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Study question Which factors are associated with low serum progesterone (P) levels on the day of frozen embryo transfer (FET), in hormonal replacement therapy (HRT) cycles? Summary answer Body Mass Index (BMI), parity, and non-European geographic origin are factors associated with low serum P levels on the day of FET in HRT cycles. What is known already While the detrimental impact of low serum P concentrations on HRT-FET outcomes is unanimously recognized, the factors accounting for P levels disparities among patients receiving the same luteal phase support treatment remain to be elucidated, in order to help clinicians predicting which subgroups of patients would benefit from a tailored P supplementation. Study design, size, duration Observational cohort study with 915 patients undergoing HRT-FET at a tertiary care university hospital, between January 2019 and March 2020. Participants/materials, setting, methods Patients undergoing single autologous blastocyst FET under HRT using exogenous estradiol and vaginal micronized progesterone for endometrial preparation. Women were only included once during the study period. The serum progesterone level was measured in the morning of the FET, in a single laboratory. Independent factors associated with low serum P levels (defined as ≤ 9.8 ng/mL, according to a previous published study) were analyzed using univariate and multivariate logistic regression models. Main results and the role of chance The live birth rate was 31.5% (288/915) in the overall population. Two hundred and twenty-six patients (24.7%) had a low serum P level, on the day of the FET. Univariate analysis showed that BMI (p Limitations, reasons for caution The main limitation of our study is linked to its observational design. Extrapolation of our results to other laboratories, or other routes and/or doses of administering progesterone also needs to be validated. Wider implications of the findings There is urgent need for future research on clinical factors affecting P concentrations to help clinicians predicting which subgroups of patients would benefit from individualized luteal phase support. More data are also needed on the underlying mechanisms explaining the relationship between patients’ characteristics and serum P levels in HRT-cycles. Trial registration number NA

The incidence of venous thromboembolism (VTE) increases with age with an annual incidence of 1.25/1 000 women in the 40-59 age group. Menopausal hormone therapy (MHT) may also increases the risk of VTE. This risk must be assessed during the first consultation before initiating a MHT and assess each renewal of the MHT. MHT with oral estrogen combined (or not) with progestin increases the risk of VTE by about 70 %. Using transdermal estrogen does not appear to increase the risk of VTE in women. VTE risk appears to be modulated by the type of progestin combined in MHT. The risk of VTE associated with MHT with transdermal estradiol appears to be safe in micronized progesterone and pregnane derivatives women users and higher in norpregnane derivatives women users. To limit the risk of VTE associated with MHT, transdermal estradiol use is recommended. In women at risk of VTE, MHT with oral estrogen is contraindicated. MHT with transdermal estradiol associated (or not) with micronized progesterone or dydrogesterone may be used in women with low or moderate risk of VTE.

STUDY QUESTION Which factors are associated with low serum progesterone (P) levels on the day of frozen embryo transfer (FET), in HRT cycles? SUMMARY ANSWER BMI, parity and non-European geographic origin are factors associated with low serum P levels on the day of FET in HRT cycles. WHAT IS KNOWN ALREADY The detrimental impact of low serum P concentrations on HRT-FET outcomes is commonly recognized. However, the factors accounting for P level disparities among patients receiving the same luteal phase support treatment remain to be elucidated, to help clinicians predicting which subgroups of patients would benefit from a tailored P supplementation. STUDY DESIGN, SIZE, DURATION Observational cohort study with 915 patients undergoing HRT-FET at a tertiary care university hospital, between January 2019 and March 2020. PARTICIPANTS/MATERIALS, SETTING, METHODS Patients undergoing single autologous blastocyst FET under HRT using exogenous estradiol and vaginal micronized progesterone for endometrial preparation. Women were only included once during the study period. The serum progesterone level was measured in the morning of the FET, in a single laboratory. Independent factors associated with low serum P levels (defined as ≤9.8 ng/ml, according to a previous published study) were analyzed using univariate and multivariate logistic regression models. MAIN RESULTS AND THE ROLE OF CHANCE Two hundred and twenty-six patients (24.7%) had a low serum P level, on the day of the FET. Patients with a serum P level ≤9.8 ng/ml had a lower live birth rate (26.1% vs 33.2%, P = 0.045) and a higher rate of early miscarriage (35.2% vs 21.5%, P = 0.008). Univariate analysis showed that BMI (P LIMITATIONS, REASONS FOR CAUTION The main limitation of this study is its observational design, leading to a risk of selection and confusion bias that cannot be ruled out, although a multivariable analysis was performed to minimize this. WIDER IMPLICATIONS OF THE FINDINGS Extrapolation of our results to other laboratories, or other routes and/or doses of administering progesterone also needs to be validated. There is urgent need for future research on clinical factors affecting P concentrations and the underlying pathophysiological mechanisms, to help clinicians in predicting which subgroups of patients would benefit from individualized luteal phase support. STUDY FUNDING/COMPETING INTEREST(S) No funding/no conflicts of interest. TRIAL REGISTRATION NUMBER N/A.

Resume Ces Recommandations pour la pratique clinique en contraception sont les premieres promues par le College national des gynecologues et obstetriciens francais (CNGOF), afin d'aider le praticien a prendre une decision medicale en lui fournissant une synthese des donnees scientifiques existantes sur le sujet. La methodologie de la Haute Autorite de sante (HAS) a ete adoptee. Douze questions pratiques ont ete selectionnees par le comite d'organisation et le groupe de travail. La litterature a ete analysee jusqu'en decembre 2017, des recommandations basees sur le niveau de preuve ont ete proposees affectees d'un grade. Les textes longs, dont cette synthese est issue, ont ete relus par des experts en contraception et des praticiens du secteur prive ou public, ayant une activite en contraception. Des recommandations pratiques sont ainsi proposees pour la conduite de la consultation de contraception, l'information sur les methodes contraceptives, leurs risques et benefices non contraceptifs, la gestion de la contraception hormonale en pratique, la contraception intra-uterine, la contraception d'urgence, les methodes locales et naturelles, la contraception chez les adolescentes, apres 40 ans, en situation a risque vasculaire ou carcinologique. La contraception definitive et l'emploi pour la contraception de molecules ne disposant pas d'une autorisation de mise sur le marche ont ete exclus du champ de ces recommandations. L'avenir de la contraception a court et moyen terme tel qu'il peut etre anticipe aujourd'hui, passe avant tout par le bon usage des moyens dont nous disposons aujourd'hui, l'information des femmes et l'amelioration de l'acces aux contraceptions pour toutes les femmes. C'est l'objectif poursuivi par ces recommandations de pratique clinique du CNGOF.

Venous thromboembolism and arterial ischemic events are the main deleterious diseases associated with the use of combined hormonal contraceptives (CHC). Even though their composition has been substantially improved, the vascular risk persists with the most recent CHCs use. If the vascular risk associated with CHCs containing 50μg EE is significantly higher than with those containing less than 50μg, there is no evidence that the CHCs containing either 30 or 20μg of EE induce different venous risks. CHC containing gestodene, desogestrel, drospirenone or cyproterone acetate are associated with a higher risk of venous thrombosis compared with levonorgestrel-containing CHCs. CHC containing norgestimate are associated with similar venous thrombosis risk than CHC containing levonorgestrel. Venous thrombosis risk of non-oral routes of administration of CHC appears to be equivalent to the risk of CHC containing gestodene or desogestrel, but this result is based on a small number of epidemiological studies. Before prescribing a CHC, it is important to determine all vascular risk factors. Family history of ischemic arterial event or venous thromboembolism disease should be routinely sought before any CHC prescription. All CHCs are contraindicated in women with biological thrombophilia, in women with combined vascular risk factors, in women with first-degree family history of arterial or venous event (under age 50) as well as in women suffering of migraine with aura. Progestin-only contraceptives are not associated with vascular risk (arterial or venous) outside of medroxyprogesterone acetate. In women with higher vascular risk, progestin-only contraceptives (administered by oral, sous-cutaneous or intra-uterine routes) can be prescribed.

STUDY QUESTION Do adenomyosis phenotypes such as external or internal adenomyosis, as diagnosed by MRI, have the same clinical characteristics? SUMMARY ANSWER External adenomyosis was found more often in young and nulliparous women and was associated with deep infiltrating endometriosis, whereas, in contrast, internal adenomyosis was more often associated with heavy menstrual bleeding (HMB) but no differences were noted in terms of pain symptoms. WHAT IS KNOWN ALREADY Adenomyosis is characterized by the presence of endometrial glands and stroma deep within the myometrium, giving rise to dysmenorrhea, pelvic pain and menorrhagia. Various forms have been described, including adenomyosis of the outer myometrium (external adenomyosis), which corresponds to lesions separated from the junctional zone (JZ), and adenomyosis of the inner myometrium (internal adenomyosis), which is mostly characterized by endometrial implants scattered throughout the myometrium and enlargement of the JZ. Although the pathogenesis of adenomyosis is not clearly understood, several lines of evidence suggest that these two phenotypes could have distinct origins. The clinical presentation of different forms of adenomyosis in patients warrants further investigation. STUDY DESIGN, SIZE, DURATION This was an observational study that used data collected prospectively in non-pregnant patients aged between 18 and 42 years who had undergone surgical exploration for benign gynecological conditions at our institution between May 2005 and May 2018. Only women with a pelvic MRI performed by a senior radiologist during the preoperative work-up were retained for this study. For each patient, a standardized questionnaire was completed during a face-to-face interview conducted by the surgeon in the month preceding the surgery. The women’s histories (notably their age, gravidity, history of surgery and associated endometriosis), as well as clinical symptoms such as the pain intensity, presence of menorrhagia and infertility, were noted. PARTICIPANTS/MATERIALS, SETTING, METHODS A pelvic MRI was performed in 496 women operated at our center for a benign gynecological disease who had provided signed informed consent. Of these, 248 women had a radiological diagnosis of adenomyosis. Based on the MRI findings, the women were diagnosed as having external and/or internal adenomyosis. The women were allocated to two groups according to the adenomyosis phenotype (only external adenomyosis vs only internal adenomyosis). Women exhibiting an association of both adenomyosis forms were analyzed separately. MAIN RESULTS AND THE ROLE OF CHANCE In all, following the MRI findings, 109 women (44.0%) exhibited only external adenomyosis, while 78 (31.5%) had only internal adenomyosis. The women with external adenomyosis were significantly younger (mean ± SD; 31.9 ± 4.6 vs 33.8 ± 5.2 years; P = 0.006), more often nulligravid (P ≤ 0.001) and more likely to exhibit an associated endometriosis (P LIMITATIONS, REASONS FOR CAUTION The exclusive inclusion of surgical patients could constitute a possible selection bias, as the women referred to our center may have suffered from particularly severe clinical symptoms. WIDER IMPLICATIONS OF THE FINDINGS Further studies are needed to explore the pathogenesis by which these types of adenomyosis occur. This could help with the development of new treatment strategies specific for each entity. STUDY FUNDING/COMPETING INTEREST(S) none. TRIAL REGISTRATION NUMBER N/A.

Si de nombreuses etudes ont ete publiees concernant le risque d’accident veineux thromboembolique (VTE) et l’utilisation d’une contraception hormonale, il n’en est pas de meme apres VTE. Toutes les contraceptions estroprogestatives (COP) augmentent le risque de VTE, ce qui n’est pas le cas des contraceptions progestatives en dehors de l’acetate de medroxyprogesterone. En effet, cette contraception modifie certains parametres de la coagulation dans un sens pro-coagulant. Cette contraception progestative ainsi que les COP sont donc contre-indiquees apres un VTE. Une recente meta-analyse combinant 4 etudes (dont trois francaises) ne montre pas d’augmentation de risque de recidive de VTE lors de l’utilisation d’une contraception microprogestative ou macroprogestative type acetate de chlormadinone. Ainsi toutes les autorites de sante francaises autorisent ce type de contraception microprogestative (par voie orale, intra-uterine ou sous-cutanee) apres un accident veineux. Dans le domaine de la menopause, les donnees sont un peu differentes. Ainsi, la voie orale d’administration des estrogenes (quelle que soit la molecule) augmente le risque de VTE ainsi que le risque de recidive, tandis que la voie transdermique (patch ou gel) semble neutre sur le risque de VTE. En effet, cette voie d’administration ne modifie pas les parametres de la coagulation et n’augmente pas le risque de 1er VTE. Une seule etude a analyse le risque de recidive de VTE en tenant compte de la voie d’administration. Ces donnees confirment l’augmentation de risque de la voie orale, et montrent une neutralite de la voie transdermique. Par ailleurs, la France dispose de nombreuses molecules progestatives indispensables a associer a l’estrogenotherapie dans le contexte du THM. L’impact du type de progestatif associe a l’estrogenotherapie sur le risque de VTE est important. Ainsi trois etudes francaises ont montre des risques plus eleves de VTE (1er VTE ou recidive) en cas d’association a des derives norpregnanes (acetate de nomegestrol ou promegestone). L’association estradiol par voie percutanee et progesterone micronisee parait neutre sur ce risque. Au total, la prescription d’une contraception microprogestative ou d’un THM associant estradiol percutanee et progesterone naturelle a distance d’un accident veineux est envisageable. Un avis en RCP est conseille. Cette utilisation doit tenir compte de la balance benefice/risque global de ces therapeutiques hormonales.

Introduction Hypertensive disorders are one of the leading causes of maternal mortality and are also associated with significant cardiovascular and renal morbidity. However very few studies have evaluated the prevalence of different hypertensive disorders of pregnancy and postpartum in France. Purpose The aim of this nationwide study was to estimate the prevalence of hypertensives disorders during the pregnancy and the post-partum. Methods All women with a delivery after 22 weeks of amenorrhea between 2010 and 2016 were selected using data from the national hospital discharge database (PMSI-MCO) integrated into the national health data system (SNDS). In these women, chronic hypertension (persisting or not during pregnancy) in the year preceding pregnancy, gestational hypertension (occurring after 20 weeks of amenorrhea) and preeclampsia/eclampsia were recorded using different algorithms taking into account hospital diagnosis, antihypertensive treatment deliveries and differential diagnosis. Results Between 2010 and 2016, 4,991,308 deliveries occurred in France corresponding to 3,786,510 women. A total of 7.8% of all pregnancies were associated with at least one hypertensive disorder. Chronic hypertension occurred in the year preceding 1.7% of pregnancies and persisted in 1.1% of cases. Gestational hypertension was recorded in 5.2% of pregnancies and Preeclampsia/Eclampsia in 2% of pregnancies. Preeclampsia occurred before 32 weeks of amenorrhea in 17% of cases, between 32 weeks and delivery in 61% of cases and after delivery in 22% of cases. Preeclampsia was not preceded by any other hypertensive disorder in 44.1% of pregnancies. In 11.6% and 44.3% of pregnancies, preeclampsia was preceded by chronic hypertension and by gestational hypertension respectively. Conclusion Hypertensive disorders affected 7.8% of pregnancies in France between 2010 and 2016. It is necessary to pay particular attention to these women in assessing their future cardio-vascular risk.

Can menopausal hormone therapy (HT) be used in hypertensive women? The group of experts of the French Society of Hypertension has carried out a review of the recent literature in order to answer this question, based on the most recent scientific publications. If use of oral HT is associated with a discreet increase in blood pressure, the transdermal route seems to be safer. The first results of major randomized trials of HT had alerted to an increase in cardiovascular events and breast cancer with the use of oral HT, generally, tipping the benefit-risk balance of the deleterious side. Complementary analyzes have shown the importance of the window of intervention (less than 10 years after the menopause) and the age of the woman to start the HT. On the contrary, they have shown a significant decrease of the coronary events. For woman suffering from hypertension and important climacteric symptoms, it is important to evaluate the whole cardiovascular risk in order to decide the possibility of prescribing a HT. Thus, the group of experts proposes a prescription assistance algorithm based on the stratification of cardiovascular risk, always favoring, when it is authorized, HT by transdermal route of administration.

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 44 - N° 10 - p. 1127-1134

Objectif Evaluation de l’impact du suivi rapproche chez les femmes aux antecedents de fausses couches spontanees repetees (RPL) idiopathiques sur les issues de grossesses ulterieures. Patients et methodes Toutes les femmes ayant eu un bilan de RPL (≥ 2 fausses couches precoces) en hopital de jour dans l’unite de gynecologie endocrinienne de Port-Royal entre Mai 2015 et Decembre 2019 etaient incluses dans l’etude (n = 245). Chez les patientes avec bilan etiologique negatif (pas d’anomalie morphologique uterine, caryotypes parentaux normaux, biologie des antiphospholipides negative, TSH Resultats Le bilan etiologique etait negatif chez 79,2 % des patientes avec un âge moyen lors de l’hospitalisation de 33,2 ans (± 4,2). Apres l’hospitalisation, 114 femmes ont ete enceintes, dont 52 ayant beneficie d’un suivi rapproche. Les caracteristiques des femmes avec suivi rapproche versus sans suivi rapproche n’etaient pas statistiquement differentes (âge moyen 34,1 ans ± 4,8 versus 34,61 ± 4,7 respectivement). Le taux de naissance vivante etait de 85 % (62 grossesses) vs 44 % (75 grossesses) respectivement (p Conclusion Chez les patientes ayant des RPL idiopathiques, un suivi rapproche combinant echographies et consultations en debut de grossesse semble ameliorer le pronostic de la grossesse ulterieure.

Venous thromboembolism and arterial ischemic events are the main deleterious diseases associated with the use of combined hormonal contraceptives (CHC). Even though their composition has been substantially improved, the vascular risk persists with the most recent CHCs use. If the vascular risk associated with CHCs containing 50μg EE is significantly higher than with those containing less than 50μg, there is no evidence that the CHCs containing either 30 or 20μg of EE induce different venous risks. CHC containing gestodene, desogestrel, drospirenone or cyproterone acetate are associated with a higher risk of venous thrombosis compared with levonorgestrel-containing CHCs. CHC containing norgestimate are associated with similar venous thrombosis risk than CHC containing levonorgestrel. Venous thrombosis risk of non-oral routes of administration of CHC appears to be equivalent to the risk of CHC containing gestodene or desogestrel, but this result is based on a small number of epidemiological studies. Before prescribing a CHC, it is important to determine all vascular risk factors. Family history of ischemic arterial event or venous thromboembolism disease should be routinely sought before any CHC prescription. All CHCs are contraindicated in women with biological thrombophilia, in women with combined vascular risk factors, in women with first-degree family history of arterial or venous event (under age 50) as well as in women suffering of migraine with aura. Progestin-only contraceptives are not associated with vascular risk (arterial or venous) outside of medroxyprogesterone acetate. In women with higher vascular risk, progestin-only contraceptives (administered by oral, sous-cutaneous or intra-uterine routes) can be prescribed.

The French College of Obstetrics and Gynecology (CNGOF) releases its first global recommendations for clinical practice in contraception, to provide physicians with an updated synthesis of available data as a basis for their practice. The French Health Authority (HAS) methodology was used. Twelve practical issues were selected by the organizing committee and the task force members. The available literature was screened until December 2017, and allowed the release of evidence-based, graded recommendations. This synthesis is issued from 12 developed texts, previously reviewed by experts and physicians from public and private practices, with an experience in the contraceptive field. Male and female sterilization, as well as the use of hormonal treatments without contraceptive label were excluded from the field of this analysis. Specific practical recommendations on the management of contraception prescription, patient information including efficacy, risks, and benefits of the different contraception methods, follow up, intrauterine contraception, emergency contraception, local and natural methods, contraception in teenagers and after 40, contraception in vascular high-risk situations, and in case of cancer risk are provided. The short/mid-term future of contraception mostly relies on improving the use of currently available methods. This includes reinforced information for users and increased access to contraception for women, whatever the social and clinical context. That is the goal of these recommendations.

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 43 - N° 10 - p. 865-882

The use of anatomic model is particularly suitable for teaching gynecological examination. Although simulation training was proved to be effective in improving medical students' technical skills, its interest in reducing their apprehension about pelvic examination was poorly evaluated. The aim of the present study was to evaluate low-fidelity simulation sessions to reduce the discomfort and apprehension of medical students towards gynecological examination. The secondary objective was to appreciate student satisfaction with these sessions.Descriptive analysis of simulation-based teaching of breast and pelvic examination on Ilumens platform at the university Paris 5 among 3rd and 4th year medical students. It consisted in a before/after evaluation, using an anonymous questionnaire of self-evaluation and satisfaction at the beginning and at the end of the session.Four hundred and thirty-two students answered both questionnaires. Seventy-two percent apprehended the pelvic examination initially and 62% were uncomfortable with the idea of performing it. Among the students who had never performed pelvic examination, more than 80% felt less uncomfortable with the idea of performing pelvic examination and were less apprehensive about it at the end of the simulation session.The benefits of low-fidelity simulation in gynecology extend to the well-being of medical students who are less apprehensive about performing gynecological examination.

Background/introduction Venous thromboembolism (VTE) is one of the leading cause of maternal morbidity and mortality in pregnancy and post-partum. The association between both the chronic hypertension or preeclampsia and the risk of pulmonary embolism (PE) is still under debate. Purpose The aim of the study was to estimate the risk of PE in women hospitalized with preeclampsia during pregnancy and post-partum. Methods All women aged 18–45 years who delivered after 20 weeks of amenorrhea between 2010 and 2015 were selected in the French hospital discharge database. In these women, hospital stays with a diagnosis of preeclampsia between the 20th week of amenorrhea and up to 6 weeks postpartum were identified. Chronic hypertension before pregnancy was also identified using the French health insurance claim database. Hospitalizations for PE after the diagnosis of preeclampsia and up to 6 weeks postpartum were selected in the same database. Adjusted Poisson regressions were used to estimate incidence rate ratios (IRR) comparing the incidence of PE following preeclampsia or chronic hypertension versus incidence in women without those conditions. Results Between 2010 and 2015, 4,483,852 women had a delivery and were included in the study. Hospitalization for preeclampsia occurred in 1.9% of these women. Among women with preeclampsia, PE occurred in 1,087 during pregnancy and in 1,693 during postpartum. Preeclampsia was associated with a significantly increased risk of PE during postpartum (adjIRR = 2.6 95%CI [2.2–3.1]) but not during pregnancy (adjIRR = 1.2 95%CI [0.8–1.7]). Chronic hypertension before pregnancy was associated with a significantly higher risk of PE during pregnancy (adjIRR = 1.6 95%CI [1.1–2.2]) and postpartum (adjIRR = 1.4 95%CI [1.0–1.8]). Conclusion This study highlighted the importance of monitoring women for PE after a hospitalization for preeclampsia and women with chronic hypertension during pregnancy and postpartum.

Le risque cardiovasculaire des femmes croit de facon importante a partir de la cinquieme decennie. Cette augmentation fait, qu’apres la menopause, le risque cardiovasculaire des femmes rejoint celui des hommes. Sur le plan de la prevention cardiovasculaire, il est extremement important d’evaluer precisement le niveau de risque cardiovasculaire des patientes, afin d’adapter au mieux les decisions therapeutiques. De nombreuses echelles ont ete proposees afin d’evaluer plus precisement le niveau de risque cardiovasculaire ; neanmoins, en 2012, la meilleure evaluation est la sommation des facteurs de risque cardiovasculaire conventionnels. La majorite des etudes d’observation a montre que les femmes utilisatrices des traitements hormonaux substitutifs de la menopause (THM) presentaient un niveau de risque cardiovasculaire moindre que les non-utilisatrices. Mais les etudes d’intervention correctement dimensionnees, et notamment les etudes Heart and Estrogen/progestin Replacement Study (HERS) et Women’s Health Initiative (WHI), ont montre que, loin d’etre associe a une amelioration du risque cardiovasculaire, le THM etait associe a une augmentation du risque cardiovasculaire. De nombreuses limitations expliquent ces resultats deleteres. Malheureusement, l’analyse de ces deux etudes permet rarement de prendre une decision therapeutique individuelle, notamment en raison du type d’œstrogene utilise, de la voie d’administration, de l’âge des femmes supplementees, du niveau de risque cardiovasculaire moyen, de la fenetre d’intervention… Il semble sage de considerer que, globalement, le THM est associe a un leger sur-risque cardiovasculaire, et que ce sur-risque doit etre interprete a la lumiere des benefices attendus. Ne nous empechons donc pas, sur le plan individuel, de prescrire un THM si la balance benefice/risque apparait favorable.

Objectifs Mise au point de la prise en charge du risque de thrombose veineuse pendant la grossesse des femmes ayant une thrombophilie hereditaire. Savoir proposer les meilleures strategies preventives issues des recommandations francaises et internationales. Methodes Revue systematique de la litterature scientifique et apport des meta-analyses les plus recentes. Comparaison des differentes recommandations des societes savantes internationales. Resultats La grossesse augmente le risque de thrombose veineuse d’un facteur 5 a 6 comparativement aux femmes de meme âge non enceintes. Les donnees recentes francaises issues de la base de donnees SNIRAM apportent des resultats interessants concernant le niveau de risque thromboembolique veineux pendant la grossesse et en post-partum. Si l’histoire familiale augmente ce risque, l’existence d’une thrombophilie biologique modifie ce risque de facon tres variable dependant du type de thrombophilie familiale. Ainsi les donnees de la meta-analyse de F Croles publiee fin octobre 2017 dans le BMJ confirme les resultats de la meta-analyse de Robertson mais detaille de facon plus precise les differents niveaux de risque et fournit des risques absolus de thrombose veineuse. Pour ces auteurs, ce sont le deficit en antithrombine et les mutations homozygotes du facteur V ou du facteur II qui constituent les situations les plus a risque justifiant une thromboprophylaxie pendant la grossesse et/ou le post-partum. Ainsi le risque absolu de VTE des femmes ayant un deficit en antithrombine est de 7,3 % (1,8–15,6 %) pendant la grossesse et de 11,1 (3,7–21,0 %) en post-partum. Ces resultats sont issus de 4 etudes totalisant seulement 125 femmes. Les deficits en proteine C ou S sont aussi consideres comme des situations a risque. En revanche, les auteurs considerent que les femmes ayant une mutation du facteur V ou du facteur II a l’etat heterozygote sont a un niveau de risque ne justifiant pas systematiquement une prophylaxie pendant la grossesse ou en post-partum s’il n’existe aucun antecedent familial de thrombose veineuse. Ces donnees ne concernent que les femmes n’ayant pas eu de VTE avant la grossesse. Les recommandations sont bien sur differentes s’il existe un antecedent personnel de VTE. Conclusion La thromboprophylaxie des VTE pendant la grossesse et le post-partum doit tenir compte de l’ensemble des facteurs de risque, les thrombophilies biologiques prenant une place importante dans la discussion de cette prevention.

Background Fertility treatments (FT) have been associated with an increased risk of thromboembolic complications (TEC). However, whether this excess risk exists for arterial thrombosis and whether it differs by type of ART remains poorly documented. Purpose The objectives were to estimate TEC rates following unsuccessful FT cycle (TC) and FT-related pregnancy, according to type of FT. Methods Women aged 18–45 years with an FT between 2012 and 2015 were selected in the French health insurance claim database. TC were classified into simple ovulation induction (OI) or ovulation stimulation (OS). All hospitalisations in women with FT, with a diagnosis of venous thromboembolism (VTE) or arterial thrombosis (AT) were identified in the French hospital discharge database. Separate analyses were performed for unsuccessful and successful TC. Poisson regressions were used to estimate incidence rate ratios (IRR) comparing both incidence of TEC following unsuccessful TC versus incidence in all non-pregnant women of same age range, and TEC incidence during FT-related pregnancy versus incidence in spontaneous pregnancy. Results During the study period, 280,000 women underwent FT (total of 809,913 TC) with 82,821 FT-related pregnancies. Among unsuccessful TC, 75 VTE and 43 AT were observed. OS TC but not OI TC was associated with a higher risk of VTE compared with the reference group [1.7, 95% CI (1.3–2.3)]. Among FT-related pregnancies, 207 VTE and 35 AT were reported. The IRR adjusted for age and multiple pregnancy showed significant higher rates of VTE and AT during first trimester comparing to spontaneous pregnancy [IRR = 3.3, 95% CI (2.2–4.8) and IRR = 2.6, 95%CI (1.1–6.5) respectively]. Conclusion This study highlights the importance of monitoring women undergoing FT, especially OS TC, regardless of pregnancy status. In FT-related pregnancy, the first trimester seems to be a high-risk period for TEC compared with spontaneous pregnancies.

Resume But de l’etude L’evaluation du bien-etre au travail en milieu professionnel a fait l’objet de nombreuses publications. L’evaluation de ce parametre se fait classiquement a l’aide de questionnaires standardises et valides. Ces questionnaires sont, le plus souvent, longs car comportant un nombre important d’items. Cette evaluation est donc difficilement realisable dans le cadre de la consultation de medecine du travail en milieu hospitalier ou les consultations sont relativement courtes. L’objectif de cette etude est de comparer deux instruments de mesures du bien-etre au travail, le questionnaire GHQ simplifie de Goldberg et une echelle visuelle analogique plus classiquement utilisee et validee dans l’appreciation du niveau de douleurs par exemple. Cette echelle n’a encore jamais ete testee dans le domaine du bien-etre au travail, dans le cadre de la medecine du travail. Methodes Entre janvier et mars 2006, 205 personnels salaries d’un hopital, vus en consultation de medecine du travail, ont ete interroges sur leur bien-etre au travail a l’aide des deux instruments proposes. Quelques caracteristiques demographiques et le type de profession ont ete repertories et informatises. Resultats L’analyse statistique a permis de montrer une correlation significative entre la reponse au questionnaire GHQ et le niveau de bien-etre determine par l’echelle analogique (coefficient de correlation = 0,898, p Conclusion Cette etude preliminaire montre l’excellente correlation entre les deux echelles evaluees. Elle devrait permettre de generaliser de facon simple et rapide la mesure du bien-etre au travail des personnels hospitaliers.

It is known for years that breast cancer is a hormone-dependent disease and that reproductive factors can contribute to the increase of its incidence. Among the factors, hormone replacement therapy (HRT) appears to be a contributor at least in some women. HRT remains to be the most efficient intervention to alleviate postmenopausal symptoms. However, the possible mild increase in the risk remains a limit to its prescription. From one country to another, regimens are different, and thus, the increase risk can also vary. It is thus important for a clinician to be informed on the evidence concerning the use of such treatments and thus be able, in front of their patients, to evaluate the risk–benefit balance in each case. Because Europe and the USA have different products and different population risks, it is also important to know the data concerning Europe. Indeed, despite the high level of evidence provided by the Women Health Initiative trials, these intervention studies cannot be fully extrapolated to immediate postmenopausal women with different clinical characteristics and different prescriptions. We will review the available information on HRT from European and US studies to provide an overview of the current knowledge on this important question.

To determine the post-partum management of women and their newborn whatever the mode of delivery.The PubMed database, the Cochrane Library and the recommendations from the French and foreign obstetrical societies or colleges have been consulted.Because breastfeeding is associated with a decrease in neonatal morbidity (lower frequency of cardiovascular diseases, infectious, atopic or infantile obesity) (EL2) and an improvement in the cognitive development of children (EL2), exclusive and extended breastfeeding is recommended (grade B) between 4 to 6 months (Professional consensus). In order to increase the rate of breastfeeding initiation and its duration, it is recommended that health professionals work closely with mothers in their project (grade A) and to promote breastfeeding on demand (grade B). There is no scientific evidence to recommend non-pharmacological measures of inhibition of lactation (Professional consensus). Pharmacological treatments for inhibition of lactation should not be given routinely to women who do not wish to breastfeed (Professional consensus). Because of potentially serious adverse effects, bromocriptin is contraindicated in inhibiting lactation (Professional consensus). For women aware of the risks of pharmacological treatment of inhibition of lactation, lisuride and cabergolin are the preferred drugs (Professional consensus). Whatever the mode of delivery, numeration blood count is not systematically recommended in a general population (Professional consensus). Anemia must be sought only in women with bleeding or symptoms of anemia (Professional consensus). The only treatment of post-dural puncture headache is the blood patch (EL2), it must not be carried out before 48 h (Professional consensus). Women vaccination status and their family is to be assessed in the early post-partum (Professional consensus). Immediate postoperative monitoring after caesarean delivery should be performed in the recovery room, but in exceptional circumstances, it may be performed in the delivery unit provided safety rules are maintained and regulatory authorities are informed (Professional consensus). An analgesic multimodal protocol developed by the medical team should be available and oral way should be favored (Professional consensus) (grade B). For every cesarean delivery, thromboprophylaxis with elastic stockings applied on the morning of the surgery and kept for at least 7 postoperative days is recommended (Professional consensus) with or without the addition of LMWH according to the presence or not of additional risk factors, and depending on the risk factor (major, minor). Early postoperative rehabilitation is encouraged (Professional consensus). Postpartum visit should be planned 6 to 8 weeks after delivery and can be performed by an obstetrician, a gynecologist, a general practitioner or a midwife, after normal pregnancy and delivery (Professional consensus). Starting effective contraception later 21 days after delivery in women who do not want closely spaced pregnancy is recommended (grade B), and to prescribe it at the maternity (Professional consensus). According to the postpartum risk of venous thromboembolism, the combined hormonal contraceptive use before six postpartum weeks is not recommended (grade B). Rehabilitation in asymptomatic women in order to prevent urinary or anal incontinence in medium or long-term is not recommended (Expert consensus). Pelvic-floor rehabilitation using pelvic-floor muscle contraction exercises is recommended to treat persistent urinary incontinence at 3 months postpartum (grade A), regardless of the type of incontinence. Postpartum pelvic-floor rehabilitation is recommended to treat anal incontinence (grade C). Postpartum pelvic-floor rehabilitation is not recommended to treat or prevent prolapse (grade C) or dyspareunia (grade C). The optimal time for maternity discharge for low risk newborn depends more on the organisation of the post-discharge follow up (Professional consensus). The months following the birth are a transitional period, and psychological alterations concern all parents (EL2). It is more difficult in case of psychosocial risk factors (EL2). In situations of proven psychological difficulties, the impact on the psycho-emotional development of children can be important (EL3). Among these difficulties, postpartum depression is the most common situation. However, the risk is generally higher in the perinatal period for all mental disorders (EL3).Postpartum is, for clinicians, a unique and privileged opportunity to address the physical, psychological, social and somatic health of their patients.

Establishment of guidelines for post-partum contraception.Systematic review of publications between 1960 and 2015 from database Medline, Embase, Cochrane Library and recommendations of international societies.The most recent French data show that approximately 2% of women with induced abortion have deliver within 6 months before this abortion and 4% had a child six to twelve months earlier (Evidence Level [EL] 3). A contraceptive counseling is ideally recommended after delivery to avoid unplanned pregnancies (grade C). Among non-breastfeeding women, the shorter median delay for recovery ovulation is 39 days after delivery (EL4). Starting effective contraception later 21 days after delivery in women who does not want closely spaced pregnancy is recommended (grade B), and to prescribe it at the maternity (Professional consensus). In breastfeeding women, the recovery of ovarian activity is dependent on breastfeeding characteristics. Only exclusive breastfeeding with very specific conditions can be used for contraception over a six months period (EL2). For all other breastfeeding conditions, contraceptive strategies are the same than without breastfeeding (grade B). According to the post-partum risk of venous thromboembolism, the combined hormonal contraceptive use before six post-partum weeks is not recommended (grade B). In women with vascular risk factors, the evaluation of benefit risk balance of this use between 6th and 12th post-partum weeks is recommended (Professional consensus). Progestin only contraceptives with low dose are allowed in earlier post-partum (grade B), except at the acute phase of severe thromboembolic event (Professional consensus). In women who want intra-uterine device (IUD) as contraception, it is recommended to prescribe IUD at the hospital and to insert the IUD during the postnatal consultation (grade B). In breastfeeding women, progestin contraception's (oral or subcutaneous) are permitted immediately after delivery (grade B). For women at short interpregnancy interval risk, long acting reversible contraceptives (implant or IUD) started at the hospital is suggested (grade B).The wide contraceptive choice permits to find the best strategy for each woman while respecting post-partum period specificities.

Venous thromboembolism (VTE) is a major cause of maternal morbidity and mortality during or early after pregnancy. Prior VTE or family history of VTE, clinical or biological risk factors increased the risk of pregnancy-related VTE. Defining the risk of VTE before or at the beginning of pregnancy is necessary to propose the best prevention. However, the management is not standardized between physicians, centres and countries. Current guidelines for prophylaxis and treatment of VTE are discussed in this review.

Evidence in favour of an association of breastfeeding with a breast cancer risk reduction remains limited and inconsistent. To evaluate the relation between breastfeeding and breast cancer a meta-analysis based on a review of the literature was carried out using as variables ever/never breastfeeding and duration of breastfeeding. Menopausal status at the time of diagnosis of breast cancer was considered to be a potential effect modifier. Only case-control studies could be included in the final analysis. A slight but significant decreased risk of breast cancer was observed in ever breastfeeding compared with never breastfeeding parous women using both the fixed and random-effect models. This decrease was more pronounced in non-menopausal women at the time of diagnosis of breast cancer and in long-term breastfeeding women. Hence breastfeeding appeared to be a protective factor but was of small magnitude compared with other known risk factors for breast cancer. Whether this result should imply a modification in the attitude of both health care providers and women towards breastfeeding which represents one of the few identified protective factors which is under the control of the mother and is thus (theoretically) modifiable remains questionable. (authors)

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 37 - N° 8S1 - p. 365-367

Hyperprolactinemia is involved in almost 30% of infertility problems. At the onset of menopause, prolactin levels often decrease; however, no data are available regarding the course of hyperprolactinemia after menopause with hormonal replacement therapy (HRT). A retrospective study was undertaken in our department to evaluate the potential role of estrogens in women with a history of hyperprolactinemia. Twenty-two patients, with hyperprolactinemia before menopause, were followed-up. Group I included 11 patients who withdrew bromocriptine treatment when menopause was confirmed. These patients were placed on HRT with no other medication administered. HRT was a combination of percutaneous estradiol gel and an oral progestin. Group II included 7 women treated by bromocriptine before menopause and after menopause concomitantly with HRT. Group III included 4 patients who did not receive HRT or other treatments once menopause was diagnosed. The mean serum prolactin level was unchanged in Group I (22.8+/-21.7 before and 22.8+/-16.1 ng/ml after HRT) while it increased but not significantly from 8.1+/-5.2 to 16.0+/-11.7 ng/ml in Group II. The mean duration of HRT was 42.8+/-23.8 (7-81) and 37.3+/-31.0 (6-99) months in Group I and II respectively. In Group III patients, PRL levels decreased spontaneously from 61.2+/-39.8 to 33.0+/-34.7 ng/ml. In conclusion, in this population of menopausal patients with a history of moderate hyperprolactinemia, HRT did not seem to affect plasma prolactin levels.