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To validate a mathematical model to predict the mean time to delivery (TTD) following cervical ripening with dinoprostone vaginal insert (DVI), and assess its impact on the risk of nocturnal deliveries.We performed a case-control retro-prospective study at Angers University Hospital. In the control group, we retrospectively included 405 patients who underwent cervical ripening with DVI between 01/2015 and 09/2016. Based on the delivery outcomes, we developed a mathematical model that integrates all the factors influencing TTD following cervical ripening with DVI. In the study group, we prospectively included 223 patients who underwent cervical ripening with DVI between 11/2017 and 11/2018. The timing of insertion was calculated using the mathematical model developed in the control group, in order to prevent the occurrence of nocturnal deliveries.The calculated mean TTD was significantly shorter than the real mean TTD (21h46 min ± 3h28 min versus 25h38 min ± 12h10 min, p 0.001), and for 44% of patients, there was at least 10 h difference between the two. The real TTD (25h38 min ± 12H10 min versus 20h39 min ± 10h49, p 0.001), and the rate of nocturnal deliveries (30.5% versus 21.2%, p = 0.01) were significantly higher in the study group compared to the control group.The mathematical model did not help predicting TTD following cervical ripening with DVI, and or reducing the number of nocturnal deliveries.

The aim of this study was to evaluate an oocyte pick-up (OPU) simulation training program for residents using the high fidelity PickUpSimTM (Accurate, Cesena, Italy) simulator. The authors carried ...

Objectives: To compare the neonatal morbidity of caesarean sections (CS) performed after conversion from neuraxial (NA) to general anaesthesia (GA) with CS performed under GA from the outset, and to assess whether the increase in DDI in urgent and extremely urgent cases with conversion from NA to GA increased the risk of neonatal morbidity. Design: Retrospective cohort study. Setting: University-affiliated hospital. Population: All CS performed under GA between 2015 and 2019. Methods & main outcome measures: Our main criteria used for assessing neonatal morbidity were: neonatal pH

Preterm delivery is a risk factor for suboptimal neurodevelopment. Pregnancies conceived after medically assisted reproduction-which includes in vitro fertilization, with or without intracytoplasmic insemination, and induction of ovulation followed by intrauterine insemination or timed intercourse-have a higher risk of preterm delivery. Few studies have evaluated the outcome at2 years of age of such preterm-born children.To evaluate neurodevelopmental outcome at 5½ years of age of children born preterm according to the mode of conception (spontaneous vs medically assisted reproduction).A total of 4349 children born between 24 and 34 weeks of gestation who survived to 5½ years of age in the 2011 French prospective national cohort study "EPIPAGE-2" were included: 814 in the medically assisted reproduction group (433 by in vitro fertilization, with or without intracytoplasmic insemination, and 381 by induction of ovulation) and 3535 in the spontaneously conceived group. The studied neurodevelopmental outcomes were sensory (hearing and vision) impairments, cerebral palsy, cognition, and developmental coordination disorders. Multivariate analyses were performed with generalized estimating equation models adjusted for gestational age, antenatal steroids, and social characteristics. All analyses were performed following multiple imputation. Sensitivity analyses were performed with the populations of singletons and cases with complete data.No differences in cerebral palsy (adjusted odds ratio, 1.00; 95% confidence interval, 0.67-1.49), neurodevelopmental impairment (adjusted odds ratio, 1.09; 95% confidence interval, 0.82-1.45), or developmental coordination disorders (adjusted odds ratio, 0.75; 95% confidence interval, 0.50-1.12) were found between children born following medically assisted reproduction and children born following spontaneous conception after adjustment for sociodemographic factors. For proportions of children with an intelligence quotient below 1 and 2 standard deviations, there were no differences between those born after medically assisted reproduction and those born after spontaneous pregnancy (respectively, adjusted odds ratio, 0.99; 95% confidence interval, 0.80-1.23 and adjusted odds ratio, 1.14; 95% confidence interval, 0.83-1.56). In subgroup analyses, no differences were observed between children born following induction of ovulation or in vitro fertilization and those conceived spontaneously. Sensitivity analyses were consistent with the main results.In this cohort of preterm-born children, there was no evidence of an impact of the mode of conception on neurodevelopmental outcomes at 5½ years of age.

Objective To evaluate whether manual rotation of fetuses in occiput posterior positions at full dilation increases the rate of spontaneous vaginal delivery. Methods In an open, single-center, randomized controlled trial, patients with a term, singleton gestation, epidural analgesia, and ultrasonogram-confirmed occiput posterior position at the start of the second stage of labor were randomized to either manual rotation or expectant management. Our primary endpoint was the rate of spontaneous vaginal delivery. Secondary endpoints were operative vaginal delivery, cesarean delivery, and maternal and neonatal morbidity. Analyses were based on an intention-to-treat method. A sample size of 107 patients per group (n=214) was planned to detect a 20% increase in the percent of patients with a spontaneous vaginal delivery (assuming 60% without manual rotation vs 80% with manual rotation) with 90% power and alpha of 0.05. Results Between February 2017 and January 2020, 236 patients were randomized to either manual rotation (n=117) or expectant management (n=119). The success rate of the manual rotation maneuver, defined by conversion to an anterior position as confirmed by ultrasonogram, was 68%. The rate of the primary endpoint did not differ between the groups (58.1% in manual rotation group vs 59.7% in expectant management group (risk difference -1.6; 95% CI -14.1 to 11.0). Manual rotation did not decrease the rate of operative vaginal delivery (29.9% in manual rotation group vs 33.6% in expectant management group (risk difference -3.7; 95% CI -16.6 to 8.2) nor the rate of cesarean delivery (12.0% in manual rotation group vs 6.7% in expectant management group (risk difference 5.3; 95% CI -2.2 to 12.6). Maternal and neonatal morbidity was also similar across the two groups. Conclusion Manual rotation of occiput posterior positions at the start of second stage of labor does not increase the rate of vaginal delivery without instrumental assistance. Clinical trial registration ClinicalTrials.gov, NCT03009435.

Background The learning curve cumulative summation test (LC CUSUM test) allows to define an individualized learning curve and determine the moment when clinical proficiency is attained. After acquisition of the skills, the cumulative summation test (CUSUM test) allows to monitor the maintenance of the required level over time. The LC CUSUM test has been frequently used in the field of Obstetrics and Gynecology (Ob/Gyn) for several procedures, but only once for OR. Methods We performed a retrospective study at Angers university hospital between May 2017 and September 2018. Seven Ob/Gyn residents and 5 senior physicians were included, and all OR performed during that time (n = 690) were analyzed. The performance index assessed was the oocyte retrieval rate (ORR), defined as the ratio of oocytes retrieved to follicles aspirated. We used the LC CUSUM test to analyze the learning curves of residents, and the CUSUM test to monitor the performance of senior physicians. An ORR ≥50% in 60% of retrievals was defined as the threshold for clinical proficiency. Results Six hundred seventy-four oocyte retrieval (OR) were included: 315 were performed by residents, 220 by senior physicians, and 139 by both residents and physicians (mixed retrievals). Four residents (57%) reached the threshold after aspirating 82, 67, 53 and 46 ovaries, respectively. The mean number of ovaries aspirated in order to reach clinical proficiency was 62, and the mean number of weeks needed was 21. The duration of the learning period varied between 26 and 80 days. Two senior physicians (40%) remained proficient across the duration of the study, while two physicians (40%) had one statistically “suboptimal” OR, and one physician (20%) had two suboptimal retrievals. Conclusion There is a large variability in the duration of the learning period and the number of procedures needed for a resident to master OR. Senior physicians maintain an adequate performance.

The aim of this study was to evaluate an oocyte pick-up (OPU) simulation training program for residents using the high fidelity PickUpSim

Objectives: To investigate the perinatal outcomes of women with a history of female genital mutilation (FGM) who underwent clitoral reconstruction (CR) compared with women with FGM who did not undergo CR. Design: Retrospective case-control study Setting: Angers University Hospital, between 2005 and 2017 Methods: Inclusion criteria: pregnant women >18 years who underwent CR after FGM. Only the first subsequent delivery after CR was included. Each woman with CR was matched for age, ethnicity, FGM type, parity, and gestational age at the time of delivery with two women with FGM who did not undergo CR during the same period of time. Main outcome measures: at birth: need for episiotomy and intact perineum Results: 84 women were included (28 in the CR group; 56 in the control group). In the CR group, patients required significantly fewer episiotomies (5/17[29.4%]) compared to the control group (28/44[63.6%], p=0.02), even after excluding operative vaginal deliveries (2/13[15.4%] vs 21/36[58.3], p

OBJECTIVE: This study aimed to evaluate if manual rotation, undertaken during labor, of fetuses in occiput posterior or occiput transverse position led to an increased rate of spontaneous vaginal delivery. DATA SOURCES: Searches were performed in MEDLINE, Ovid, Scopus, ClinicalTrials.gov, and the Cochrane Central Register of Controlled Trials with the use of a combination of keywords and text words related to "occiput posterior," "occiput transverse," and "manual rotation" from inception of the databases to July 2021. STUDY ELIGIBILITY CRITERIA: We included all randomized controlled trials evaluating manual rotation of fetuses in the occiput posterior or occiput transverse position during labor. METHODS: The primary outcome was the rate of spontaneous vaginal delivery. Meta-analyses were performed using the random effects model of DerSimonian and Laird to determine the relative risks or mean differences with 95% confidence intervals. RESULTS: A total of 643 records were screened with inclusion of 6 articles and 1002 randomized patients. All included studies compared manual rotation of fetuses in occiput posterior or occiput transverse position, all confirmed using ultrasound examinations, after complete cervical dilation with either no rotation or a sham rotation procedure. There was no difference in the rate of spontaneous vaginal delivery with manual rotation (relative risk, 1.07; 95% confidence interval, 0.95-1.20) nor was there any difference in any other maternal or fetal outcomes. In a subgroup analysis of occiput posterior fetuses, there was a 12.80-minute decrease in the length of the second stage of labor in the manual rotation group (mean difference, -12.80; 95% confidence interval, -22.61 to -2.99). There were no significant differences in any other maternal or fetal outcomes in the occiput posterior subgroup and no differences in the occiput transverse subgroup. CONCLUSION: Prophylactic manual rotation of fetuses in occiput posterior or occiput transverse position, confirmed using ultrasound examination, did not increase the rate of spontaneous vaginal delivery compared with no manual rotation. Manual rotation of the occiput posterior fetal head early during the second stage of labor was associated with a significant 12.8-minute decrease in the length of the second stage of labor with no changes in any other maternal or fetal outcomes. There were no differences demonstrated for fetuses rotated from occiput transverse position or for the combination of occiput posterior and occiput transverse fetuses. Because there is some evidence of benefit, prophylactic manual rotation can be offered to patients during the second stage of labor presenting with occiput posterior position of the fetal head documented during ultrasound examination.

The objective of this study was to identify the factors predictive of the success of external cephalic version (ECV).A single-centre retrospective observational study was performed in the maternity ward of the Angers University Hospital, France, between January 2010 and May 2020. The study included all patients (n = 613) for whom an ECV was performed for a breech or transverse foetus. The primary endpoint was measured by the success of the ECV, defined by the visualisation, using pelvic ultrasound, of the foetus in cephalic presentation immediately after the manoeuvre. Following to the ECV, the cohort was separated into two groups; ECV Success and ECV Failure. In order to determine the predictive factors of success, a logistic regression model was performed, including the parameters of: parity, foetal presentation during ECV, the side of the foetal back, placental location, type of operator and maternal age. The results are presented as (odds ratio [confidence intervals]; p-value). The significance threshold was defined by a p-value0.05.The ECV success rate was 21.4% (131/613). The factors predictive of the success of ECV were: transverse foetal presentation (2.7 [1.3-5.6]; p0.01); a senior physician operator (1.6 [1.2-2]; p0.01); multiparity (1.6 [1.2-2]; p0.01); non anterior placental localization (1.4 [1.1-2]; p0.01). A number of attempts greater than 3 were significantly associated with reduced chances of success (0.3 [0.2-0.4]; p0.01).The study shows that transverse foetal presentation, a senior physician operator, multiparity, as well as a non-anterior placental location are factors predictive of the success of ECV. Knowledge of these factors can improve the information given to patients.

The objective was to compare the endometrial thickness (ET) in a frozen embryo transfer (FET) cycle between transdermal and vaginal estrogen. Our secondary objectives were to compare the patient satisfaction and the pregnancy outcomes. Prospective monocentric cohort study between 01/2017 and 12/2017 at a single institution. Choice of administration was left to the patient. 119 cycles had transdermal estrogen (T-group) and 199 had vaginal estrogen (V-group). The ET at 10 ± 1 days of treatment was significantly higher in the T-group compared to the V-group (9.9 vs 9.3 mm, p = 0.03). In the T-group, the mean duration of treatment was shorter (13.6 vs 15.5 days, p

Giant condyloma acuminata (GCA) is a large condyloma of the anogenital region with a cauliflowerlike appearance. The tumor is extremely rare and is related to human papilloma virus (HPV) infection (HPV type 6 and 11 in 90% of cases).1 The definitive treatment is wide surgical excision, but topical medical treatment can be effective in selected cases.2, 3 Here we report the first case, to our knowledge, of complete regression of vulvar GCA after treatment with topical imiquimod (5% cream) therapy, with no recurrence reported over a 3-year follow-up period. Signed informed consent was obtained from the patient.

Purpose To determine the risk of multiple pregnancies (MP) following conversion of in vitro fertilization (IVF) cycles to intrauterine insemination (IUI) when a poor ovarian response (POR) is diagnosed during controlled ovarian stimulation (COS). Methods We undertook a retrospective study in our teaching hospital from January 2012 to December 2017. We included all IVF cycles with POR that were converted to IUI ( ≥ 14 mm and peak estradiol level Results Overall, 205 IVF cycles that were converted to IUI in 128 patients were analyzed. Mean age was 34.1 ± 4.6 years, mean antral follicle count was 11 ± 5.3 and mean AMH was 1.8 ± 2.9 ng/L. The main causes of infertility were unexplained (41 %) (84/205) and diminished ovarian reserve (35 %) (72/205). Of all the cycles converted to IUI, 53 (26 %) had one mature follicle on trigger day, 56 (27 %) had 2, 56 (27 %) had 3, and 40 (20 %) had 4. The live birth rate (LBR) was 7.3 % (15/205), and the miscarriage rate was 28.6 % (6/21). There were 3 twin pregnancies, but no higher order pregnancies; the MP rate was 14.3 % (3/21). There was no significant difference in the MP rate between patients with 1−2 mature follicles and patients with 3−4 mature follicles (18.2 % vs 10 %, p = 0.99, respectively). Conclusion In IVF cycles converted to IUI for poor response, the risk of MP is acceptable (14 %) with no higher order pregnancies, even with 3 or 4 follicles ≥14 mm on trigger day.

Objective Our study aimed to assess the impact of a simulation training program for residents for the disclosure of diagnosis on the psychological experience of couples following a first trimester pregnancy loss (PL). Methods We performed an uncontrolled prospective single center, before-after study, at the gynecological emergency department of Angers University Hospital in France, between May 2014 and April 2015. We included all patients who had a confirmed diagnosis of first trimester PL. A self-administering questionnaire (SAQ) that included the short version of the perinatal grief scale (PGS) and questions about the couples’ personal experience was sent by mail 8 weeks after the diagnosis. Patients were included before and after simulation training of the residents on the communication of the diagnosis of PL, and scores were compared between the two groups (before and after training). Results Overall 72 patients fulfilled the inclusion criteria and responded to the SAQ, 45 before and 27 after simulation training. Overall, simulation training significantly lowered the overall PGS (39.4 ± 4.9 vs 57.3 ± 5.6, p = 0.03), significantly improved the attitude of the resident when announcing the diagnosis (more considerate (74.1 % vs 48.9 %, p = 0.04) and available (59.3 % vs 28.9 %, p = 0.01)), and significantly improved the quality of the information given (less incomprehensible (22.2 % vs 46.7 %, p = 0.04). Finally, significantly fewer patients reported needing an additional consultation for further information following training (33.3 % vs 73.3 %, p = 0.01). Conclusion Simulation training of residents for the disclosure of early pregnancy loss significantly improves the couples’ personal experience and decreases the psychological morbidity associated with the communication.

The rupture of the ureter during pregnancy is a rare complication and is most frequently observed in the right ureter. We report below the case of a rupture in the left ureter. A 36-year old woman gave birth vaginally to a 3010-g girl without operative vaginal delivery or episiotomy. The following day, the patient exhibited a sudden pain in the left side spreading to the left iliac fossa. An abdominopelvic CT scan was carried out and revealed a flow of contrast agent at the left ureteral lumbar level and a left urinoma. A ureteral stent was inserted on the left side under X-ray control. Six weeks after delivery the ureteral stent was removed. The Uro CT scan allowed us to confirm the total recovery of the left ureter. We have reported below the first case of left rupture treated in a conservative manner with positive and functional clinical progress.

Background The frequency of posterior presentations (occiput of the fetus towards the sacrum of the mother) in labor is approximately 20% and, of this, 5% remain posterior until the end of labor. These posterior presentations are associated with higher rates of cesarean section and instrumental delivery. Manual rotation of a posterior position in order to rotate the fetus to an anterior position has been proposed in order to reduce the rate of instrumental fetal delivery. No randomized study has compared the efficacy of this procedure to expectant management. We therefore propose a monocentric, interventional, randomized, prospective study to show the superiority of vaginal delivery rates using the manual rotation of the posterior position at full dilation over expectant management. Methods Ultrasound imaging of the presentation will be performed at full dilation on all the singleton pregnancies for which a clinical suspicion of a posterior position was raised at more than 37 weeks’ gestation (WG). In the event of an ultrasound confirming a posterior position, the patient will be randomized into an experimental group (manual rotation) or a control group (expectative management with no rotation). For a power of 90% and the hypothesis that vaginal deliveries will increase by 20%, (10% of patients lost to follow-up) 238 patients will need to be included in the study. The primary endpoint will be the rate of spontaneous vaginal deliveries (expected rate without rotation: 60%). The secondary endpoints will be the rate of fetal extractions (cesarean or instrumental) and the maternal and fetal morbidity and mortality rates. The intent-to-treat study will be conducted over 24 months. Recruitment started in February 2017. To achieve the primary objective, we will perform a test comparing the number of spontaneous vaginal deliveries in the two groups using Pearson’s chi-squared test (provided that the conditions for using this test are satisfactory in terms of numbers). In the event that this test cannot be performed, we will use Fisher’s exact test. Discussion Given that the efficacy of manual rotation has not been proven with a high level of evidence, the practice of this technique is not systematically recommended by scholarly societies and is, therefore, rarely performed by obstetric gynecologists. If our hypothesis regarding the superiority of manual rotation is confirmed, our study will help change delivery practices in cases of posterior fetal position. An increase in the rates of vaginal delivery will help decrease the short- and long-term rates of morbidity and mortality following cesarean section. Manual rotation is a simple and effective method with a success rate of almost 90%. Several preliminary studies have shown that manual rotation is associated with reduced rates for fetal extraction and maternal complications: Shaffer has shown that the cesarean section rate is lower in patients for whom a manual rotation is performed successfully (2%) with a 9% rate of cesarean sections when manual rotation is performed versus 41% when it is not performed. Le Ray has shown that manual rotation significantly reduces vaginal delivery rates via fetal extraction (23.2% vs 38.7%, p < 0.01). However, manual rotation is not systematically performed due to the absence of proof of its efficacy in retrospective studies and quasi-experimental before/after studies. Trial registration ClinicalTrials.gov, Identifier: NCT03009435. Registered on 30 December 2016 Electronic supplementary material The online version of this article (10.1186/s13063-018-2497-7) contains supplementary material, which is available to authorized users.

The development of video tutorials is flourishing and may make it possible to maintain knowledge learned during instruction with simulation. The aim of this study was to assess the effect of adding a video tutorial to a lecture and simulation for learning the maneuvers and protocol for the management of shoulder dystocia. Student midwives and medical students attended a lecture class including instruction about maneuvers and a presentation of an algorithm for the management of shoulder dystocia. They were randomized into two groups. The video group was reminded every two weeks to watch a short tutorial. The control group was reminded to consult the slide show. At the end of two months, they were evaluated by graders. The practice, theory, and global scores of the students in the video group were significantly higher than those of the students in the control group (14.8 vs. 10.4; 5.6 vs. 3.4; and 9.3 vs. 7.0, P