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Resume Objectifs Les tumeurs frontieres ovariennes (TFO) constituent un groupe heterogene de lesions, avec des specificites en fonction du sous-type histologique. La classification histologique correcte de la tumeur ovarienne et des implants peritoneaux constitue une etape importante de la prise en charge des patientes. Materiel et methodes La selection bibliographique a ete effectuee dans PubMed de janvier 2000 a janvier 2019 inclus, en selectionnant les publications en langue anglaise et francaise. Resultats et conclusions Il est recommande de classer les TFO selon la classification OMS la plus recente. Il est recommande de signaler la presence d’un foyer micro-invasif ( 10 cm de zone papillaire ou solide (grade C). L’echantillonnage doit etre plus extensif (2 blocs/cm) en cas de TFO mucineuse, surtout si carcinome intra-epithelial et/ou micro-invasion, TFO sereuse micropapillaire ou TFO a cellules claires. En cas de TFO, en l’absence d’atteinte macroscopique de l’epiploon, apres un examen macroscopique attentif, il est recommande de realiser au moins 4 a 6 blocs de prelevements systematiques sur la piece et d’inclure la totalite des implants (grade C). Il est recommande (INCa – Reseau TMRG) la relecture aupres d’un gynecopathologiste expert, en cas de doute sur le caractere frontiere de la tumeur, doute sur le sous-type histologique, doute sur le caractere invasif ou non d’implant, systematiquement devant toutes TFO sereuses non classiques et en presence d’implants peritoneaux, systematiquement devant toutes tumeurs mucineuses ou a cellules claires frontieres ou carcinomateuses (grade C). Il est recommande de ne pas ponctionner un kyste ovarien suspect (grade C). Il est recommande de recourir a un pathologiste expert en gynecologie en cas de demande d’examen extemporane d’une masse ovarienne suspecte d’etre frontiere (grade C).

Introduction: Hanging is one of the most common methods of suicide. It can also be used to conceal a crime. Thus, it is important to systematically have a forensic autopsy performed in cases of hanging. Only that examination can determine the actual forensic form of the death. At the national level, there is no epidemiological data on suicide by hanging in Benin. Aims: This study aims to describe the epidemiological and forensic features observed in the cases of suicide by hanging in Benin. Material and Methods: This is a descriptive and retrospective study of all the suicidal deaths by hanging collated in the Forensic & Legal Medicine Unit of the Faculty of Health Sciences (UML_FSS) for a period of 12 years, 2005–2017, in Benin. Result: Suicides by hanging accounted for 8.3% of the cases of suspicious deaths autopsied in the south and center of Benin. Males represented 85.9% of the corpses, and most individuals were under 40 years old (62.0%). Hangings were complete in 65.4% of the cases. The material used most often for hanging (28.7% of cases) was nylon rope. Subcutaneous hemorrhages (46.2%) and ecchymosis in the sterno-cleido-mastoid muscles (61.3%) were the most common finding at the neck dissection. Conclusion: Hanging is a common method of suicide, especially among young men. In Benin, it occurs behind closed doors and by means of tools used in everyday life. Forensic autopsies, however, remain infrequent in cases of suicides. Keywords: Hanging, Suicide, Autopsy, Benin.

Resume Objectifs Determiner les modalites du suivi apres une infection genitale haute (IGH) et les conseils a donner a la patiente. Methodes Une recherche bibliographique a ete realisee a partir des mots cles decrivant le suivi apres IGH de 1990 a 2018 dans les bases de donnees Cochrane, PubMed et Google. Toutes les etudes publiees en langue francaise ou anglaise pertinentes ont ete considerees. Les donnees ont ete decrites avec un niveau de preuve, de facon a etablir un grade de recommandations. Resultats La frequence des recidives des infections genitales hautes (IGH) est de 15 a 21 %. Elles sont liees a une reinfection par les bacteries des infections sexuellement transmissibles (IST) dans 20 a 34 % des cas et augmentent le risque d’infertilite et de douleurs pelviennes chroniques (NP2). Un suivi est recommande apres IGH (grade C). Le taux de perdues de vue est de l’ordre de 40 %. La compliance au suivi est amelioree par un rappel individualise des patientes (grade B). Un examen microbiologique par un test d’amplification des acides nucleiques sur prelevement vaginal de controle 3 a 6 mois apres le traitement d’une IGH associee aux IST est recommande pour eliminer une infection persistante ou une reinfection (grade C). L’utilisation des preservatifs est recommandee dans les suites d’une IGH associee a une IST afin de reduire le risque de recidives et de sequelles (grade C). La prescription des contraceptifs oraux au decours d’une IGH ne peut etre recommandee dans le seul but de reduire le risque de douleurs ou d’infertilite. La pose d’un DIU n’est pas contre-indiquee apres un episode d’IGH, mais doit etre precedee d’un prelevement vaginal a la recherche d’une IST chez les femmes a risque (grade B). Les femmes qui souhaitent concevoir apres une IGH doivent etre averties du risque de grossesse extra-uterine et des signes cliniques qui doivent faire consulter. Conclusion L’information des patientes et les examens microbiologiques realises au cours du suivi diminuent le risque d’IST et donc de recidives d’IGH.

It is recommended to classify Borderline Ovarian Tumors (BOTs) according to the WHO classification. Transvaginal and suprapubic ultrasonography are recommended for the analysis of an ovarian mass (Grade A). In case of an undetermined ovarian lesion on ultrasonography, it is recommended to perform a pelvic MRI (Grade A) with a score for malignancy (ADNEX MR/O-RADS) (Grade C) included in the report and to formulate a histological hypothesis (Grade C). Pelvic MRI is recommended to characterize a tumor suspected of being BOT (Grade C). It is recommended to evaluate serum levels of HE4 and CA125 and to use the ROMA score for the diagnosis of indeterminate ovarian mass on imaging (grade A). If there is a suspicion of a mucinous BOT on imaging, serum levels of CA 19-9 may be proposed (Grade C). For Early Stages (ES) of BOT, if surgery without risk of tumor rupture is possible, laparoscopy with protected extraction is recommended over laparotomy (Grade C). For treatment of a bilateral serous ES BOT with a strategy to preserve fertility and/or endocrine function, bilateral cystectomy is recommended where possible (Grade B). For mucinous BOTs with a treatment strategy of fertility and/or endocrine function preservation, unilateral salpingo-oophorectomy is recommended (grade C). For mucinous BOTs treated by initial cystectomy, unilateral salpingo-oophorectomy is recommended (grade C). For serous or mucinous ES BOTs, routine hysterectomy is not recommended (Grade C). For ES BOTs, lymphadenectomy is not recommended (Grade C). For ES BOTs, appendectomy is recommended only in case of a macroscopically pathological appendix (Grade C). Restaging surgery is recommended in cases of serous BOTs with micropapillary architecture and an incomplete abdominal cavity inspection during initial surgery (Grade C). Restaging surgery is recommended for mucinous BOTs after initial cystectomy or in cases where the appendix was not examined (Grade C). If restaging surgery is decided for ES BOTs, the following procedures should be performed: peritoneal washing (grade C), omentectomy (grade B), complete exploration of the abdominal cavity with peritoneal biopsies (grade C), visualization of the appendix and appendectomy in case of a pathological macroscopic appearance (grade C) as well as unilateral salpingo-oophorectomy in case of a mucinous BOT initially treated by cystectomy (grade C). In advanced stages (AS) of BOT, it is not recommended to perform a lymphadenectomy as a routine procedure (Grade C). For AS BOT in a patient with a desire to fall pregnant, conservative treatment involving preservation of the uterus and all or part of the ovary may be proposed (Grade C). Restaging surgery aimed at removing all lesions, not performed initially, is recommended for AS BOTs (Grade C). After treatment, follow-up for a duration greater than 5 years is recommended due to the median recurrence time of BOTs (Grade B). It is recommended that a systematic clinical examination be carried out during follow-up of a treated BOT (Grade B). If the determination of tumor markers is normal preoperatively, the routine dosage of tumor markers in BOT follow-up is not recommended (Grade C). In case of an initial elevation in serum CA 125 levels, it is recommended to monitor CA 125 during follow up (Grade B). In case of conservative treatment, it is recommended to use transvaginal and transabdominal ultrasound during follow up of a treated BOT (Grade B). In the event of a BOT recurrence in a woman of childbearing age, a second conservative treatment may be proposed (Grade C). A consultation with a physician specialized in Assisted Reproductive Technique (ART) should be offered in the case of BOTs in women of childbearing age (Grade C). When possible, a conservative surgical strategy is recommended to preserve fertility in women of childbearing age (Grade C). In the case of optimally treated BOT, there is no evidence to contraindicate the use of ART. The use of hormonal contraception after serous or mucinous BOT is not contraindicated (Grade C). After management of mucinous BOT, for women under 45 years, given the benefit of Hormonal Replacement Therapy (HRT) on cardiovascular and bone risks, and the lack of hormone sensitivity of mucinous BOTs, it is recommended to offer HRT (Grade C). Over 45 years of age, HRT can be prescribed in case of a climacteric syndrome after individual benefit to risk assessment (Grade C).

To evaluate the effect of a 10 mg per day 12 week treatment of ulipristal acetate (UPA) on abnormal uterine bleeding due to adenomyosis.A double-blind phase 2 randomized controlled pilot study.From May 2015 to February 2018 in five teaching hospitals.Premenopausal women with abnormal uterine bleeding (with a pictorial blood loss assessment score (PBAC) higher than 100 at inclusion) and a sonographic or MRI diagnosis of adenomyosis.After random allocation, either UPA 10 mg or placebo were orally administered during 12 weeks. A 3:1 ratio was used.The primary outcome was the rate of women with a PBAC score of less than 75 as evaluated over the 28 days following the 12-week treatment. Secondary outcomes included rate of amenorrhea, evolution of pain, quality of life and tolerance.Thirty women were included in the UPA group and 10 in the placebo group. No woman in the placebo group versus 95.24 % of women in the UPA group had a PBAC score under 75 during the 28 day period following the 12-week treatment (p0.01). A significant decrease in pain was noticed between inclusion and 13 weeks in the UPA group (p0.01). At 6 months, there was no significant difference in PBAC score or pain between groups. No serious adverse event was recorded.UPA could be an interesting option for treatment of abnormal uterine bleeding related to adenomyosis in women wishing to preserve their fertility.

To determine clinical, pathological and virological factors predicting the spontaneous regression of HSIL/CIN2. This retrospective study included 73 patients with HSIL/CIN2 diagnosed by biopsy between 2012 and 2016 and followed-up without treatment in the department of gynecology at Bordeaux University Hospital. All biopsies sampled inside or outside our department were reviewed and immunolabelled for p16 and Ki67. The response rate was the regression or the disappearance of HSIL/CIN2 as defined by the regression or the disappearance of initial colposcopic findings, cytological and/or histological results. The diagnosis of CIN2 was confirmed in 63 of 70 biopsies available for review. The Cohen’s kappa coefficient was κ = 90%, indicating almost perfect inter-observer agreement. The lesion spontaneously regressed or disappeared in 36 of 60 patients (60%) with confirmed CIN2 during a median follow-up of 20 months (range 6–55). Baseline factors influencing the response rate were colposcopic findings (69% with minor change vs 31% with major change, p = 0.033), cytological results (72% with ASCUS/LSIL vs 28% with ASC-H/HSIL, p = 0.018), and HPV genotyping (71% with HPV not 16 vs 42% with HPV-16, p = 0.027). The other factors (age, smoking, surface area of the lesion, p16 and Ki67 expressions) did not significantly influence the outcome. Colposcopic findings, cytological results, and HPV genotyping were baseline factors predicting spontaneous regression of HSIL/CIN2.

Background. The diagnosis of the neglected tropical skin and soft tissue disease Buruli ulcer (BU) is made on clinical and epidemiological grounds, after which treatment with BU-specific antibiotics is initiated empirically. Given the current decline in BU incidence, clinical expertise in the recognition of BU is likely to wane and laboratory confirmation of BU becomes increasingly important. We therefore aimed to determine the diagnostic accuracy of clinical signs and microbiological tests in patients presenting with lesions clinically compatible with BU. Methods. A total of 227 consecutive patients were recruited in southern Benin and evaluated by clinical diagnosis, direct smear examination (DSE), polymerase chain reaction (PCR), culture, and histopathology. In the absence of a gold standard, the final diagnosis in each patient was made using an expert panel approach. We estimated the accuracy of each test in comparison to the final diagnosis and evaluated the performance of 3 diagnostic algorithms. Results. Among the 205 patients with complete data, the attending clinicians recognized BU with a sensitivity of 92% (95% confidence interval [CI], 85%-96%), which was higher than the sensitivity of any of the laboratory tests. However, 14% (95% CI, 7%-24%) of patients not suspected to have BU at diagnosis were classified as BU by the expert panel. The specificities of all diagnostics were high (>= 91%). All diagnostic algorithms had similar performances. Conclusions. A broader clinical suspicion should be recommended to reduce missed BU diagnoses. Taking into consideration diagnostic accuracy, time to results, cost-effectiveness, and clinical generalizability, a stepwise diagnostic approach reserving PCR to DSE-negative patients performed best.

Objectives To characterize and describe treatment with ulipristal acetate (UPA) in a preoperative setting and to evaluate the safety, effectiveness, and Health Related Quality of Life (HRQoL) outcomes in a French population treated according to standard clinical practice. Materials and methods Multicentre, prospective, non-interventional study (PREMYA) of patients diagnosed with moderate to severe symptoms of uterine fibroids and undergoing a preoperative treatment with UPA 5 mg (Esmya ® ). Patients were followed for a total of 15 months (3 months UPA treatment and 12 months after). Data were collected approximatively every 3 months according to centre usual visit schedule. Results A total of 206 women were enrolled in France, of whom 197 were found to be eligible for data analysis. Physicians’ assessments of patients’ overall symptomatic changes, as measured on the Clinical Global Impression-Improvement (CGI-I) scale, indicated that 83.7% of patients were improved at end of treatment (month 3). On the patients’ treatment benefit scale (PTBS), 94.7% of patients reported an improvement. These 2 measurements, pain and quality of life, remained improved after treatment cessation and during the entire period of follow-up. Only 58.4% of patients underwent surgery within the timeframe of the study follow-up of which the majority were of a conservative/minimal invasive nature. Conclusion Many patients did not undergo surgery during the planned 12 months follow-up period after treatment whereas all patients had an indication of surgery. All measurements of treatment outcome were markedly improved by 3 months of UPA 5 mg treatment. Clinical trial number NCT01635452 .

Summary Dissection of a human cadaver is a particular rite of passage for medical students and, for a large majority, constitutes the students’ first confrontation with a dead human body. This process can be the subject of various reactions and concerns depending on the sensitivity of each student, due to the cultural beliefs of the individuals concerned. In order to highlight these variations of work related to personal traditions, the experiences of two groups of medical students from Benin and France in the autopsy room were surveyed via a questionnaire. Similarities and differences relating to behaviours and concerns of the physical and spiritual realms are then discussed.

To compare the outcomes of percutaneous image-guided cryoablation of symptomatic abdominal wall endometriosis (AWE) versus surgery alone. From 2004 to 2016, cryoablation or surgery alone was performed under local (n = 5) or general anaesthesia (n = 15) for AWE in a single institution in 7 (mean age, 36.1 years) and 13 (mean age, 31.9 years) patients, respectively. Fifteen lesions were treated by cryoablation (mean size, 2.3 cm; range, 0.5-7 cm) and 16 by surgery (2.5 cm; 1.1-3.4 cm). Tolerance, efficacy and patient and procedural characteristics were compared. Median follow-up was 22.5 (range, 6-42) months after cryoablation and 54 (14-149) after surgery. The median procedure and hospitalisation durations were 41.5 min (24-66) and 0.8 days (0-1) after cryoablation, and 73.5 min (35-160) and 2.8 days (1-12 days) after surgery (both P = 0.01). Three patients (23.1%) had severe complications and nine aesthetic sequels (69.2%) after surgery, none after cryoablation (P = 0.05). The median 12- and 24-month symptom free-survival rates were 100% and 66.7% (95% CI, 5.4; 94.5) after cryoablation and 92% (55.3; 98.9) after surgery at both time points (P = 0.45). Cryoablation presents similar effectiveness to surgery alone for local control of AWE while reducing hospitalisation duration and complications. Any aesthetic sequels were associated with the cryoablation treatment. • Hospitalisation is shorter after cryoablation than after surgery of abdominal wall endometriosis. • A significantly lower rate of complications is observed after cryoablation compared to surgery. • Cryoablation of abdominal wall endometriosis presents similar effectiveness to surgery alone. • A significant reduction of pain is observed 6 months after treatment. • A significant reduction of abdominal wall endometriosis is observed at 6 months.

International audience; This work was carried out under the aegis of the CNGOF (Collège national des gynécologues et obstétriciens français) and proposes guidelines based on the evidence available in the literature. The objective was to define the diagnostic and surgical management strategy, the fertility preservation and surveillance strategy in Borderline Ovarian Tumor (BOT). No screening modality can be proposed in the general population. An expert pathological review is recommended in case of doubt concerning the borderline nature, the histological subtype, the invasive nature of the implant, for all micropapillary/cribriform serous BOT or in the presence of peritoneal implants, and for all mucinous or clear cell tumors (grade C). Macroscopic MRI analysis should be performed to differentiate the different subtypes of BOT: serous, seromucinous and mucinous (intestinal type) (grade C). If preoperative biomarkers are normal, follow up of biomarkers is not recommended (grade C). In cases of bilateral early serous BOT with a desire to preserve fertility and/or endocrine function, it is recommended to perform a bilateral cystectomy if possible (grade B). In case of early mucinous BOT, with a desire to preserve fertility and/or endocrine function, it is recommended to perform a unilateral adnexectomy (grade C). Secondary surgical staging is recommended in case of serous BOT with micropapillary appearance and uncomplete inspection of the abdominal cavity during initial surgery (grade C). For early-stage serous or mucinous BOT, it is not recommended to perform a systematic hysterectomy (grade C). Follow up after BOT must be pursued for more than 5 years (grade B). Conservative treatment involving at least the conservation of the uterus and a fragment of the ovary in a patient wishing to conceive may be proposed in advanced stages of BOT (grade C). A new surgical treatment that preserves fertility after a first non-invasive recurrence may be proposed in women of childbearing age (grade C). It is recommended to offer a specialized consultation for Reproductive Medicine when diagnosing BOT in a woman of childbearing age. Hormonal contraceptive use after serous or mucinous BOT is not contraindicated (grade C).

Introduction Music Care is a smartphone-based music intervention for pain and anxiety management that has previously been evaluated in large variety of patients with primary chronic painful conditions. The objective of this study was to evaluate the use of the app to reduce pain and anxiety in women attending an obstetrics before or during labor. Methods This observational study describes the first evaluation of the app in 62 women before or during labor in a department of obstetrics. Results Participants reported a significant reduction of pain intensity and anxiety after the use of the intervention, with small to moderate effect-size for pain reduction (ES 0.32) and large effect size for anxiety reduction (ES 0.76). Responder rates (> = 33% pre-post reduction of pain/anxiety) for ratings of pain intensity were at 31.6% (n = 19) and 50% for anxiety (n = 31). In general, participants rated high satisfaction with the intervention. Conclusion Overall, these data support the use of the Music Care app as adjuvant tool – in particular for the reduction of pain and anxiety in women in labor. More large-scaled and well-controlled studies are needed to further evaluate the effectiveness of this intervention.

Pelvic inflammatory diseases (PID) must be suspected when spontaneous pelvic pain is associated with induced adnexal or uterine pain (grade B). Pelvic ultrasonography is necessary to rule out tubo-ovarian abscess (TOA) (grade C). Microbiological diagnosis requires endocervical and TOA sampling for molecular and bacteriological analysis (grade B). First-line treatment for uncomplicated PID combines ceftriaxone 1 g, once, IM or IV, doxycycline 100 mg ×2/day, and metronidazole 500 mg ×2/day PO for 10 days (grade A). First-line treatment for complicated PID combines IV ceftriaxone 1-2 g/day until clinical improvement, doxycycline 100 mg ×2/day, IV or PO, and metronidazole 500 mg ×3/day, IV or PO for 14 days (grade B). Drainage of TOA is indicated if the pelvic fluid collection measures more than 3 cm (grade B). Follow-up is required in women with sexually transmitted infections (STIs) (grade C). The use of condoms is recommended (grade B). Vaginal sampling for microbiological diagnosis is recommended 3-6 months after PID (grade C), before the insertion of an intrauterine device (grade B), and before elective termination of pregnancy or hysterosalpingography. When specific bacteria are identified, antibiotics targeted at them are preferable to systematic antibiotic prophylaxis.

Objective: To study epidemiologic, diagnostic, therapeutic and prognostic aspects of hydatidiform mole (HM) at CHUD/B. Material and methods: It was about a retrospective descriptive study which covered a 10- year period from 1 st January 2007 to 31st December 2016. It was performed in the gynecological department of the University Teaching Hospital of Borgou/ Alibori. Results: Ninety-one cases of HM meeting inclusion criteria were collected. The incidence of HM was 1 mole in 246 pregnancies. The 20- 29 age group was the most affected (46.2%). Most of the patients were not attending school (50.5%) and they were housewives predominantly (52.7%). Metrorrhagia represented the most frequent circumstance of discovery (81.3%). It was noticed excessive fundal height in 79.1% of cases. β-HCG proportioning was carried out in 13 patients out of 91 (14.3%). The anatomopathological examination confirmed the diagnosis of HM in 2 of 9 cases. The treatment was a uterine evacuation by intrauterine manual vacuum aspiration (MVA) in 76.9% of cases. After 12 months, almost all of our patients were lost to follow-up, the cure rate was 9.9%. Conclusion: HM is relatively frequent at the maternity hospital of CHUD/B and its management is hampered by a lack of monitoring which must be reviewed in order to improve prognosis. Objectif : Etudier les aspects epidemiologique, diagnostique, therapeutique et pronostique de la mole hydatiforme (MH) au CHUD/B. Materiel et Methodes : Il s’est agi d’une etude retrospective de type descriptif s’etendant sur une periode de 10 ans allant du 1 er Janvier 2007 au 31 Decembre 2016. Elle a eu pour cadre, le service de gynecologie du Centre Hospitalier Universitaire du Borgou/ Alibori. Resultats : Quatre-vingt-onze cas de MH remplissant les criteres d’inclusion ont ete colliges. La frequence de la MH etait de 1 e mole pour 246 grossesses. La tranche d’âge de 20 a 29 ans etait la plus concernee (46,2%). Les patientes etaient en majorite non scolarisees (50,5%) et etaient a predominance des femmes au foyer (52,7%). Les metrorragies representaient la circonstance de decouverte la plus frequente (81,3%). La hauteur uterine excessive avait ete retrouvee dans 79,1% des cas. L’echographie pelvienne avait revele des images typiques en grappe de raisin dans 96,4% des cas. Le dosage des β-hCG avait ete realise chez 13 patientes sur 91 (14,3%). L’examen anatomopathologique avait permis de confirmer le diagnostic de MH dans 2 cas sur 9. Le traitement etait une evacuation uterine par aspiration manuelle intra-uterine dans 76,9% des cas. Au bout de 12 mois, presque toutes nos patientes etaient perdues de vue, le taux de guerison etant de 9,9%. Conclusion : La MH est relativement frequente a la maternite du CHUD/B et sa prise en charge souffre d’une insuffisance de surveillance qui doit etre revue afin d’ameliorer le pronostic.

Objective: To analyse the colposcopy results at the Gynaecological Clinic of Houeyiho. Patients and methods: Retrospective, descriptive and analytical studies were conducted by the Clinic of Houeyiho in Cotonou from January 2013 to December 2015. Results: 440 women were received in colposcopy including 251 (57%) referred by health workers for VIA (Visual Inspection with Acetique Acid)/VILI (Visual Inspection with Lugol’s Iodine) abnormalities, forty-seven (47) for abnormal smears (10.7%), thirty-eight (38) for metrorrhagia (8.6%). 10% of cases were mainly concerned with post-therapeutic monitoring (six colposcopies of the vagina fundus after hysterectomy for cervical cancer and four after conization). The average age of patients is 41 years within plus or minus 5 years. Forty (40) cases of Grade 1 Atypical Transformation, twenty-nine (29) cases of Grade 2 Atypical Transformation including two (2) cases of leukoplakia (1 post-conization for CINIII, 1 in a HIV+ patient), ten (10) cases of Grade 1 Atypical Transformation/Grade 2 Atypical Transformation association were recorded. A colposcopy biopsy was performed in 95 patients meaning 21.6% of patients. Five biopsies were realized for a cervical neoplasia suspicion and were sent to Pasteur Cerba laboratory in France for the sake of efficiency and rapidity of results. In Grade 1 Atypical Transformation, 66.6% of CIN1 and condylomata plana were noted. Nevertheless, a case of mucinous adenocarcinoma with metaplasia has been discovered in a TAG1 with a 23-year old patient. In Grade 2 Atypical Transformation, the histology reveals 44.4% of CIN 1, 40.7% of severe dysplasia and 11.1% of carcinomas. Conclusion: The colposcopy may be a good screening method with a good colpo-histology agreement in Cotonou. But it’s relatively expensive (20.000 CFA francs) and the reduced number of colposcopists restricts its use in Benin.

The incidence (rate per 100 000) of borderline ovarian tumors (BOTs) increases progressively with age, starting at 15-19 years and peaking at around 4.5 cases per 100 000 at an age of 55-59 years (LE3) with a median age of 46 years. The five year survival for FIGO stages I, II, III and IV is 99.7 % (95 % CI: 96.2-100 %), 99.6 % (95 % CI: 92.6-100 %), 95.3 % (95 % CI: 91.8-97.4 %) and 77.1 % (95 % CI: 58.0-88.3 %), respectively (LE3). An epidemiological association exists between the individual risk of BOT and family history of BOT and certain other cancers (pancreatic, lung, bone, leukemia) (LE3), a personal history of benign ovarian cyst (LE2), a personal history of tubo-ovarian infection (LE3), the use of a levonorgestrel intrauterine device (LE3), oral contraceptive use (LE3), multiparity (LE3), Hormonal replacement therapy (LE3), high consumption of Coumestrol (LE4), medical treatment for infertility with progesterone (LE3) and non-steroidal anti-inflammatory drug use (LE3). Screening for BOTs is not recommended for patients (Grade C). The overall risk of recurrence of BOTs varies between 2% and 24 %, with an overall survival greater than 94 % at 10 years, and the risk of an invasive recurrence of a BOT ranges from 0.5 % to 3.8 %. The use of scores and nomograms can be useful in assessing the risk of recurrence, and providing patients with information (Grade C). The WHO classification is recommended for classifying BOTs. It is recommended that the presence of a microinvasive focus (5 mm) and microinvasive carcinoma (5 mm with an atypical nuclei and a desmoplastic stroma reaction) within a BOT be reported. In cases of serous BOT, it is recommended to specify the classic histological subtype or micropapillary / cribriform type (Grade C). When confronted with a BOT, it is recommended that the invasive or non-invasive nature of peritoneal implants can be investigated based solely on the invasion and destruction of underlying adipose or peritoneal tissue which has a desmoplastic stromal reaction where in contact with the invasive clusters (Grade B). For bilateral mucinous BOTs and / or in cases with peritoneal implants or peritoneal pseudomyxoma, it is recommended to also look for a primitive digestive or pancreato-biliary cancer (Grade C). It is recommended to sample ovarian tumors suspected of being BOTs by focusing samples on vegetations and solid components, with at least 1 sample per cm in tumors with a size less than 10 cm and 2 samples per cm in tumors with a size greater than 10 cm (Grade C). In cases of BOTs and in the absence of macroscopic omental involvement after careful macroscopic examination, it is recommended to perform at least 4-6 systematic sampling blocks and to include all peritoneal implants (Grade C). It is recommended to consult an expert pathologist in gynecology when a BOT suspicion requires intraoperative extemporaneous histology (grade C). Endo-vaginal and suprapubic ultrasonography are recommended for the analysis of an ovarian mass (Grade A). In case of an undetermined ovarian lesion on ultrasonography, it is recommended that a pelvic MRI be performed (Grade A). To analyze an adnexal mass with MRI, it is recommended to use an MRI protocol with T2, T1, T1 Fat Sat, dynamic and diffusion sequences as well as gadolinium injection (Grade B). To characterize an adnexal mass with MRI, it is recommended to include a score system for malignancy (ADNEX MR/O-RADS) (Grade C) in the report and to formulate a histological hypothesis (Grade C). Pelvic MRI is recommended to characterize a tumor suspected of being a BOT (Grade C). Macroscopic MRI features should be analyzed to differentiate BOT subtypes (Grade C). Pelvic ultrasound is the first-line examination for the detection and characterization of adnexal masses during pregnancy (Grade C). Pelvic MRI is recommended from 12 weeks of gestation in case of an indeterminate adnexal mass and should provide a diagnostic score (Grade C). Gadolinium injection must be minimized as fetal impairment has been proven (Grade C). It is recommended that serum levels of HE4 and CA125 be evaluated and that the ROMA score for the diagnosis of an indeterminate ovarian mass on imaging be used (grade A). In case of suspicion of a mucinous BOT on imaging, dosage of serum levels of CA 19-9 can be considered (Grade C). If the determination of tumor markers is normal preoperatively, routine dosage of tumor markers in BOT follow-up is not recommended (Grade C). In case of preoperative elevation in tumor markers, the determination of serum CA 125 levels is recommended in the follow-up of BOT (Grade B). When conservative treatment of a BOT has been adopted, the use of endovaginal and transabdominal ultrasonography is recommended during follow-up (Grade B).

In the Early Stages (ES) of Borderline Ovarian Tumor (BOT), if surgery without risk of tumor rupture is possible, then laparoscopy with protected extraction is recommended over laparotomy (Grade C). In case of bilateral serous ES BOT treatment with a strategy to preserve fertility and/or endocrine function, bilateral cystectomy is recommended if possible (Grade B). In case of mucinous BOT treatment with a strategy to preserve fertility and/or endocrine function, unilateral adnexectomy is recommended (grade C). In the case of a mucinous BOT in a patient who has had an initial cystectomy, unilateral adnexectomy is recommended (grade C). In the case of treatment of a serous ES BOT in a patient who has had an initial cystectomy, with a strategy to preserve fertility and/or endocrine function, restaging surgery for adnexectomy is not recommended in the absence of suspicious residual lesions at the time of surgery and/or postoperative imaging (reference ultrasonography or pelvic MRI) (grade C). For serous or mucinous ES BOTs, routine hysterectomy is not recommended (Grade C). In cases of ES BOTs, lymphadenectomy is not recommended (Grade C). For ES BOTs, appendectomy is recommended only if there is a macroscopically pathological aspect to the appendix (Grade C). Restaging surgery is recommended in case of a serous BOT with a micropapillary aspect and an unsatisfactory inspection of the abdominal cavity during initial surgery (Grade C). Restaging surgery is recommended in cases of mucinous BOT if only a cystectomy has been performed or if the appendix has not been evaluated (Grade C). If restaging surgery is decided for an ES BOT, the following procedures should be performed: peritoneal cytology (grade C), omentectomy (there is no data in literature to recommend which type of omentectomy should be performed) (grade B), complete exploration of the abdominal cavity with peritoneal biopsies (grade C), visualization of the appendix +/- appendectomy in case of pathological macroscopic appearance (grade C) and unilateral adnexectomy in case of a mucinous BOT (grade C). In advanced stages of BOT it is not recommended to perform a lymphadenectomy as a routine procedure (Grade C). In cases of an advanced stage BOT, in a patient with a desire to fall pregnant, conservative treatment involving preservation of the uterus and all or part of the ovary may be proposed after a multidisciplinary meeting (Grade C). Second surgery aimed at removing all lesions, if not performed initially, is recommended in cases of advanced stage BOT (Grade C). It is not recommended to perform completion surgery after conservative treatment (preservation of the ovaries and the uterus) and after the achievement of fertility desire for a serous BOT (Grade B). After treatment for a BOT, follow-up beyond 5 years is recommended due to the median time to recurrence (Grade B). It is recommended that a systematic clinical examination be carried out during follow-up of a treated BOT (Grade B). In the particular case of an initial elevation of CA 125 levels, it is recommended to monitor CA 125 during follow up (Grade B). In cases treated conservatively (ovarian and uterine conservation), it is recommended to use endovaginal and transabdominal ultrasonography during the follow up period (Grade B). In the event of a recurrence of a BOT, in a woman of childbearing age, a conservative treatment strategy can again be proposed (Grade C). In the presence of non-invasive BOT implants, conservative treatment may be considered after a first non-invasive recurrence in women who wish to preserve their fertility (Grade C). Pelvic MRI is recommended after 12 weeks of amenorrhea in case of an undetermined adnexal mass and should be concluded with a diagnostic score (Grade C). The injection of gadolinium, in case of pregnancy, should be discussed on a case-by-case basis due to the proven risks for the foetus (Grade C). If feasible, a laparoscopic approach should be preferred during pregnancy (Grade C). A consultation with a specialist reproductive physician should be offered to patients with a BOT and of childbearing age (Grade C). It is recommended that patients be provided with full information on the risk of decreased ovarian reserve following to surgical treatment. It is recommended that the ovarian reserve be evaluated prior to surgical management of a suspected BOT (Grade C). When possible, a conservative surgical strategy is recommended to preserve fertility in women of childbearing age (Grade C). There is no specific data on the management of infertility following to conservative treatment of BOT. In case of durable infertility following to conservative treatment of BOT, a consultation with a specialist reproductive physician is required (Grade C). In the case of optimally treated BOT, there is no evidence in literature to contraindicate the use of Assisted Reproductive Techniques (ART). The use of hormonal contraception after serous or mucinous BOT is not contraindicated (Grade C). After treatment of a mucinous BOT, for women aged under 45 years, given the benefit of hormonal replacement therapy (HRT) on cardiovascular and bone risks, and the lack of hormone-sensitivity of mucinous BOTs, it is recommended to offer HRT (Grade C). After treatment of a mucinous BOT, for women over 45 years of age, there is no argument to contraindicate the use of HRT. HRT can be prescribed in case of a climacteric syndrome, as part of an individual benefit to risk assessment (Grade C).

Objective To evaluate the performance of magnetic resonance imaging (MRI) with susceptibility-weighted imaging (SWI) in the assessment of endometriosis. Material and methods This prospective study was performed during the diagnostic step or the pre-operative assessment of endometriosis, between June 2017 and April 2018. The MRI was conducted with a 3T MRI device; protocol included T2W, T1W, with and without fat-saturation sequences completed with a SWI sequence: T2-star weighted angiography (SWAN). The diagnostic performance values of MRI and inter-observer agreement were first evaluated with a conventional MR protocol and then with the complementary SWAN sequence by 2 readers. MRI results were correlated with surgical findings in patients who underwent laparoscopy. Results 74 patients were included in the study, and among them 10 patients were treated by laparoscopy. 81% of the endometriosis lesions had signal losses on the SWAN sequence related to hemorrhagic character whereas only 52% of the lesions had T1-weighted hyperintense implants. Diagnostic performance of the MRI examination was improved by the use of the SWAN sequence compared to the conventional MR protocol (Se = 94% and Spe = 73% in complete protocol and Se = 88% and Spe = 69% in conventional protocol), especially for the involvement of torus uterinus, utero-sacral ligament and retro-cervical site. An excellent interobserver agreement (қ-value = 0,94) was noted between the two readers. Conclusion SWI can improve the diagnostic accuracy of MRI by allowing the detection of hemorrhagic character of endometriosis lesions.

Endometriosis is a common condition that causes pain and infertility. It can lead to absenteeism and also to multiple surgeries with a consequent risk of impaired fertility, and constitutes a major public health cost. Despite the existence of numerous national and international guidelines, the management of endometriosis remains suboptimal. To address this issue, the French College of Gynaecologists and Obstetricians (CNGOF) and the Society of Gynaecological and Pelvic Surgery (SCGP) convened a committee of experts tasked with defining the criteria for establishing a system of care networks, headed by Expert Centres, covering all of mainland France and its overseas territories. This document sets out the criteria for the designation of Expert Centres. It will serve as a guide for the authorities concerned, to ensure that the means are provided to adequately manage patients with endometriosis.

Objective To retrospectively compare the imaging findings and the outcomes for patients with vascular uterine abnormalities (VUA) and to identify prognostic factors. Material and methods Between 2007 and 2012, 38 patients with vaginal bleeding and abnormal ultrasonographic (US) findings consistent with acquired VUA were consecutively included (mean age 31.6 years, range 19–62). Follow-up was 32 months in mean (1–78 months). Seventeen women (44.7%) started bleeding immediately after curettage, spontaneous miscarriage, trophoblastic disease, or section scars, with the remainder starting bleeding after 8 days to 2 years. All US, CT ( n = 2), MR ( n = 5) and angiographic ( n = 26) images were reviewed and compared to medical reports in order to identify severe VUA requiring treatment, and predictive factors. Results No information about severity was provided by US, MRI or CT. Twelve patients were successfully managed conservatively. Angiography identified 6 non-severe VUA, corresponding to an isolated uterine hyperemia, and 20 severe VUA, corresponding to an association of a nidus and early venous drainage. Recurrences were more often observed for severe VUA ( p = 0.001). The hemoglobin level was significantly lower (below 11 g/L) in these cases ( p = 0.004). Recurrences were significantly more frequently observed for patients with history of dilatation and curettage ( p = 0.02). Hysterectomy was performed for three patients only (8%). Among the women who wished to have children, 14 (77.8%) were pregnant after 9 months in mean (range 2–23). Conclusions Recurrence happens more frequently after curettage and in case of anemia or severe VUA findings on angiography, justifying adequate embolization for these patients.

Background. Basidiobolomycosis is a rare subcutaneous mycosis, which can be mistaken for several other diseases, such as soft tissue tumors, lymphoma, or Buruli ulcer in the preulcerative stage. Microbiological confirmation by PCR for Basidiobolus ranarum and culture yield the most specific diagnosis, yet they are not widely available in endemic areas and with varying sensitivity. A combination of histopathological findings, namely, granulomatous inflammation with giant cells, septate hyphal fragments, and the Splendore-Hoeppli phenomenon, can confirm basidiobolomycosis in patients presenting with painless, hard induration of soft tissue. Case Presentations. We report on three patients misdiagnosed as suffering from Buruli ulcer, who did not respond to Buruli treatment. Histopathological review of the tissue sections from these patients suggests basidiobolomycosis. All patients had been lost to follow-up, and none received antifungal therapy. On visiting the patients at their homes, two were reported to have died of unknown causes. The third patient was found alive and well and had experienced local spontaneous healing. Conclusion. Basidiobolomycosis is a rare subcutaneous fungal disease mimicking preulcerative Buruli ulcer. We stress the importance of the early recognition by clinicians and pathologists of this treatable disease, so patients can timely receive antifungal therapy.

We conducted a survey to assess the performance of preoperative staging and the application of French surgical guidelines in women with presumed stage I endometrial cancer (EC). The survey included 26 questions about the number of patients in low-, intermediate-, and high-risk groups operated on in 2012, the proportion of patients upstaged or downstaged by the examination of the uterus, and the proportion of subsequent surgery for lymph node dissection. Thirty-two (70 %) of the 46 French university hospitals responded to the questionnaire. Among 886 patients with EC treated, 661 had stage 1 EC. The rates of presumed preoperative type 1 low-, intermediate-, high-risk EC and type 2 EC were 310 (46.9 %), 218 (33 %), 39 (5.9 %), and 94 (14.2 %) respectively. Among 567 type 1 patients, 35 % were upstaged and 6 % were downstaged. Fair agreement was found between preoperative and postoperative risk assessment (κ = 0.37). Patients with presumed low- and intermediate-risk EC upstaged postoperatively to FIGO stage II/III were more likely to have a restaging operation than patients upstaged to type 1 high-risk FIGO stage I EC: 37/70 (52.8 %) versus 26/75 (34.6 %), p = 0.027. The proportions of patients undergoing the recommended subsequent pelvic and/or para-aortic lymph node dissection were low: 34/85 (40 %) and 47/145 (32.4 %) respectively. Lymph node samplings were mainly performed by laparoscopy: 31/34 (91.2 %) and 40/47 (85.1 %) for pelvic and para-aortic dissection respectively. Our survey showed that the performance of preoperative assessment of FIGO stage I EC was moderate and that adherence to the guidelines was low.

Targeted immunotherapy of high-grade cervical intra-epithelial neoplasia (CIN) has been developed as an alternative to conization, to preserve future reproductive outcomes and avoid human papillomavirus (HPV) persistence. The objectives of the review are to present drugs according to their process of development and to examine their potential future use. A search for key words associated with CIN and targeted immunotherapy was carried out in the Cochrane library, Pubmed, Embase, and ClinicalTrials.gov from 1990 to 2016. Publications (randomized, prospective and retrospective studies) in any language were eligible for inclusion, as well as ongoing trials registered on the ClinicalTrials.gov website. Targeted immunotherapy includes peptide/protein-based vaccines, nucleic acid-based vaccines (DNA), and live vector-based vaccines (bacterial or viral). A total of 18 vaccines were identified for treatment of CIN at various stages of development, and the majority were well-tolerated. Adverse effects were primarily injection site reactions and flu-like symptoms under grade 2. The efficacy of vaccines defined by regression of CIN2/3 to no CIN or CIN1 ranged from 17 to 59% following a minimum of a 12-week follow-up. In the majority of studies, there was no association demonstrated between histological response and HPV clearance, or between histological or virological response and immune T cell response. Given that the spontaneous regression of CIN2/3 is 20-25% at 6 months, targeted immunotherapy occurs an additional value, which never reaches 50%, with one trial an exception to this. However, research and development on HPV eradication drugs needs to be encouraged, due to HPV-associated disease burden.

Human papilloma virus (HPV) infection remains a worldwide concern, especially in Sub-Saharan Africa where cervical cancer is the leading cause of cancer death in women. The aim of the study was to determine the prevalence and genotypic distribution of High-Risk HPV (HR-HPV) involved in Cervical Intraepithelial Neoplasia (CIN) II and III and in cervical cancer in Parakou. Out of a total of 149 samples of cervical tissues archived, fixed and paraffin-embedded, 78 samples with histological diagnosis of CIN-II, CIN-III and cervical cancer went through deparaffinization with xylene, followed by an extraction of HPV DNA and the detection of HR-HPV by real-time multiplex PCR. The average age of the women was 40.05±13.99 years. The samples were positive to at least one HR-HPV genotype in 76.92% (50/65) of cases. The HR-HPV genotypes which are most common in the cervical cancer and in CIN-II and III were, respectively HPV-39 (38 and 37.50%), HPV-18 (35 and 31.30%), HPV-45 (35 and 31.30%), HPV-35 (9 and 25%) and HPV-52 (9 and 12.50%). The HPV-16 was absent. This study helped to detect (in samples archived, fixed and paraffin-embedded tissues) HR-HPV involved in high-grade precancerous lesions and in cervical cancer in Parakou, some of which are not covered by currently available vaccines.

To determine the proportion and the characteristics of patients who did or did not respond after 3 months of ulipristal acetate (UPA) therapy.In this retrospective cohort study conducted in the University Hospital of Bordeaux (France) and University Medical Center Ljubljana (Slovenia), symptomatic non-menopausal patients with fibroids that qualified for surgery were pretreated by 3 months of oral UPA 5 mg/day. Clinical success was defined by normalization of the bleeding score, and/or regression of pelvic pain, and/or abdominal distension. Imaging success was defined by reduction in fibroid volume ≥ 25%.The clinical and imaging success rates were 54/66 (82%) and 39/66 (59%) respectively. The absence of previous pregnancy (p = 0.004) and the size of the dominant fibroid ≥ 80 mm (p = 0.004) were independent factors associated with clinical failure. Age35 years (p = 0.02) was the only independent factor associated with imaging failure.Young women developing fibroids and/or women with large fibroids may be resistant to ulipristal acetate therapy.

Objective The aim of this study was to evaluate 36 quality indicators (QIs) for monitoring the quality of care of uterine cancer to be implemented in the EFFECT (effectiveness of endometrial cancer treatment) project. Methods The 36 QIs were evaluated in the first 10 patients diagnosed with endometrial cancer and managed in 14 French hospitals in 2011. To assess the status of each QI, a questionnaire detailing the 36 QIs was sent to each hospital, and the information was cross-checked with information from the multidisciplinary staff meeting, surgical reports, and pathological reports. The QIs were evaluated in terms of measurability and improvability. The remaining QIs were evaluated with a multiple correspondence analysis to highlight the interrelationships between qualitative variables describing a population. Results Thirteen of the 14 institutions responded to the survey for a total of 130 patients. Twenty-five of the 36 QIs affected less than 80% of the patients. Thirteen QIs were found not to be improvable because they reached more than 95% of the theoretical target. Finally, 5 QIs concerning more than 80% of the patients were found to be improvable. The multiple correspondence analysis finally identified 3 dimensions—outcome, safety, and perioperative management—that included the 5 QIs. Conclusions In the present study, 5 of the 36 QIs suggested by the EFFECT project seem to be sufficient to report on the quality of endometrial cancer management. Further studies are needed to correlate the information provided by those 5 questions and the relevant outcomes reflecting quality of care in endometrial cancer.

Uterine fibroids are the commonest benign tumor of the female genital tract. They affect a significant proportion of reproductive aged women and while some women are asymptomatic, fibroids can cause excessive menstrual bleeding, pelvic pressure, and adversely affect reproductive outcomes. Myomectomy is the most suitable surgical option for women who desire preservation of their fertility potential. However, only a selected group of women of childbearing age will benefit from a myomectomy. Furthermore, the consequences of myomectomy on reproductive function have remained controversial. The purpose of this paper is to review the main surgical approaches for myomectomy - hysteroscopic resection, laparoscopic myomectomy and open myomectomy (by laparotomy) - and discuss evidence-based indications for myomectomy in women with fibroids, especially with regards to its impact on reproductive outcomes. A critical review of the literature pertaining to the surgical approaches of myomectomy and the indications for myomectomy was performed, focusing on their impact on fertility and reproductive outcomes. Myomectomy is useful for the treatment of symptomatic fibroids and in selected women with infertility. Symptomatic submucosal fibroids are classically treated by hysteroscopic resection. Symptomatic intramural and subserosal fibroids may be treated by myomectomy, either by laparotomy or laparoscopy depending on their number and size. Prophylactic myomectomy is not recommended for preventing obstetrical complications or the risk of leiomyosarcoma. Although fibroids can have a negative effect on fertility, only the removal of submucosal fibroids has been consistently shown to improve spontaneous fertility or outcomes of assisted reproduction technology.

The purpose of this preliminary study was to report the short-term local control of percutaneous image-guided cryoablation of localized symptomatic abdominal scar endometrioma. Four consecutive patients (mean age 34.5 years) with a total of ten lesions were included, with mean preoperative pain of 7 (range 5–9) on the visual analog scale. Cryoablation was performed in a single session under general anesthesia. Postoperative superficial edema disappeared within 2 weeks for all patients. No severe complications (>grade 2 according to the CTCAE classification) were reported. Mean postoperative pain was 1.7 at 6 months (range 0–5) and magnetic resonance imaging demonstrated a significant volume decrease for all patients (range 72.2–100 %; p = 0.028). Percutaneous cryoablation shows promising local control in patients with symptomatic abdominal wall endometriosis.

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 42 - N° 8 - p. 710-714

ObjectiveTo describe the surgical technique of the V-Y cutaneous supra-fascial (modified) gluteal advancement flaps for reconstruction after radical vulvectomy and to assess the outcome of patients according to their clinical characteristics.MethodsBetween January 2006 and July 2012, 36 V-Y flaps were performed in 21 patients to cover the defect after radical surgery of primary vulvar cancers. Surgery duration, blood loss, hospital stay, and wound healing were assessed according to patient age, body mass index (BMI), American Society of Anesthesiologists (ASA) score, and the initial defect size.ResultsMedian patient age, BMI, and ASA score were 80 (range, 31–91), 28 (range, 18–36), 3 (range, 1–3), respectively. Median surgery duration and blood loss were 180 minutes (range, 60–275) and 400 mL (range, 100–1000), respectively. Median operating time was higher in patients ASA3 than ASA less than 3, 200 versus 120 minutes (P = 0.038). Median initial defect size was higher in patients with BMI greater than 28 than 28 or less, 92 versus 55 cm2 (P = 0.004). Local scar defect was observed in 16 patients (76%), mild, less than 10 cm2 in 10 patients. Median wound healing duration was higher in patients with bilateral than unilateral flap, 16 versus 9.5 days (P = 0.034).ConclusionsThe V-Y cutaneous suprafascial gluteal advancement flap for vulvar reconstruction after vulvectomy is an easy, safe, and reliable procedure. However, even mild local scar defect after bilateral flap may impact on wound healing and hospital stay, in elderly and ASA3 patients.

Resume Motivee par l’arrivee de nouveaux antibiotiques et l’evolution des resistances bacteriennes, cette analyse methodique de la litterature actualise les recommandations emises par la conference de consensus francaise de 1993 concernant les infections genitales hautes (IGH) non compliquees. Une antibiotherapie doit etre mise en place precocement (NP3). Un traitement en hospitalisation, par voie intraveineuse, n’a pas d’avantage sur un traitement en externe, par voie orale (NP1). L’association ofloxacine + metronidazole peut etre proposee en premiere intention. (NP1). En cas de decouverte secondaire de gonocoque, une injection complementaire de ceftriaxone doit etre associee (NP4). Les autres associations ont aussi fait la preuve de leur efficacite sauf l’association metronidazole + doxycycline qui n’est pas indiquee (NP2). Une duree de deux semaines de traitement semble etre suffisante (NP4). Une prise en charge cœliochirugicale en premiere intention n’est pas justifiee en dehors des doutes diagnostiques ou d’une evolution defavorable du traitement medicamenteux (NP4). Ni les AINS, ni les corticoides n’ont fait la preuve de leur efficacite pour reduire le risque adherentiel des IGH non compliquees (NP3). L’ablation precoce d’un eventuel dispositif intra-uterin (DIU) permet une amelioration symptomatologique (NP2). Un traitement du (des) partenaire(s) par azithromycine permet une amelioration des resultats bacteriologiques a quatre mois (NP2). Les patientes seropositives pour le VIH ne necessitent pas de prise en charge specifique (NP3).

Background Asthma-related sudden deaths are rare. While most deaths occur in hospitalised individuals with severe asthma, it has been reported that sudden and unexpected death may occur in subjects with only mild disease. Objective To describe the exact causes of sudden death according to autopsy findings in asthmatic patients. Methods In this study, the clinicopathological features of 14 cases of asthmatic patients victims of sudden death, and autopsied in the Department of Forensic Medicine and Pathology (Garches, France) over a 19-year period are reported. Results Subjects were aged between 18 and 58 years (average = 39.3 years), with a male to female ratio of 9/5. Deaths occurred either at home, in another private place, in jail, in public place, but never at the hospital. Overweight and positive toxicology were common associated findings (respectively six individuals = 40%; four individuals = 28.6%). Conclusion Our study highlights the complexity of the mechanism of death, as asphyxia following bronchial diffuse obstruction is not always the only cause of sudden death in asthmatic patients: acute complications directly related to asthmatic hypo- or anoxia such as an ischemic cardiomyopathy, even in young individuals, may not be underestimated, because they considerably obscure the prognosis. More, a deleterious effect of long-term drugs may be present (particularly heart anomalies or biochemical disequilibrium) with acute aggravation due to asthmatic asphyxia. Last, control of overweight and alcohol/cannabis consummation should be intensified, as they are frequently associated to sudden death in our series of asthmatic patients.

Evidence of post-mortem breath movements are rarely reported. We present two cases of broncho-pulmonary aspiration of brain and cartilage tissue following two fatal suicidal gunshots to the head. We also discuss the physiopathological implications for the agony.

Vaginal agenesis in Mayer-Rokitansky-Küster-Hauser syndrome can be managed either by various surgeries or dilation. The choice still depends on surgeon's preferences rather than on quality comparative studies and validated protocols.We sought to compare dilation and surgical management of vaginal agenesis in Mayer-Rokitansky-Küster-Hauser syndrome, in terms of quality of life, anatomical results, and complications in a large multicenter population.Our multicenter study included 131 patients18 years, at least 1 year after completing vaginal agenesis management. All had an independent gynecological evaluation including a standardized pelvic exam, and completed the World Health Organization Quality of Life instrument (general quality of life) as well as the Female Sexual Function Index and Female Sexual Distress Scale-Revised (sexual quality of life) scales. Groups were: surgery (N = 84), dilation therapy (N = 26), and intercourse (N = 20). One patient was secondarily excluded because of incomplete surgical data. For statistics, data were compared using analysis of variance, Student, Kruskal-Wallis, Wilcoxon, and Student exact test.Mean age was 26.5 ± 5.5 years at inclusion. In all groups, World Health Organization Quality of Life scores were not different between patients and the general population except for lower psychosocial health and social relationship scores (which were not different between groups). Global Female Sexual Function Index scores were significantly lower in the surgery and dilation therapy groups (median 26 range [2.8-34.8] and 24.7 [2.6-34.4], respectively) than the intercourse group (30.2 [7.8-34.8], P = .044), which had a higher score only in the satisfaction dimension (P = .004). However, the scores in the other dimensions of Female Sexual Function Index were not different between groups. The Female Sexual Distress Scale-Revised median scores were, respectively, 17 [0-52], 20 [0-47], and 10 [10-40] in the surgery, dilation therapy, and intercourse groups (P = .38), with sexual distress in 71% of patients. Median vaginal depth was shorter in dilatation therapy group (9.6 cm [5.5-12]) compared to surgery group (11 cm [6-15]) and intercourse group (11 cm [6-12.5]) (P = .039), but remained within normal ranges. One bias in the surgery group was the high number of sigmoid vaginoplasties (57/84, 68%), but no differences were observed between surgeries. Only 4 patients achieved vaginas6.5 cm. Delay between management and first intercourse was 6 months (not significant). Seventy patients (53%) had dyspareunia (not significant), and 17 patients all from the surgery group had an abnormal pelvic exam. In the surgery group, 34 patients (40.5%) had complications, requiring 20 secondary surgeries in 17 patients, and 35 (42%) needed postoperative dilation. In the dilation therapy group, 13 (50%) needed maintenance dilation.Surgery is not superior to therapeutic or intercourse dilation, bears complications, and should therefore be only a second-line treatment. Psychological counseling is mandatory at diagnosis and during therapeutic management.

Lymphoepithelioma-like carcinoma (LELC), which is commonly reported in the nasopharynx and occasionally in other organs, remains a rare condition in gynecology. It is morphologically defined as a poorly differentiated carcinoma with prominent lymphoplasmacytic infiltrate. We present a case of an 82-year-old woman with a 10 cm LELC of the ovary shown by inguinal lymph nodes. There was no peritoneal carcinomatosis. Cytoreductive surgery was performed to remove a left ovarian neoplasm and multiple involved lymph nodes. Cytoreduction was complete. The tumor was a mixed poorly undifferentiated ovarian carcinoma consisting of 95% LELC and 5% moderately differentiated serous adenocarcinoma. Immunohistochemistry showed a large infiltration of T lymphocytes and plasma cells. Epstein-Barr virus was not detected by immunolabeling and polymerase chain reaction. The patient was still alive at 24 months of follow-up. To our knowledge, this is the second case of ovarian LELC and the first description of the native tumor before chemotherapy. In conclusion, this rare tumor of the ovary is difficult to diagnose both preoperatively and perioperatively. However, clinicians and pathologists should be aware that ovarian tumors with massive involvement of lymph nodes and no peritoneal carcinomatosis are suggestive of such a diagnosis and that prognosis is relatively good.

BACKGROUND: Menstruation is associated with a striking increase in matrix metalloproteinase (MMP) activity. However, it is still unknown whether the level of MMP activity correlates with the amount of menstrual bleeding. METHODS: We used histochemistry to investigate the degradation of the extracellular matrix (ECM), and immunohistochemical labelling and zymographic analysis to determine the level of expression and activity of MMP-2 and -9, and of their tissue inhibitors (TIMPs) -1, -2 and -3, in endometria sampled during menstruation in 14 women experiencing excessive menstrual bleeding and in 10 women successfully treated for menorrhagia by thermal ablation of the endometrium. RESULTS: After thermal ablation, regenerated menstrual endometria showed reduced areas of collagen fibre lysis and increased content of TIMP-1 and TIMP-2 compared with endometria from non-treated menorrhagic women. Surprisingly, treated endometria contained more latent gelatinase A (proMMP-2) but a lower proportion of the active form of gelatinase B (MMP-9) than non-treated endometria. CONCLUSIONS: These results suggest that ECM degradation is decreased at menstruation in the endometrium regenerated after thermal ablation, mostly because of an increased TIMP expression. This represents the first molecular explanation for the decreased amount of menstrual bleeding.

Objectives. To report various descriptions of the combination of a benign genital tumour with pleural and/or abdominal effusion throughout the years and to determine the paternity of this syndrome, commonly known as Meigs' syndrome. Methods. A systematic review of the literature from 1728 to 2004. Results. Before 1880, publications were rare and limited to clinical and anatomical descriptions drawing no conclusions between the cause and effect of this condition and even less about its management. Demons described the syndrome between 1887 and 1902. He was the first to specify that removal of the tumour (benign ovarian cyst, solid ovarian tumour, fibroma of the broad ligament) was essential for the patient to be cured of the effusions and that it was wrong to postpone surgery. In 1937, Meigs arrived at the same findings concerning ovarian fibromas and granulosa cell tumours, hence the name of Demons–Meigs which was given to this syndrome with the agreement of Meigs. Current literature reports on pseudosyndromes of Demons–Meigs including genital malignancies with negative cytology. These entities should not be called Demons or Meigs pseudosyndromes. Inversely, all benign tumours of the genital tract should be included in Demons syndrome, even if Demons did not actually encounter any during his years of practice, but it was in the spirit of his observations. Conclusion. Demons' syndrome includes all benign genital tumours, the Demons–Meigs eponym is reserved for the description of ovarian fibromas and granulosa cell tumours, and the Demons' pseudosyndrome includes all other entities.

International audience; Objective The aim of the study was to assess whether direct colposcopic ă vision (DCV) of the cervix during large loop excision of the ă transformation zone (LLETZ) is associated with a decrease in the volume ă and dimensions of specimens or affects margin status at histology. ă Materials and Methods A prospective multicenter observational study of ă 216 women who underwent LLETZ for grades 2 and 3 cervical ă intraepithelial neoplasia was conducted. The volume and dimensions ă (circumference, length, and thickness) of the surgical specimens were ă measured before fixation. Data were compared according to the use of ă colposcopy during LLETZ. The following 3 groups were considered: LLETZ ă performed without colposcopy (n = 91), LLETZ performed immediately after ă colposcopy (n = 51), and LLETZ performed under DCV (n = 74). ă Results Patient characteristics were comparable with regard to age, ă parity, history of excision, indication of the procedure, and the size ă of the cervix. We found a significant decrease in all dimensions of the ă specimens obtained under DCV (p < .001). Margin status was not affected. ă After adjusting for confounders, the mean volumes were significantly ă lower in the DCV group (adjusted mean difference = -0.66 mL; 95% CI = ă -1.17 to -0.14). The probability that negative margins would be achieved ă together with the attainment of a volume less than 5 mL and a thickness ă less than 10 mm was the highest in the DCV group (adjusted OR = 2.80; ă 95% CI = 1.13 to 6.90). ă Conclusions Direct colposcopic vision is associated with a significant ă decrease in the volume and in all dimensions of LLETZ specimens with no ă compromise in the margin status.

Objectives The objectives were to estimate the prevalence of Chlamydia trachomatis infection in subfertile couples and to study the relationship between markers of C. trachomatis infection and male infertility as well as pregnancy rates after in vitro fertilization (IVF). Study design All consecutive couples consulting for infertility and IVF in Pellegrin Hospital were screened for C. trachomatis by direct (PCR test) and serological methods. Results Two hundred and seventy-seven couples were included in the study (mean age in years: 35 for men, 32 for women; mean duration of infertility: 4 years). The most frequent indication for IVF was tubal factor in 33%, endometriosis in 6%, dysovarian function in 12%, male infertility in 36% and others in 13%. C. trachomatis PCR was positive in 1.2% of men, 95% confidence interval (CI 95% ): (0.2%; 3.3%) and in 2.7% of women, CI 95% : (1.1%; 5.5%). When combining all chlamydial markers, 17.3% of men, CI 95% : (12.7%; 22.8%) and 20.4% of women, CI 95% : (15.6%; 25.9%) had at least one positive marker. The presence of positive markers was not associated with altered semen characteristics. Couples with positive markers had a pregnancy rate of 23.1% (12 out of 52) compared with 20.2% (24 out of 119) among those with negative markers. Conclusion In this population, the presence of past or current C. trachomatis infection was associated with neither semen characteristics nor outcome of IVF in subfertile couples.

The paper briefly reviews the main pathologies of the endometrium that can be detected by hysteroscopy. Emphasis is put on dysfunctional endometrial bleeding and the recently discovered molecular mechanisms that trigger its occurrence, on the difference between hyperplasia and intra-epithelial neoplasia of the endometrium and on the DNA alterations commonly found in endometrial adenocarcinomas. This review of uterine pathology is intended for gynecologic endoscopists and is accordingly focused on lesions of the endometrium and of the inner portion of the myometrium.

Objectives: To evaluate oxidative and antioxidative status in pregnant diabetic women between 26 and 32 weeks of gestation. Design and Methods: Free and total malondialdehyde (MDA), superoxide dismutase (SOD), glutathione peroxidase (GPX), and vitamins A and E were determined in plasma and erythrocytes of 54 pregnant women. Among these, 27 were diabetics with either gestational diabetes mellitus (GDM), sub-group I, or previous insulin-dependent diabetes mellitus (type 1 diabetes), sub-group II. The other 27 patients were controls. Fasting plasma glucose and HbA 1c levels were determined in all women. Results: HbA 1c levels, plasma-, and erythrocyte-free MDA levels were significantly higher in all diabetic women and in both sub-groups than in controls. Plasma vitamin E and erythrocyte vitamin A levels were significantly lower in all diabetic women than in controls. Moreover, GPX and SOD activities were significantly reduced in all diabetic women, GPX in both sub-groups and SOD only in type 1 diabetes. Conclusions: The increased oxidative stress we demonstrated in pregnant women with previous type 1 diabetes or with GDM should be monitored by strictly controlling blood glucose during pregnancy with stringent recommendations and perhaps antioxidant supplementation.

Deciduosis classically occurs in the context of known endometriosis in the pelvis, most commonly in the ovaries, but also in the peritoneum. However, ovarian deciduosis outside the context of endometriosis is rare and makes diagnosis difficult, especially as the sonographic appearance suggests a malignant process. We report a case of decidualized ovarian mass in a patient without prior history of endometriosis that mimicked an ovarian malignancy. MRI may be a useful imaging modality to monitor these lesions and guide management. Consultation with a multidisciplinary team accustomed to such conditions will help to tailor the management to each individual.

International audience; We present here the results of our inter-disciplinary examination of the mummified heart of Blessed Anne-Madeleine Remuzat (1696–1730). This organ has been examined in the context of a canonization process. This analysis is related to important aspects of the early history of anatomy in Europe, that of “Holy autopsies”, and to the relationship between anatomical investigations, Catholic theology, and religious/medical customs. According to anatomical, genetic, toxicological, and palynological analyses, it has been shown that this organ has not been naturally (“miraculously”) conserved but embalmed using myrtle, honey, and lime. Moreover, a right ventricle dilatation has been diagnosed, that may represent a post-tuberculosis condition and may have played a role in the cause of death of this religious figure.

Transvaginal pelvic ultrasound is the first-line imaging examination for presumed benign ovarian tumors (PBOT) in adult women (Grade A). Ultrasound is sufficient for characterizing a unilocular anechoic cyst smaller than 7cm (Grade A). Magnetic resonance imaging is the recommended second-line investigation for indeterminate masses or masses larger than 7cm (Grade B). Serum CA-125 assay is not recommended for first-line diagnosis in adult women (Grade C). In women with a unilocular anechoic cyst, hormone therapy is ineffective and not recommended (Grade A). Ultrasound-guided aspiration is not recommended (Grade B). Abstention is an option in adult women with a unilocular asymptomatic anechoic cyst smaller than 10cm and no history of cancer (Grade B). If symptoms develop, laparoscopy is the gold standard for surgical treatment of PBOT (Grade A). Conservative surgical treatment (cystectomy) should be preferred to oophorectomy in pre-menopausal women without a previous history of cancer (Grade C). In cases of suspected adnexal torsion, laparoscopic surgical exploration is recommended (Grade B). Conservative treatment or detorsion without oophorectomy is recommended for pre-menopausal women regardless of the estimated torsion duration and macroscopic appearance of the ovary (Grade B). During pregnancy, expectant management is recommended for unilocular asymptomatic anechoic cysts smaller than 6cm (Grade C).

Angiotensin II antagonists (AIIA) are part of a new rational treatment of hypertension. Because adverse circulatory effects during anesthesia can occur in patients chronically treated with angiotensin-converting enzyme inhibitors, some clinicians discontinue them at least 24 h before operation. No data are available concerning AIIA administration in patients scheduled for vascular surgery performed under general anesthesia. The aim of this prospective randomized study was to compare hemodynamics during induction of anesthesia in patients chronically treated with AIIA and those of patients not receiving this drug on the morning before operation. Thirty-seven patients chronically treated with AIIA for hypertension were randomly assigned to two groups: Group I: AIIA discontinued on the day before surgery (n = 18); Group II: AIIA given 1 h before anesthesia (n = 19). Patients received sufentanil 0.4 microg/kg, propofol 1.5 mg/kg, and atracurium 0.5 mg/kg. During the procedure, the anesthesiologist was required to maintain systolic blood pressure and heart rate within 30% of baseline values using intravascular fluid administration and vasoconstric- tors (e.g. , ephedrine, phenylephrine, or terlipressin). Hemodynamic variables were recorded each 1 min. Hemodynamic study ended at incision. The number and duration of hemodynamic events were collected, and total doses of vasoactive drugs were noted in each group. Systolic arterial pressure was significantly decreased in Group II at 5, 15 and 23 min after induction of anesthesia (*P0.05). In this group, the decrease in systolic arterial pressure was associated with more frequent episodes of hypotension (AIIA withdrawn: 1 +/- 1; AIIA given: 2 +/- 1; P0.01), with a larger number of patients developing at least 1 episode of hypotension (AIIA withdrawn: 12; AIIA given: 19; P0.01), and a longer duration of an episode of hypotension (AIIA withdrawn: 3 +/- 4 min; AIIA given: 8 +/- 7 min; P0.01), and an increased need for vasoactive drugs. In conclusion, blockade of the renin-angiotensin system increases the potential hypotensive effect of anesthetic induction. A severe hypotensive episode, requiring vasoconstrictor treatment, occurs after induction of general anesthesia in patients chronically treated with AIIA. Recommendations to discontinue AIIA drugs on the day before the surgery may be justified.This prospective randomized study demonstrated that more severe hypotensive episodes, requiring vasoconstrictor treatment, occur after induction of general anesthesia in patients chronically treated with AIIA and receiving this drug on the morning before operation, in comparison with those in whom AIIA were discontinued on the day before operation. Recommendations to discontinue these drugs on the day before the surgery may be justified.

The aim of this study was to evaluate long-term results and to assess prognostic factors which have an impact on overall survival in patients with epithelial ovarian cancer.A retrospective analysis of 287 patients treated between 1975 and 1995 was performed. All operations were performed by senior surgeons. Histologic sections were reviewed by the same pathologist. Successive adjuvant chemotherapy regimens are described. Survival was evaluated in 1997. Follow-up lasted 25-260 months (median 90). Statistical methods included Kaplan-Meier survival curves, log-rank test, and multivariate analysis.The 5-year survival rates were 76, 42, 21, and 6% for patients with stage I, II, III, and IV disease, respectively. Age, FIGO stage, cytology of ascites, histologic type and grade, extent of surgery, and number of residual tumors were significant prognostic indicators in univariate analysis. Multivariate analysis showed that the risk of mortality according to FIGO stage was 2.8, 95% CI [1.2-6.3], P = 0.01 for FIGO II, 5.6, 95% CI [2.9-10.8], P0.001 for FIGO III, and 10.5, 95% CI [4.9-22. 1], P0.001 for FIGO IV in comparison with FIGO I. Patients with a serous epithelial carcinoma had a 1.7-fold higher risk of mortality than patients with other histologic types: RR = 1.7, 95% CI [1.1-2. 8], P0.001. Patients whose tumors distribution permitted optimal surgery had a 2.3-fold lower risk of mortality than patients treated with sub- or nonoptimal surgery: RR = 0.43, 95% CI [0.29-0.64], P0.001. The risk of mortality for patients treated with alkylating agents, platinum-based combination chemotherapy without taxanes, or carboplatin plus paclitaxel regimens compared with patients who did not receive treatment was reduced by 47%, 95% CI [8-69%], P = 0.025, 55%, 95% CI [22-74%], P = 0.005, and 70%, 95% CI [35-86%], P = 0.002, respectively.Our study confirms the benefit of cytoreductive surgery and the efficacy of platinum plus paclitaxel first-line chemotherapy which has recently been recognized as the standard treatment for advanced epithelial ovarian cancer.