjusted for baseline differences, center effect, and associated surgery.

RESULTS

A total of 1830 participants received a retropubic sling and 852 received a transobturator sling in 27 French centers that were placed by 167 surgeons. The cumulative 2-year estimate of serious complications was 5.8% (95% confidence interval, 4.8-7.0) in the retropubic group and 2.9% (95% confidence interval, 1.9-4.3) in the transobturator group, that is, after adjustment, half of the retropubic group was affected (adjusted hazard ratio, 0.41; 95% confidence interval, 0.3-0.6). The cumulative 2-year estimate of reoperation for recurrence of stress urinary incontinence was 2.7% (95% confidence interval, 2.0-3.6) in the retropubic group and 2.8% (95% confidence interval, 1.7-4.2) in the transobturator group with risk for revision for recurrence being higher in the transobturator group after adjustment (adjusted hazard ratio, 1.9; 95% confidence interval, 1.2-2.9); this surplus risk disappeared after exclusion of the patients with a previous surgery for stress urinary incontinence.

CONCLUSION

The transobturator route for midurethral sling placement is associated with a lower risk for serious complications but a higher risk for surgical reoperation for recurrence than the retropubic route. Despite the large number of surgeons involved, these risks were low. The data are therefore reassuring.

Interstitial pregnancy management: A multicentric analysis of 98 patients from the FRANCOGENT group comparing surgery and medical treatment

OBJECTIVE

To evaluate the outcomes associated with each therapeutic option for patients diagnosed with interstitial pregnancy (IP).

METHODS

We conducted a multicentric retrospective cohort study within the departments of Gynecology and Obstetrics involved in the Francogent research group. Women treated for an interstitial pregnancy between January 2008 to December 2019 were included. Three therapeutic options were evaluated: surgical treatment (ST); in situ methotrexate combined with systemic methotrexate (IS-MTX); and systemic methotrexate (IM-MTX). Success of first-line treatment was defined by hCG negativation (<5I U/L). Secondary outcomes included the need for secondary surgical procedure, secondary medical treatment, emergency surgery, postoperative complications, duration of hospitalization, and delay before hCG negativation.

RESULTS

A total of 98 patients were managed for IP: 42 (42.9%) patients had IM-MTX; 34 (34.7%) had IS-MTX; and 22 (22.4%) had ST. First-line treatment was successful in all patients of the ST group (22/22, 100%), in 31% of patients within the IM-MTX group (13/42) and 70.6% (24/34) in the IS-MTX group. The sole parameter associated with the risk of treatment failure was the mode of methotrexate administration. The size of the gestational sac or the presence of fetal heartbeat was not associated with decreased medical treatment (IS or IM-MTX) efficiency.

CONCLUSION

Either ST or IS-MTX are good options for IP treatment associated with high success rates. A single-dose regimen of IM-MTX is less efficient than IS-MTX or ST. Symptomatic patients with severity criteria should always undergo emergency surgery. IP remains a high-risk condition that should be managed, whenever possible, in referral centers to potentialize the chances of favorable outcomes.

Diagnosis and management of complications following pelvic organ prolapse surgery using a synthetic mesh: French national guidelines for clinical practice

Complications associated with pelvic organ prolapse (POP) surgery using a synthetic non-absorbable mesh are uncommon (<5%) but may be severe and may hugely diminish the quality of life of some women. In drawing up these multidisciplinary clinical practice recommendations, the French National Authority for Health (Haute Autorité de santé, HAS) conducted an exhaustive review of the literature concerning the diagnosis, prevention, and management of complications associated with POP surgery using a synthetic mesh. Each recommendation for practice was allocated a grade (A,B or C; or expert opinion (EO)), which depends on the level of evidence (clinical practice guidelines).

PREOPERATIVE PATIENTS' INFORMATION

Each patient must be informed concerning the risks associated with POP surgery (EO).

HEMORRHAGE, HEMATOMA

Vaginal infiltration using a vasoconstrictive solution is not recommended during POP surgery by the vaginal route (grade C). The placement of vaginal packing is not recommended following POP surgery by the vaginal route (grade C). During laparoscopic sacral colpopexy, when the promontory seems highly dangerous or when severe adhesions prevent access to the anterior vertebral ligament, alternative surgical techniques should be discussed per operatively, including colpopexy by lateral mesh laparoscopic suspension, uterosacral ligament suspension, open abdominal mesh surgery, or surgery by the vaginal route (EO).

BLADDER INJURY

When a bladder injury is diagnosed, bladder repair by suturing is recommended, using a slow resorption suture thread, plus monitoring of the permeability of the ureters (before and after bladder repair) when the injury is located at the level of the trigone (EO). When a bladder injury is diagnosed, after bladder repair, a prosthetic mesh (polypropylene or polyester material) can be placed between the repaired bladder and the vagina, if the quality of the suturing is good. The recommended duration of bladder catheterization following bladder repair in this context of POP mesh surgery is from 5 to 10 days (EO).

URETER INJURY

After ureteral repair, it is possible to continue sacral colpopexy and place the mesh if it is located away from the ureteral repair (EO).

RECTAL INJURY

Regardless of the approach, when a rectal injury occurs, a posterior mesh should not be placed between the rectum and the vagina wall (EO). Concerning the anterior mesh, it is recommended to use a macroporous monofilament polypropylene mesh (EO). A polyester mesh is not recommended in this situation (EO).

VAGINAL WALL INJURY

After vaginal wall repair, an anterior or a posterior microporous polypropylene mesh can be placed, if the quality of the repair is found to be satisfactory (EO). A polyester mesh should not be used after vaginal wall repair (EO).

MESH INFECTION (ABSCESS, CELLULITIS, SPONDYLODISCITIS)

Regardless of the surgical approach, intravenous antibiotic prophylaxis is recommended (aminopenicillin + beta-lactamase inhibitor: 30 min before skin incision +/- repeated after 2 h if surgery lasts longer) (EO). When spondylodiscitis is diagnosed following sacral colpopexy, treatment should be discussed by a multidisciplinary group, including especially spine specialists (rheumatologists, orthopedists, neurosurgeons) and infectious disease specialists (EO). When a pelvic abscess occurs following synthetic mesh sacral colpopexy, it is recommended to carry out complete mesh removal as soon as possible, combined with collection of intraoperative bacteriological samples, drainage of the collection and targeted antibiotic therapy (EO). Non-surgical conservative management with antibiotic therapy may be an option (EO) in certain conditions (absence of signs of sepsis, macroporous monofilament polypropylene type 1 mesh, prior microbiological documentation and multidisciplinary consultation for the choice of type and duration of antibiotic therapy), associated with close monitoring of the patient.

BOWEL OCCLUSION RELATED TO NON-CLOSURE OF THE PERITONEUM

Peritoneal closure is recommended after placement of a synthetic mesh by the abdominal approach (EO).

URINARY RETENTION

Preoperative urodynamics is recommended in women presenting with urinary symptoms (bladder outlet obstruction symptoms, overactive bladder syndrome or incontinence) (EO). It is recommended to remove the bladder catheter at the end of the procedure or within 48 h after POP surgery (grade B). Bladder emptying and post-void residual should be checked following POP surgery, before discharge (EO). When postoperative urine retention occurs after POP surgery, it is recommended to carry out indwelling catheterization and to prefer intermittent self-catheterization (EO).

POSTOPERATIVE PAIN

Before POP surgery, the patient should be asked about risk factors for prolonged and chronic postoperative pain (pain sensitization, allodynia, chronic pelvic or non-pelvic pain) (EO). Concerning the prevention of postoperative pain, it is recommended to carry out a pre-, per- and postoperative multimodal pain treatment (grade B). The use of ketamine intraoperatively is recommended for the prevention of chronic postoperative pelvic pain, especially for patients with risk factors (preoperative painful sensitization, allodynia, chronic pelvic or non-pelvic pain) (EO). Postoperative prescription of opioids should be limited in quantity and duration (grade C). When acute neuropathic pain (sciatalgia or pudendal neuralgia) resistant to level I and II analgesics occurs following sacrospinous fixation, a reintervention is recommended for suspension suture removal (EO). When chronic postoperative pain occurs after POP surgery, it is recommended to systematically seek arguments in favor of neuropathic pain with the DN4 questionnaire (EO). When chronic postoperative pelvic pain occurs after POP surgery, central sensitization should be identified since it requires a consultation in a chronic pain department (EO). Concerning myofascial pain syndrome (clinical pain condition associated with increased muscle tension caused by myofascial trigger points), when chronic postoperative pain occurs after POP surgery, it is recommended to examine the levator ani, piriformis and obturator internus muscles, so as to identify trigger points on the pathway of the synthetic mesh (EO). Pelvic floor muscle training with muscle relaxation is recommended when myofascial pain syndrome is associated with chronic postoperative pain following POP surgery (EO). After failure of pelvic floor muscle training (3 months), it is recommended to discuss surgical removal of the synthetic mesh, during a multidisciplinary discussion group meeting (EO). Partial removal of synthetic mesh is indicated when a trigger point is located on the pathway of the mesh (EO). Total removal of synthetic mesh should be discussed during a multidisciplinary discussion group meeting when diffuse (no trigger point) chronic postoperative pain occurs following POP surgery, with or without central sensitization or neuropathic pain syndromes (EO).

POSTOPERATIVE DYSPAREUNIA

When de novo postoperative dyspareunia occurs after POP surgery, surgical removal of the mesh should be discussed (EO).

VAGINAL MESH EXPOSURE

To reduce the risk of vaginal mesh exposure, when hysterectomy is required during sacral colpopexy, subtotal hysterectomy is recommended (grade C). When asymptomatic vaginal macroporous monofilament polypropylene mesh exposure occurs, systematic imaging is not recommended. When vaginal polyester mesh exposure occurs, pelvic +/- lumbar MRI (EO) should be used to look for an abscess or spondylodiscitis, given the greater risk of infection associated with this type of material. When asymptomatic vaginal mesh exposure of less than 1 cm2 occurs in a woman with no sexual intercourse, the patient should be offered observation (no treatment) or local estrogen therapy (EO). However, if the patient wishes, partial excision of the mesh can be offered. When asymptomatic vaginal mesh exposure of more than 1 cm2 occurs or if the woman has sexual intercourse, or if it is a polyester prosthesis, partial mesh excision, either immediately or after local estrogen therapy, should be offered (EO). When symptomatic vaginal mesh exposure occurs, but without infectious complications, surgical removal of the exposed part of the mesh by the vaginal route is recommended (EO), and not systematic complete excision of the mesh. Following sacral colpopexy, complete removal of the mesh (by laparoscopy or laparotomy) is only required in the presence of an abscess or spondylodiscitis (EO). When vaginal mesh exposure recurs after a first reoperation, the patient should be treated by an experienced team specialized in this type of complication (EO).

SUTURE THREAD VAGINAL EXPOSURE

For women presenting with vaginal exposure to non-absorbable suture thread following POP surgery with mesh reinforcement, the suture thread should be removed by the vaginal route (EO). Removal of the surrounding mesh is only recommended when vaginal mesh exposure or associated abscess is diagnosed.

BLADDER AND URETERAL MESH EXPOSURE

When bladder mesh exposure occurs, removal of the exposed part of the mesh is recommended (grade B). Both alternatives (total or partial mesh removal) should be discussed with the patient and should be debated during a multidisciplinary discussion group meeting (EO).

Evaluation Tools for Assessing Autonomy of Surgical Residents in the Operating Room and Factors Influencing Access to Autonomy: A Systematic Literature Review

BACKGROUND

Surgical residents in France lack a clear pedagogical framework for achieving autonomy in the operating room. The progressive acquisition of surgical autonomy is a determining factor in the confidence of operators for their future independent practice. Currently, there is no autonomy scale commonly used in Europe. The objective of this study is to identify existing tools for quantifying the autonomy of residents and the factors that influence it.

MATERIALS AND METHODS

We conducted a qualitative systematic review following the recommendations of the Systematic Review Without Meta-Analysis (SWiM) guidelines. Publications were extracted from the MEDLINE (PubMed), EMBASE, and PSYCINFO databases. All publications without date restrictions up to July 2022 were identified.

RESULTS

Among the 231 identified publications, 21 met the inclusion criteria. Seventeen publications used a graded autonomy assessment tool by the student and/or the teacher, while 4 used evaluations by an observing third party. We found 8 different autonomy scales, with the Zwisch Scale representing 57.1% of the cases. Factors influencing autonomy were diverse, including the work context, experience, and gender of the resident and their teacher.

DISCUSSION

We found heterogeneity in the tools used to "measure" the autonomy of a resident in the operating room. The SIMPL tool or the Zwisch Scale appear to be the most frequently used tools. The relationship between autonomy, performance, confidence, and knowledge may require multidimensional tools that encompass various areas of competence, but this could make their daily application more challenging. The factors influencing autonomy are numerous; and understanding them would improve teaching in the operating room. There is a significant lack of data on surgical autonomy in France, as well as a lack of evaluation in the field of gynecology-obstetrics worldwide.

Prevention of Rhesus-D Alloimmunization in the First Trimester of Pregnancy: Economic Analysis of Three Management Strategies

Anti-D alloimmunization in the first trimester of pregnancy has long been the subject of prevention with anti-D immunoglobulins during events at risk of fetomaternal hemorrhage. Although the efficacy of preventing anti-D alloimmunization by an injection of immunoglobulin at 28 weeks of gestation (WG) is obvious, the literature provides little evidence of the effectiveness before 12+6 WG and several countries have modified their recommendations. In the presumed absence of a difference in alloimmunization risk between early and late prevention, our objective was to evaluate and compare the cost of treatment for 3 alloimmunization prevention strategies in France, the United Kingdom, and the Netherlands. This was a single-center retrospective study. Our target population included all women who received anti-D immunoglobulins (Rhophylac) in the first trimester of pregnancy before 12+6 WG at Nantes University Hospital in 2018 (N = 356). Within the target population, 2 other populations were constituted based on British (N = 145) and Dutch (N = 142) clinical practice guidelines (CPG). These 3 populations were analyzed for the comparative cost of treatment for prevention from a health system perspective. The average cost of Rhophylac alloimmunization prevention for 1 episode was €117.8 from a health system perspective. The total cost attributed to prevention in 2018 at Nantes University Hospital (N = 356) was €41,931.4 according to this perspective. If the UK CPG or Dutch CPG had been applied to the Nantes target population, a saving of around 60% would have been achieved. At the national level, the cost according to the health system perspective specifically attributable to induced abortion (N estimated = 26,916) could represent a total cost of €3,170,704. This study highlighted the high cost of the French prevention strategy in the first trimester of pregnancy compared with British or Dutch strategies. The modification of our practices would allow substantial financial savings to the French health system but would also avoid the nonrecommended exposure to a blood product at this term, would allow a faster medical management and a relief of the care system.

Evaluation of a scoring system for the detection of central sensitization among women with chronic pelvic pain

BACKGROUND

Central sensitization is frequently associated with chronic pelvic pain and requires specific management. The pain is described as hypersensitivity to an innocuous stimulus that is both widespread and persistent. However, no study has evaluated if central sensitization can be measured objectively with neurophysiological tests in the pelvic and perineal area to prove this concept in women with chronic pelvic pain.

OBJECTIVE

This study aimed to evaluate nociceptive thresholds (primary objective) and spatial and temporal diffusion of pain among women with chronic pelvic pain and high or low scores of central sensitization.

STUDY DESIGN

This prospective, assessor-blinded, comparative study compared a cohort of women with chronic pelvic pain and a high (>5/10; n=29) vs low (<5/10; n=24) score of sensitization according to the Convergences PP criteria. Participants underwent a noninvasive bladder sensory test, a rectal barostat test, and a muscular (algometer) and a vulvar (vulvagesiometer) sensory test. Poststimulation pain (minutes), quality of life (Medical Outcomes Study 36-Item Short Form Survey), and psychological state, comprising anxiety (State-Trait Anxiety Inventory), depression (Beck Depression Inventory Short Form), and catastrophizing (Pain Catastrophizing Scale), were assessed.

RESULTS

The participants mostly suffered from endometriosis (35.8%), irritable bowel syndrome (35.8%), bladder pain syndrome (32.1%), and vestibulodynia (28.3%). Baseline characteristics were similar. Women with a high sensitization score had more painful diseases diagnosed (2.7±1.3 vs 1.6±0.8; P=.002) and suffered for longer (11±8 vs 6±5 years; P=.028) than participants with a low score. The bladder maximum capacity was equivalent between participants (399±168 vs 465±164 mL; P=.18). However, the pain felt at each cystometric threshold was significantly increased in women with a high sensitization score. No difference was identified for the rectal pain pressure step (29.3±5.5 vs 30.7±6.5 mm Hg; P=.38). Rectal compliance was decreased in women with a high sensitization score with a considerable increase in pain felt. The average of pain pressure thresholds at the 5 vulvar sites tested was decreased in these participants (162.5±90.5 vs 358.7±196.5 g; P=.0003). Similar results were found for the average of the pain pressure thresholds at 6 muscles tested (1.34±0.41 vs 2.63±1.52 kg/m2; P=.0002). A longer period was needed for patients with high sensitization score to obtain a VAS <3 out of 10 after the stimulation of the bladder (4.52±5.26 vs 1.27±2.96 minutes; P=.01), the rectum (3.75±3.81 vs 1.19±1.23 minutes; P=.009), and the muscles (1.46±1.69 vs 0.64±0.40 minutes; P=.002). The psychological state was equivalent between groups. No association was found between the sensory thresholds and the psychological state results. The physical component of the quality of life score was reduced in women with high sensitization score (P=.0005), with no difference in the mental component.

CONCLUSION

Using neurophysiological tests, this study showed that there are objective elements to assess for the presence of central sensitization, independently of psychological factors.

Management of women with abnormal uterine bleeding: Clinical practice guidelines of the French National College of Gynaecologists and Obstetricians (CNGOF)

OBJECTIVE

To provide French guidelines for the management of women with abnormal uterine bleeding (AUB).

DESIGN

A consensus committee of 26 experts was formed. A formal conflict-of-interest policy was developed at the beginning of the process and enforced throughout. The entire guidelines process was conducted independently of any industry funding (i.e. pharmaceutical or medical device companies). The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized.

METHODS

The last guidelines from the Collège National des Gynécologues et Obstétriciens Français on the management of women with AUB were published in 2008. The literature seems now sufficient for an update. The committee studied questions within 7 fields (diagnosis; adolescents; idiopathic AUB; endometrial hyperplasia and polyps; type 0-2 fibroids; type 3 or higher fibroids; and adenomyosis). Each question was formulated in a PICO (Patients, Intervention, Comparison, Outcome) format and evidence profiles were compiled. The GRADE® methodology was applied to the literature review and the formulation of recommendations.

RESULTS

The experts' synthesis work and the application of the GRADE method resulted in 36 recommendations. Among the formalized recommendations, 19 are strong and 17 weak. No response was found in the literature for 14 questions. We chose to abstain from recommendations rather than providing advice based solely on expert clinical experience.

CONCLUSIONS

The 36 recommendations make it possible to specify the diagnostic and therapeutic strategies for various clinical situations practitioners encounter, from the simplest to the most complex.

[Pelvic exam in gynecology and obstetrics: Guidelines for clinical practice]

OBJECTIVE

To provide guidelines for the pelvic clinical exam in gynecology and obstetrics.

MATERIAL AND METHODS

A multidisciplinary experts consensus committee of 45 experts was formed, including representatives of patients' associations and users of the health system. The entire guidelines process was conducted independently of any funding. The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized.

METHODS

The committee studied 40 questions within 4 fields for symptomatic or asymptomatic women (emergency conditions, gynecological consultation, gynecological diseases, obstetrics, and pregnancy). Each question was formulated in a PICO (Patients, Intervention, Comparison, Outcome) format and the evidence profiles were produced. The literature review and recommendations were made according to the GRADE® methodology.

RESULTS

The experts' synthesis work and the application of the GRADE method resulted in 27 recommendations. Among the formalized recommendations, 17 present a strong agreement, 7 a weak agreement and 3 an expert consensus agreement. Thirteen questions resulted in an absence of recommendation due to lack of evidence in the literature.

CONCLUSIONS

The need to perform clinical examination in gynecological and obstetrics patients was specified in 27 pre-defined situations based on scientific evidence. More research is required to investigate the benefit in other cases.

Robot-assisted laparoscopy repair of uterine isthmocele: A two-center observational study

OBJECTIVE

To analyze outcomes and postoperative complications in patients undergoing robot-assisted isthmocele repair.

METHOD

This retrospective cohort study included 33 patients who had robot-assisted laparoscopic surgical management of an isthmocele between September 2013 and August 2020 in two French university hospitals. All charts were reviewed to identify patient characteristics, preoperative and postoperative anatomical findings, complications, and postoperative fertility and symptoms. Patients who had undergone this procedure were asked to complete a telephone questionnaire about their treatment satisfaction and symptoms.

RESULTS

The isthmocele was discovered most often as a result of subfertility (57.6%), but also ectopic pregnancy (18.2%), pelvic pain (15.2%), and postmenstrual bleeding (9.1%). Robot-assisted repair of the isthmocele significantly improved myometrial thickness (from 1.55 mm before surgery to 4.26 mm after surgery [mean difference 2.71; 95% confidence interval, 1.91-3.51], P = 0.0005). Among 20 patients who still desired a child after surgery, 15 became pregnant and 14 had full-term live births. Among the nine patients who had surgery for disabling symptoms, five had no persistent symptoms, three reported global improvement, and one had the same gynecologic discomfort. Seventeen patients agreed to complete the questionnaires (51.5%), and all stated that they would choose to have this surgery again.

CONCLUSION

Robot-assisted repair of an isthmocele is a viable minimally invasive procedure.

[Tocolysis during External Cephalic Version (ECV): A retrospective before/after study in a type III maternity hospital]

OBJECTIVE

On January 2020, the French College of Gynecologists and Obstetricians (CNGOF) issued new Clinical Practice Guidelines (CPG) "Breech Presentation". Since then, it is recommended to use a tocolytic agent to improve the success rate of External Cephalic Version (ECV). The aim of this study, one year after these CPG, is to compare ECV without (before CPG) and with (after CPG) tocolysis in a type III maternity hospital. We intend to assess its effects on immediate success rate of ECV and obstetrical and neonatal outcomes.

MATERIALS AND METHODS

This is a single-center retrospective study conducted in Nantes University Hospital. We collected patient characteristics, immediate success rate, and maternal and neonatal outcomes at delivery of all ECV over two periods: the first one during 2019 (before CPG) and the second one from June 2020 to June 2021 (after CPG).

RESULTS

We included 253 patients: 126 in the first period and 127 in the second period. Immediate success rate of ECV was significantly higher since the use of tocolysis: 38.6 % (period 2) vs 23.8 % (period 1) (P=0.011). However, there was not significant difference found for cephalic presentation at birth, mode of delivery or obstetrical and neonatal outcomes.

CONCLUSION

The immediate success rate is significantly improved with the widespread use of tocolysis during ECV, with no change in obstetrical and neonatal outcomes.

Ropivacaine perineal infiltration for postpartum pain management in episiotomy repair: a double-blind, randomised, placebo-controlled trial

OBJECTIVE

To investigate whether perineal infiltration of ropivacaine after episiotomy would decrease the incidence of postpartum pain compared with placebo.

DESIGN

Two-centre, double-blind, randomised, controlled trial.

SETTING

Two French maternity units, October 2017 to April 2020.

POPULATION

272 women undergoing epidural analgesia with vaginal singleton delivery and mediolateral episiotomy at term (≥37 weeks) were randomly allocated perineal infiltration of ropivacaine (n = 135) or placebo (n = 137) in a 1:1 ratio before episiotomy repair.

METHODS

Patients were followed at short term (12, 24, 48 h), mid-term (day 7) and long-term (3 and 6 months).

MAIN OUTCOME MEASURES

The primary outcome was the rate of perineal pain, defined by a Numerical Pain Rating Scale (NPRS) exceeding 3/10, in the mid-term (day 7) postpartum period. Secondary outcomes were perineal pain (NPRS) and analgesic intake, quality of life (SF-36), postpartum depression (EPDS), pain neuropathic component (DN4) and sexual health (FSFI).

RESULTS

Perineal pain occurred to an equal extent in the ropivacaine and placebo groups at day 7 (34.2% versus 30.4%, odds ratio 1.1, 95% confidence interval 0.7-1.8, p = 0.63). Similar results were recorded in the short and long term. High rates of dyspareunia and postpartum depression were documented in both groups. No differences were highlighted between the groups in terms of analgesic intake, adverse events, pain neuropathic component and postpartum quality of life.

CONCLUSIONS

This study did not demonstrate any benefit of ropivacaine infiltration over placebo.

DOES HYALURONIC ACID GEL REDUCE INTRAUTERINE ADHESIONS AFTER DILATION AND CURETTAGE IN WOMEN WITH MISCARRIAGE? MULTICENTRIC RANDOMIZED CONTROLLED TRIAL (HYFACO STUDY)

BACKGROUND

Miscarriage is a frequent problem that requires dilation and curettage in 30 % of cases. This routine surgery may lead to intrauterine adhesions and severe infertility. Hyaluronic acid gel is known to reduce intrauterine adhesions after hysteroscopic surgery.

OBJECTIVE

This study aimed to evaluate the rate of intrauterine adhesions after dilation and curettage for miscarriage with and without hyaluronic acid gel.

STUDY DESIGN

This was a multicentric (nine hospitals in France), prospective, open-labelled randomized trial. Patients who had a miscarriage between weeks 7 and 14 of gestation, requiring dilation and curettage, and who were wishing for another pregnancy were eligible for the study. Women were randomly assigned 1:1 to surgery alone (control group) vs surgery with intrauterine instillation of hyaluronic acid gel (gel group). An office hysteroscopy was planned six to eight weeks after surgery. The primary endpoint was the rate of intrauterine adhesions during this office follow-up hysteroscopy. Two different follow-up fertility surveys were sent at 6 months and one year after the end of the intervention respectively.

RESULTS

Among the 343 patients who had curettage, 278 had hysteroscopy. After multiple imputation, the rate of intrauterine adhesions was lower in the gel group compared to the control group (9.1% vs. 18.4%, respectively, p=0.0171). Among the 110 responders to the surveys, the overall pregnancy rate twelve months after surgery was 64.5% (71/110), and similar in both groups (57.4 % (27/47) in control group vs. 69.8% (44/63) in gel group, p=0.1789).

CONCLUSION

Intrauterine instillation of hyaluronic acid gel reduces the rate of intrauterine adhesions in women treated with dilation and curettage for miscarriage.

Local Injection of Methotrexate Ultrasound guided-transvaginal

Non-tubal ectopic pregnancies can be located in the uterine portion of the tube (interstitial or cornual), in the cervix (cervical), in a caesarean scar, in the ovary, or intra-abdominally. Even though they are rare, they are associated with a high mortality. Invasive surgeries such as cornuectomy and hysterectomy were common to treat them in case of hemorrhage. Thanks to recent advances in imaging techniques, diagnosis of non-tubal ectopic pregnancy is made earlier and conservative management has been developed in order to respect fertility of patients. Beyond these treatments, systemic or local injection of Methotrexate shows very good success. In the article, we aimed to describe the technics of vaginal injection of in situ methotrexate with ultrasound guidance.

Étude MUMI-19 (mothers undergoing mental impact of COVID-19 pandemic) : évaluation de l’impact de l’isolement maternel dans le post-partum immédiat sur le taux de dépression du post-partum en période de pandémie COVID-19

Introduction

La pandémie de COVID-19 a bouleversé le monde en imposant des mesures sanitaires inédites, notamment en suites de couches. Cette étude a pour but d’évaluer l’impact de l’isolement maternel dans le post-partum immédiat sur le taux de dépression du post-partum (DPP) dans une maternité de type 3.

Méthodes

Nous avons mené une étude de cohorte prospective de type exposés–non exposés, entre le 22 avril et le 29 octobre 2020, en utilisant des questionnaires anonymes sur 265 parturientes (129 pendant le confinement et 135 en dehors). L’échelle postnatale d’Edimbourg (EPDS) a été utilisée. Nous avons utilisé un modèle de régression logistique univariée pour l’association entre les facteurs de risques et la DPP.

Résultats

Il n’y avait pas de différence entre les deux groupes concernant la DPP évaluée par un score > 10,5 à l’EPDS à j30 et/ou j60 (23,1 % vs 29,3 %, p = 0,661). En revanche, dans le groupe « confiné », le score à j3 était plus élevé (31 % vs 17,8 %, p = 0,015) et les conjoints davantage impactés sur le plan psychologique (48,3 % vs 10,5 %, p < 0,001). La parité ?1 était un facteur protecteur de DPP (OR = 0,2, IC95 % [0,1–0,6], p = 0,003). Les antécédents de violence psychologiques (OR = 6,4, IC95 % [1,1–37,6], p = 0,04), la présence d’un stress durant la grossesse (OR = 4,5, IC95 % [1,6–12,6], p = 0,004) et le vécu traumatique de l’accouchement (OR = 5,1, IC95 % [1,4–17,8], p = 0,012) étaient associés à un sur-risque de DPP.

Conclusion

L’isolement maternel dans le post-partum immédiat est associé à un sur-risque de symptômes sévères de blues du post-partum.

[Management of women with abnormal uterine bleeding: Clinical practice guidelines of the French National College of Gynecologists and Obstetricians (CNGOF)]

OBJECTIVE

To provide French guidelines for the management of women with abnormal uterine bleeding (AUB).

DESIGN

A consensus committee of 26 experts was formed. A formal conflict-of-interest (COI) policy was developed at the beginning of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding (i.e. pharmaceutical, or medical devices). The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized.

METHODS

The last guidelines from the Collège national des gynécologues et obstétriciens français (CNGOF) on the management of women with AUB was published in 2008. The literature seems now sufficient for an update. The committee studied questions within 7 fields (diagnosis; adolescent; idiopathic AUB; endometrial hyperplasia and polyps; fibroids type 0 to 2; fibroids type 3 and more; adenomyosis). Each question was formulated in a PICO (Patients, Intervention, Comparison, Outcome) format and the evidence profiles were produced. The literature review and recommendations were made according to the GRADE® methodology.

RESULTS

The experts' synthesis work and the application of the GRADE method resulted in 36 recommendations. Among the formalized recommendations, 19 present a strong agreement and 17 a weak agreement. Fourteen questions did not find any response in the literature. We preferred to abstain from recommending instead of providing expert advice.

CONCLUSIONS

The 36 recommendations made it possible to specify the diagnostic and therapeutic strategies of various clinical situations managed by the practitioner, from the simplest to the most complex.

How is functionning the Ethical Review Board « Comité d'Ethique pour la Recherche en Obstétrique et Gynécologie » (CEROG) ?

INTRODUCTION

The French College of Gynecology and Obstetrics (CNGOF) has created an Ethical Review Board called the CEROG that aim to ensure the research projects are in conformity with the regulation and the laws, as well as to allow their publication in international scientific journals. The aim of this work was to analyze the work of this committee through the application received and to review the ethical procedures required by type of research project.

METHODS

We conducted a national retrospective study of all applications from 2018 to 2021 received by the CEROG Ethical Review Board. Each application must contain a verification of conformity with the MR004 regulation, a submission form and an information form to the patients involved. At reception, the documents are anonymized and then addressed to the members of one of the two independent sections (Obstetric and Prenatal diagnosis or Gynecology and Assisted Reproductive Therapy).

RESULTS

Two hundred and sixty applications were received, including 52% in the Gynecology section and 48% in the Obstetrics' section. Only 10% (14/136) and 8% (10/124) were disapproved, respectively. In total, 35% of the applications to the Gynecology section leaded to publications in scientific journals but only 23% did so in the Obstetrics section. Most publications (60.8%) were in low impact factors journals (rank D and E).

CONCLUSION

The Ethical Review Board CEROG is essential to ensure the conformity of the research projects with French regulations and allow fast publication in international journals.

Management of external cephalic version in France: A national practice survey

INTRODUCTION

The breech presentation represents 4,7% of deliveries at term. There is a method of external cephalic version (ECV) performed from 36 weeks of gestation. French guidelines for the clinical practice of ECV were published in 2020.

OBJECTIVE

To evaluate the national practices of ECV in French maternity units, especially on the use of tocolysis, 1 year after publication of the French clinical recommendations guidelines by the French national college of obstetricians and gynecologists (CNGOF).

METHODS

Data self-reported for this national descriptive study were collected from March to May 2021 by an online questionnaire distributed to all French maternities. The 25 items of the questionnaire collected information of maternity units, the general practice of ECV, use or not of tocolysis for ECV attempt and the relevance of a prospective study.

RESULTS

Of the 517 French maternity units, 150 (29%) responded to the online survey.  95,3% systematically performed ECV. A Kleihauer test was routinely performed in 71 units (49.7%). A tocolysis was associated with ECV attempt in 52.4% of cases. The drugs used were intravenous atosiban (30,7%), mainly in levels 2b and 3 maternity units, intravenous salbutamol (24%), other mode of administration of salbutamol (14,7%) and oral nifedipine (22,6%) mainly in levels 1 and 2a maternity units. Adverse effects were described in 20%, mainly with the use of salbutamol (73,3%).

CONCLUSIONS

52.4% of the French maternity units surveyed used tocolysis for the ECV attempt, although it is systematically recommended. The choice of tocolytic drug differed according to the maternity units.

Serious complications and recurrences after pelvic organ prolapse surgery for 2309 women in the VIGI-MESH registry

OBJECTIVE

To assess the incidence of serious complications and reoperations for recurrence after surgery for pelvic organ prolapse (POP) and compare the three most common types of repair.

DESIGN

Prospective cohort study using a registry.

SETTING

Nineteen French surgical centres.

POPULATION

A total of 2309 women participated between 2017 and 2019.

METHODS

A multivariate analysis including an inverse probability of treatment weighting approach was used to obtain three comparable groups.

MAIN OUTCOME MEASURES

Serious complications and subsequent reoperations for POP recurrence.

RESULTS

The median follow-up time was 17.6 months. Surgeries were native tissue vaginal repairs (n = 504), transvaginal mesh placements (n = 692) and laparoscopic sacropexies with mesh (n = 1113). Serious complications occurred among 52 women (2.3%), and reoperation for POP recurrence was required for 32 women (1.4%). At 1 year the cumulative weighted incidence of serious complications was 1.8% for native tissue vaginal repair, 3.9% for transvaginal mesh and 2.2% for sacropexy, and the rates for reoperation for recurrence of POP were 1.5, 0.7 and 1.1%, respectively. Compared with native tissue vaginal repair, the risk of serious complications was higher in the transvaginal mesh group (weighted hazard ratio, wHR 3.84, 95% CI 2.43-6.08) and the sacropexy group (wHR 2.48, 95% CI 1.45-4.23), whereas the risk of reoperation for prolapse recurrence was lower in both the transvaginal mesh (wHR 0.22, 95% CI 0.13-0.39) and sacropexy (wHR 0.29, 95% CI 0.18-0.47) groups.

CONCLUSIONS

Our results suggest that native tissue vaginal repairs have the lowest risk of serious complications but the highest risk of reoperation for recurrence. These results are useful for informing women and for shared decision making.

TWEETABLE ABSTRACT

Laparoscopic sacropexy had fewer serious complications than transvaginal mesh and fewer reoperations for recurrence than vaginal repair.

[Pelvic fracture and urogenital dysfunction in women: A literature review]

INTRODUCTION

The consequences of a pelvic fracture on pelvic statics and sexuality in women are often overlooked and relegated to secondary care.

OBJECTIVE

To carry out a state of knowledge on disorders of pelvic statics and sexuality in patients with a history of pelvic fracture: incidence, risk factors, management.

METHODS

Literature review on the Pubmed, Medline, Embase and Cochrane database using the following keywords and MeSH terms: pelvis floor dysfunction, urinary dysfunction, sexual dysfunction, pelvic organ prolapse, in association with the terms pelvic fracture, pelvic trauma.

RESULTS

Among the 270 initial articles, 21 were selected. Finally, one retrospective cohort study has evaluated the impact of pelvic fracture on the onset of a genital prolapse, 2 comparative retrospective studies and one prospective study focused on the impact of pelvic fracture on lower urinary tract symptoms. One comprehensive review studied pelvic fracture and sexuality outcomes. The incidence of prolapse following pelvic fracture could not be identified. The incidence of lower urinary tract symptoms varies between 21 and 67% with a significant difference for urinary urgency without leakage (P=0.016) and SUI (P=0.004). The incidence of sexual disorders varies between 21 and 62% with a predominance of dyspareunia. The mechanism of the trauma is thought to be a contributing factor, as well as the damage of the pubic symphysis (RR 4.8 95% CI 2.0-11.2).

CONCLUSION

The evaluation of urogenital, sexual and anorectal dysfunctions following trauma to the pelvis has so far been little explored in the literature. Future prospective studies are to be carried out to improve patient care.

Efficacy of In Situ Methotrexate Injection in the Treatment of Nontubal Ectopic Pregnancies: A Retrospective Multicenter Study

STUDY OBJECTIVE

Evaluation of the efficacy of different injection sites of methotrexate in the treatment of nontubal ectopic pregnancies.

DESIGN

Retrospective multicenter study.

SETTING

Multicenter, including 3 teaching hospitals, an intercommunal hospital, and a clinic.

PATIENTS

A total of 106 patients with nontubal ectopic pregnancies, including 59 interstitial, 39 cesarean scar, and 8 cervical or isthmic.

INTERVENTIONS

Overall, 58 patients received methotrexate via intramuscular injection (IM group), 35 received methotrexate via in situ injection (IS group), and 13 received a combination of both in situ and intramuscular injections of methotrexate (IS + IM group).

MEASUREMENTS AND MAIN RESULTS

The main end point of this study was measured via the primary success rate (defined as a negative β-human chorionic gonadotropin level without recourse to any additional treatment) of treatment with methotrexate according to injection site. The primary success rate was 46.55% in the IM group, 60% in the IS group, and 61.54% in the IS + IM group, respectively. In the multivariate analysis, the primary success rate of treatment was significantly correlated to the in situ injection of methotrexate, either solely or in conjunction with an intramuscular injection of methotrexate administered the following day, (odds ratio = 2.7; 95% confidence interval, 1.03-7.14).

CONCLUSION

Solely an intramuscular injection of methotrexate is a less efficient first-line treatment strategy for the conservative management of nontubular ectopic pregnancy. The use of an in situ injection of methotrexate should therefore be preferred.

HE4 in the Diagnostic Approach of Endometrial Cancer in Patients with Postmenopausal Bleeding, the METRODEC Protocol: Protocol for a Multicenter Prospective Study

Background: Endometrial cancer is the most common pelvic gynecological cancer in France. The most frequent symptom is post-menopausal bleeding and is one of the primary reasons for consultation in gynecological emergencies. The treatment is very codified and consists of a surgical intervention for anatomopathological analysis. The latter is frequently reassuring. These interventions are often performed in mild situations and there is currently no element to be sufficiently reassuring to avoid surgery. This study aims to explore the sensitivity of an innovative marker: Human Epididymis 4 (HE4) in the diagnosis approach of endometrial cancer in case of postmenopausal bleedings. Methods: This is a prospective multicenter diagnostic study with three centers involved. Inclusion criteria are any patient with post-menopausal bleeding who is to undergo hysteroscopy, endometrial biopsy, or endometrial resection. In accordance with the recommendations for the management of post-menopausal bleedings, the medical conduct consists of performing a clinical examination, an ultrasound and, in general, even in case of paraclinical examination reassuring, an anatomopathological analysis. This pathological analysis can be obtained in several ways: biopsy, hysteroscopy-curettage (which is the most frequently performed surgery), and hysterectomy. Our protocol consists of taking a blood sample from each woman who will undergo one of the interventions mentioned above. The dosage of HE4 and CA125 requires the withdrawal of an additional heparinized tube during the preoperative assessment usually performed. This research is therefore classified as non-interventional. The primary outcome is to evaluate the sensitivity of the HE4 marker in patients with postmenopausal bleeding in the diagnosis of endometrial cancer. The secondary outcomes are other parameters (specificity, VPP, VPN) of HE4, Evaluating the diagnostic capabilities of the CA125 marker alone and associated with HE4, as well as those of the REM and REM-B algorithms. We aim to include 100 patients over a period of one year in three centers. Discussion: As of now, there is no biological marker used in routine practice in the diagnosis of endometrial cancer. The ultimate goal of HE4 in endometrial cancer is to avoid surgery for those who are identified as non-sick. This study is the precursor of others for use in routine practice, HE4 would represent a great help to diagnosis if our study demonstrates it as reliable in the management of these patients and avoid many unnecessary and risky surgeries.

Methods of detection and prevention of preterm labour and the PAMG-1 detection test: a review

OBJECTIVES

Preterm labour is the leading cause of hospitalization during pregnancy. In France, it results in more than 60,000 births before 37 weeks of gestation every year. Recent studies suggest that detection of placental α-microglobulin-1 (PAMG-1) in vaginal secretions among women presenting symptoms of preterm labour with intact membranes has good predictive value for the onset of spontaneous preterm delivery within 7 days. The test is especially interesting, in that the repetition of antenatal corticosteroids for foetal lung maturation is no longer recommended in France and the effect of the initial administration is most beneficial in the 24 h to 7 days afterwards.

METHODS

We included all studies listed in PubMed and clinicaltrials.gov with the terms "PAMG-1" and either "preterm labor" or "preterm labour", while excluding all studies on the subject of "rupture of the membranes" from 2000 through 2017. Ten studies were thus included.

RESULTS

In women who had both the PAMG-1 and foetal fibronectin test, the PAMG-1 test was statistically superior to the measurement of cervical length for positive predictive value (p<0.0074), negative predictive value (p=0.0169) and specificity (p<0.001) for the prediction of spontaneous preterm delivery within 7 days.

CONCLUSIONS

The use of PAMG-1 may make it possible to target the women at risk with a shortened cervix on ultrasound (<25 mm) those with an imminent preterm delivery and therefore to adapt management, especially the administration of antenatal corticosteroid therapy.

Management and consequences of obstetrical anal sphincter injuries: Review

Obstetrical anal sphincter injuries (OASI), formerly referred to as "complete" or "incomplete" perineal tears, are a frequent complication of childbirth. They can lead to intestinal consequences (anal incontinence, ano-genital fistula) or sexual consequences (dyspareunia, genital pain). The complexity of management of OASI lies in the multi-factorial nature of these consequences but also in the frequently lengthy interval before their appearance, often long after childbirth. Indeed, while 2.4% of women in childbirth develop OASI, up to 61% of them will present with anal incontinence15 to 25 years after childbirth. Immediate or delayed repair of the sphincter and perineum within a few hours of injury is therefore the rule, but there is no consensus on longer-term management. The patient must be educated on preventive actions (avoidance of pushing or straining, regularization of stool transit, muscle strengthening, etc.). Early detection of anal incontinence leads to prompt management, which is more effective. This review aims to synthesize the information necessary to provide clear and up-to-date patient information on OASI (risk factors and prevalence), the management of OASI, and the management of eventual complications in the setting of dedicated specialty consultations. Dedicated "post-OASI" consultations by a specialist in ano-perineal pathologies could therefore become a first step in the development of care for women, particularly by removing the "shameful" nature of the symptoms.

Endometrial cancer: A systematic review of HE4, REM and REM-B

INTRODUCTION

Endometrial cancer, one of the most frequent pelvic gynecologic cancer worldwide, currently has no biomarker used to assess it in daily practice. Nonetheless, human epididymis 4 (HE4) appears to offer the best prospects, alone or combined with CA125. This study sought to systematically review the work on HE4 from the first publications in 2008 until now.

MATERIAL AND METHODS

Two independent reviewers searched the PubMed database with the terms "HE4″, "endometrial cancer", "endometrial carcinoma", and HE4 or human epididymis protein 4. Only original clinical research articles and meta-analyses, published in English, were included, with literature reviews and case reports excluded.

RESULTS

Studies were organized into 3 categories: diagnosis, prognosis, and recurrence/survival. Overall we identified 117 articles dealing with HE4 and endometrial cancer and selected 52 relevant texts: 46 articles, 6 meta-analyses. The sensitivity of HE4 for the diagnosis of endometrial cancer varied from 44.2% to 91% and its specificity from 65.5 to 100%, versus 24.1 to 71.5% and from 65.6 to 100% for CA125. Two meta-analyses of their combination produced areas under the curve (AUC): 0.83 and 0.86. Two available algorithms - the REM (risk of endometrial malignancy) and REM-B (risk of endometrial malignancy associated with BMI) scores - require more study. HE4 is also strongly associated with prognostic factors such as myometrial invasion, tumor grade, FIGO stage, and lymph node involvement. It also predicts recurrence and can serve as a monitoring tool, as reported by a 2018 meta-analysis with a hazard ratio of 2.15 (P < 0.001).

CONCLUSION

HE4, alone or associated with CA125, appears to be an important tool in the management of endometrial cancer, initially for diagnosis, but for assessing prognosis and survival. Other prospective and multicenter studies are necessary to confirm these hopes and be able to recommend the use of HE4 in regular practice.

Angiographic findings and outcomes after embolization of patients with suspected postabortion uterine arteriovenous fistula

INTRODUCTION

The purpose of this study is to assess the angiographic incidence of uterine arteriovenous fistula (UAVF) in women referred for a high ultrasonographic suspicion in a postabortion setting and to evaluate the safety, efficacy and impact on further fertility of uterine artery embolization (UAE) in this indication.

MATERIALS AND METHODS

A monocentric retrospective study of 31patients managed by uterine artery embolization for suspected UAVF after spontaneous or induced first trimester abortion. The diagnosis of UAVF was confirmed when an early venous drainage was identified on the angiogram. Technical success was defined as complete exclusion of the vascular lesion. Clinical success was defined as the absence of bleeding during the clinical follow-up and during the surgery in case of hysteroscopic resection. Information about further fertility was gathered by phone calls to the patients.

RESULTS

The mean age of the patients was 30.8 (±6.0) years. The diagnosis of UAVF was angiographically confirmed in 6 patients (19.4 %). Angiographic findings of retained product of conception (RPOC) with varying degrees of vascularity were observed in remaining patients. The technical success rate of UAE was 100 %, mostly through a proximal and bilateral embolization using a resorbable agent (27/31 patients, 87.1 %). The clinical success rate of UAE was 100 % in the group treated by a single UAE. We did not notice any bleeding during the surgery in the group of patients who needed a further hysteroscopic resection. 14 patients led at least one subsequent pregnancy to term without any difficulty.

CONCLUSION

UAVF is a rare condition. We supposed it may constitute the ultimate stage in the natural history of the retained products of conception with "marked vascularity". UAE seems to be an effective and safe first-line treatment.

National survey of surgical practices: Sacropexy in France in 2019

INTRODUCTION AND HYPOTHESIS

Sacropexy is a reference surgical treatment for pelvic organ prolapse in women. The great variability in surgical techniques for this procedure is a source of bias that complicates analysis of the results of trials assessing it. Using the French guidelines issued in 2016 by the SCGP, AFU, SIFUD-PP, and CNGOF as a reference, we sought to inventory the surgical practices of the surgeons who perform these procedures.

METHODS

In November 2018, a questionnaire about the technical aspects of this procedure was distributed by email to the French physicians performing it. It was distributed to members of several professional societies (CNGOF, SCGP, and SIFUD) and to gynecologists practicing in clinics owned by the ELSAN group.

RESULTS

Of the 273 responders, 92% reported that they perform most operations laparoscopically. Overall, 83% of gynecologic surgeons used polypropylene prostheses (mesh); 38% routinely placed a posterior mesh, while the rest did so only in cases of clinical rectocele with anorectal symptoms. A concomitant hysterectomy was performed by 51% of respondents when the uterus was bulky and/or associated with substantial uterine prolapse. Finally, half the surgeons suggested the placement of a suburethral sling for women with stress urinary incontinence.

CONCLUSIONS

Although practices are largely consistent with the most recent guidelines, surgical techniques vary widely between surgeons, both in France and internationally.

The value of a vaginal sample for detecting PAMG-1 (Partosure®) in women with a threatened preterm delivery (the MAPOSURE Study): protocol for a multicenter prospective study

BACKGROUND

Threatened preterm delivery (TPD) is the leading cause of inpatient admissions during pregnancy. The ability to predict the risk of imminent preterm delivery is thus a major priority in obstetrics. The aim of our study is to assess the diagnostic performance of the test to detect the placental alpha microglobulin 1 (PAMG-1) for the prediction of delivery within 7 days in women with TPD.

METHODS

This is a prospective multicenter diagnostic study. Inclusion criteria are singleton pregnancy, gestational age between 24 + 0 and 33 + 6 weeks inclusive, cervical measurement 25 mm or less assessed by transvaginal ultrasound (with or without uterine contractions), clinically intact membranes and cervical dilatation < 3 cm assessed by digital examination. According to the current protocol, when a women presents with TPD and the diagnosis is confirmed by transvaginal ultrasound, a vaginal sample to test for genital infection is performed. At the same time, the midwife will perform the PartoSure® test. To perform this analysis, a sample of cervicovaginal secretions is taken with the vaginal swab furnished in the test kit. The primary outcome is the specificity of the PartoSure® test of women who gave birth more than 7 days after their hospitalization for TPD. The secondary outcomes are the sensitivity, PPV, and NPV of the Partosure® test and the factors associated with false positives (with a univariate logistic regression model). Starting with the hypothesis of an anticipated specificity of 89%, if we want to estimate this specificity with a confidence interval of ± 5%, we will require 151 women who do not give birth within 7 days. We therefore decided to include 400 women over a period of two years to have a larger number of events (deliveries within 7 days).

DISCUSSION

The different tests already used such as fetal fibronectin and phIGFBP-1, are not sufficiently relevant to recommend their use in daily practice. The different studies of PAMG-1 described above thus provide support for the use of this substance, tested by PartoSure®. Nonetheless, other larger studies are necessary to validate its use in daily practice and our study could answer this question.

TRIAL REGISTRATION

NCT03401255 (January 15, 2018).

[Pelvic and perineal pain after genital prolapse: A literature review]

INTRODUCTION

Pelvic and perineal pain after genital prolapse surgery is a serious and frequent post-operative complication which diagnosis and therapeutic management can be complex.

MATERIALS ET METHODS

A literature review was carried out on the Pubmed database using the following words and MeSH : genital prolapse, pain, dyspareunia, genital prolapse and pain, genital prolapse and dyspareunia, genital prolapse and surgery, pain and surgery.

RESULTS

Among the 133 articles found, 74 were selected. Post-operative chronic pelvic pain persisting more than 3 months after surgery according to the International Association for the Study of Pain. It can be nociceptive, neuropathic or dysfunctional. Its diagnosis is mainly clinical. Its incidence is estimated between 1% and 50% and the risk factors are young age, the presence of comorbidities, history of prolapse surgery, severe prolapse, preoperative pain, invasive surgical approach, simultaneous placement of several meshes, less operator experience, increased operative time and early post-operative pain. The vaginal approach can cause a change in compliance and vaginal length as well as injury to the pudendal, sciatic and obturator nerves and in some cases lead to myofascial pelvic pain syndrome, whereas the laparoscopic approach can lead to parietal nerve damage. Therapeutic management is multidisciplinary and complex.

CONCLUSION

Pelvic pain after genital prolapse surgery is still obscure to this day.

[Impact of hysterectomy on urinary incontinence: A systematic review]

INTRODUCTION

The impact of a hysterectomy on urinary incontinence is a controversial subject in the literature.

OBJECTIVE

To evaluate the prevalence and incidence of urinary incontinence after a hysterectomy as well as associated risk factors such as the type of hysterectomy, the surgical approach, urodynamic criteria and uterine disease.

STUDY DESIGN

We conducted a systematic review in Pubmed database with the following keywords and MeSH term: hysterectomy, urinary incontinence.

RESULTS

A total of 1340 articles were retrieved, 42 articles were selected for the final text analysis. The results of the different studies were heterogeneous. Hysterectomy seemed to increase the rate of sphincter deficiency (VLPP<60mmH₂O for 20% of cases versus 1,7% without hysterectomy, P=0.003). The vaginal route could increase the incidence of UI with OR of 2.3 (95%CI 1.0-5.2). Subtotal hysterectomy appears to increase UI with a 0,74 RR for total hysterectomy (95%CI 0.58-0.94). A radical hysterectomy with nerve conservation would preserve urinary functions, unlike pelvic radiotherapy, which is responsible for irreversible nerve damage by demyelination and bladder fibrosis.

Diastasis of the rectus abdominis muscles in postpartum: Concordance of patient and clinician evaluations, prevalence, associated pelvic floor symptoms and quality of life

OBJECTIVES

The main objective was to assess the reliability of the patient's measurement of diastasis. The secondary aims were the estimation postpartum diastasis prevalence, of diastasis-associated pelvic floor symptoms and quality of life immediately after childbirth and at 3-6 months postpartum.

STUDY DESIGN

Using a prospective observational design, women who gave birth in a French university hospital were eligible. After a learning phase, both clinician and patient conducted a clinical evaluation of diastasis. Then, patients were asked to complete the HerQLes, the FPFQ and a general questionnaire. Three to 6 months later, patients completed the same questionnaires online and performed a clinical evaluation of diastasis at home, as learned previously.

RESULTS

Of 253 patients included in the study, 139 (54.9 %) completed the questionnaires at 3-6 months of follow-up. There was good correlation between clinician and patient evaluations of diastasis (kappa coefficient 0.76 [95 % CI, 0.5-0.7]). Immediately after childbirth, 210 (83 %) of the women presented diastasis including 116/210 (55 %) cases of severe diastasis and 51 (42 %) of those had persistent diastasis at 3-6 months of follow-up. Cesarean section (p = 0.05) and multiparity (p = 0.04) were factors of persistent diastasis. Severe diastasis had a significant impact on quality of life (HerQLes score) at birth (p = 0.001) and at 3-6 months (p = 0.01), but no effect on pelvic floor symptoms according the FPFQ. The occurrence and severity of diastasis did not significantly impact lumbar or pubic symphysis pain. Furthermore, the aesthetic discomfort felt by patients was significantly increased by the presence of diastasis on a numerical scale at 3-6 months (p = 0.03).

CONCLUSION

Good agreement between clinician and patient evaluations of postpartum diastasis indicated that the evaluation method is reliable. Persistent diastasis was associated with impaired quality of life.

Description and classification of postpartum chronic pain: A multicentric prospective study

INTRODUCTION

To classify persistent perineal and pelvic postpartum pain using the classification usually employed in chronic pelvic pain.

MATERIAL AND METHOD

Prospective observational study including all women who have consulted an algologist or gynecologist at one of the six French centers for a chronic pain (superior or equal to 3 months) spontaneous linked by the mother with her childbirth were included. During semi-directed interviews, a questionnaire regarding sociodemographic factors and detailed questions about pain were collected. Then, pelvic and perineal pain were classified into 7 pain syndromes: pelvic sensitization (Convergences PP criteria), complex regional pain syndrome (Budapest criteria), pudendal or cluneal neuralgia (Nantes criteria), neuroma, thoraco-lumbar junction syndrome, myofascial pain (muscle trigger zone), fibromyalgia (American College of Rheumatology criteria). The principal objective of this study is to assess the prevalence of each painful disorder. The secondary aims were the description of socio-demographic factors and clinical characteristics of this population, identify the related symptoms and the impact on daily function associated with the chronic pelvic or perineal postpartum pain.

RESULTS

40 women with chronic pelvic or perineal pain spontaneously linked with childbirth were included. 78 % experienced pain for more than 12 months. A large majority had a vaginal birth (95 %) with perineal suture (90 %) and severe acute pain within the first week postpartum (62 %). Postpartum pain impacted participant's sexual activity (80 %), micturition (28 %) and defecation (38 %). In the sample, 17 cases of neuroma, 6 patients with pudendal or cluneal neuralgia, 13 patients with pelvic sensitization and 2 cases of fibromyalgia were identified. Complex regional pain syndrome was diagnosed in 8 patients, and myofascial pain in 11 women, and only 1 patient had thoraco-lumbar junction syndrome. Neuropathic pain was found in 31 participants (77.5 %) according to DN4 criteria.

DISCUSSION

The classification scheme proposed in this study may be a very useful tool to investigate postpartum pelvic and perineal pain and to propose a treatment.

Rupture of Non-communicating Rudimentary Horn of Uterus at 12 Weeks' Gestation

The rudimentary horn of uterus is an extremely rare malformation and potentially serious obstetric entity, threatening maternal and fetal outcome. Diagnostic sonography of early pregnancy in a non-communicating rudimentary horn is difficult but important. We report a case of ruptured non-communicating rudimentary horn with unicornuate uterus at 12 weeks’ gestation, where diagnosis is made before surgery. Excision of the rudimentary horn and ipsilateral salpingectomy (to prevent a further ectopic tubal gestation), conserving the ovary, is the recommended surgical procedure for patients desiring to maintain their fertility potential. The subsequent obstetric prognosis is reassuring. Diagnostic imaging examinations of the reproductive system after this treatment showed no negative effect from surgery on subsequent fertility and there was no reported case of uterine rupture during subsequent pregnancy in the remaining unicornuate uterus after rudimentary horn excision. Future pregnancies will require extremely close monitoring and a caesarean section is highly recommended.

Effectiveness of nitrous oxide in external cephalic version on success rate: A randomized controlled trial

INTRODUCTION

Approximately 4% of singleton pregnancies at term are in breech presentation. External cephalic version (ECV) can reduce the risks of noncephalic birth and cesarean delivery, but this maneuver can be painful. Our aim was to analyze the effect of administering inhaled nitrous oxide for analgesia on the ECV success rate.

MATERIAL AND METHODS

This prospective, randomized, single-blind, controlled trial included women with singleton pregnancies in breech presentation at term who were referred for ECV in a tertiary care center. Women were assigned according to a balanced (1:1) restricted randomization design to inhale either nitrous oxide (N₂ O) in a 50:50 mix with oxygen or medical air during the procedure. The main outcomes reported are the ECV success rate, degree of pain, adverse event rate, and women's satisfaction.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01948115.

RESULTS

The study included 150 women (nitrous oxide group: n = 74; medical air: n = 76). Inhaled nitrous oxide was not associated with a higher ECV success rate than medical air (24.3 vs 19.7%, P = 0.51). Among parous women (n = 34 in each group), the ECV success rate appeared higher in the nitrous oxide group, respectively 47.1% (n = 16) vs 23.5% (n = 8) (P = 0.042). Neither the median pain level nor adverse event rates differed significantly in women with inhaled nitrous oxide compared with medical air.

CONCLUSIONS

Use of an equimolar mixture of oxygen and nitrous oxide during ECV appears safe. Although it does not seem to change the overall success rate, it may increase success in parous women.

[Validation of the cervical length education and review program in a population of French residents in obstetrics and gynecology]

OBJECTIVES

Evaluate an educational program based on "CLEAR" (Cervical Length Education and Review) in the teaching of measuring sonographic cervical length to residents in gynecology and obstetrics.

METHODS

This is a prospective cohort study in a tertiary care center between May and November 2017. The residents were asked to collect 5 cervical length images from patients suspected with threatened preterm labor. A theoretical session on cervix measurement image criteria based on "CLEAR" program was taught to all residents. Then, they had to collect 5 new cervical length images. All the images were reviewed by two experienced reviewers, blinded to the resident and whether the image was obtained before or after the theoretical session and based on 8 criteria.

RESULTS

Ten residents participated to the study. The mean total score CLEAR was significantly higher post-intervention: 6.6±0.9 vs. 4.3±2.1, positive difference of 2.3±2.3 (P<0.001). Improvement was most significant with the junior residents: 3.6 pre vs. 6.5 post-intervention.

CONCLUSION

Educational program based on CLEAR criteria allowed to improve the competence of residents in measuring sonographic cervical length, although this can also be correlated with the progression of residents during the semester. It could be implemented systematically with the aim of CLEAR certification to standardize the teaching of residents in gynecology and obstetrics.

[Uterine preservation or not during prolapse surgery: Review of the literature]

OBJECTIVE

To evaluate the impact of hysterectomy in case of genital prolapse on the anatomical and functional results, and on per and post operative complications compared with uterine preservation.

MATERIAL AND METHODS

We conducted a review of the Pubmed, Medline, Embase and Cochrane literature using the following terms and MeSH (Medical Subject Headings of the National Library of Medicine): uterine prolapse; genital prolapse; prolapse surgery; vaginal prolapse surgery; abdominal prolapse surgery; hysterectomy; hysteropexy; sacrocolpopexy; surgical meshes; complications; sexuality; neoplasia; urinary; incontinence; cancer.

RESULTS

Among the 168 abstracts studied, 63 publications were retained. Whatever performance of hysterectomy or not, anatomical and functional results were similar in abdominal surgery (sacrocolpopexy) (OR=2.21 [95% CI: 0.33-14.67]) or vaginal surgery (OR=1.07 [95% CI: 0.38-2.99]). There was no difference in terms of urinary symptoms or sexuality after surgery. Hysterectomy was associated to a higher morbidity (bleeding, prolonged operating time, longer hospital stay), to an increased risk of mesh exposure particularly in case of total hysterectomy (8.6%; 95% CI: 6.3-11).

CONCLUSION

In the absence of evidence of superiority in terms of anatomical and functional outcomes, with an increased rate of complications, concomitant hysterectomy with prolapse surgery should probably not be performed routinely.

Uterine myomas and lower urinary tract dysfunctions: A literature review

Different types of urinary symptoms associated with myomas are reported, including urinary incontinence or dysuria. They are rarely investigated in patients and their prevalence is not well known. While myomas are the first reason to perform hysterectomy in France, few studies have evaluated the impact of surgical treatment in women with urinary symptoms. Our objective was to conduct a review of the literature regarding urinary symptoms associated with myomas and the impact of their treatment on these symptoms. We reviewed articles indexed in MEDLINE dealing with urinary symptoms and myomas, and published until September 2018. The prevalence of urinary symptoms in women with uterine myomas is highly variable depending on whether the authors are interested in symptoms or urodynamic results. The most frequently reported urinary symptoms are urgency (31-59%), dysuria (4-36%) and stress urinary incontinence (SUI, 20 80%). While some studies have found the anterior location of myomas and the size superior to 5 cm as a risk factor for UI, other studies have not found a correlation between myomas topography and symptom scores. The treatments of uterine myomas seem to have an impact on women's urinary symptoms. Although hysterectomy is considered as a risk factor for pelvic floor disorders, the removal of the uterus may sometimes improve or cure urinary symptoms. Most authors also found a significant improvement in urinary symptom scores after myomectomy and myomas embolization. More studies are needed to clarify the impact of myomas treatment on urinary symptoms.