Search

Study Objective Evaluation of the efficacy of different injection sites of methotrexate in the treatment of nontubal ectopic pregnancies. Design Retrospective multicenter study. Setting Multicenter, including 3 teaching hospitals, an intercommunal hospital, and a clinic. Patients A total of 106 patients with nontubal ectopic pregnancies, including 59 interstitial, 39 cesarean scar, and 8 cervical or isthmic. Interventions Overall, 58 patients received methotrexate via intramuscular injection (IM group), 35 received methotrexate via in situ injection (IS group), and 13 received a combination of both in situ and intramuscular injections of methotrexate (IS + IM group). Measurements and Main Results The main end point of this study was measured via the primary success rate (defined as a negative β-human chorionic gonadotropin level without recourse to any additional treatment) of treatment with methotrexate according to injection site. The primary success rate was 46.55% in the IM group, 60% in the IS group, and 61.54% in the IS + IM group, respectively. In the multivariate analysis, the primary success rate of treatment was significantly correlated to the in situ injection of methotrexate, either solely or in conjunction with an intramuscular injection of methotrexate administered the following day, (odds ratio = 2.7; 95% confidence interval, 1.03–7.14). Conclusion Solely an intramuscular injection of methotrexate is a less efficient first-line treatment strategy for the conservative management of nontubular ectopic pregnancy. The use of an in situ injection of methotrexate should therefore be preferred.

Resume Introduction Les consequences d’une fracture du pelvis chez la femme sur la statique pelvienne et la sexualite sont souvent negligees et releguees au second plan de la prise en charge. Objectif Effectuer un etat des connaissances sur les troubles de la statique pelvienne et de la sexualite chez les patientes ayant eu un antecedent de fracture du pelvis : incidence, facteurs de risques, prise en charge. Methodes Revue de la litterature sur la base de donnees de Pubmed, Medline, Embase et Cochrane en utilisant les mots cles et termes MeSH suivants : pelvis floor dysfunction, urinary dysfunction, sexual dysfunction, pelvic organ prolapse, en association avec les termes pelvic fracture, pelvic trauma. Resultats Parmi les 270 articles initiaux, 21 ont ete retenus. Au total, une etude de cohorte retrospective comparative a evalue l’impact d’une fracture sur la survenue d’un prolapsus genital, 2 etudes comparatives retrospectives et une prospective ont etudie leur impact sur les troubles du bas appareil urinaire et finalement une revue de la litterature a evalue leur impact sur la sexualite. L’incidence du prolapsus dans les suites d’une fracture de pelvis n’a pas pu etre identifie. L’incidence des troubles urinaires du bas appareil varient entre 21 et 67 % avec une difference significative pour l’urgenturie sans fuite (p = 0,016) et l’incontinence urinaire a l’effort (p = 0,004). L’incidence des troubles de la sexualite varient entre 21 et 62 % avec une predominance des dyspareunies. Le mecanisme du traumatisme serait un facteur favorisant tout comme l’atteinte de la symphyse pubienne (RR 4,8 IC95 % 2,0-11,2). Conclusion L’evaluation des dysfonctions urogenitale, sexuelle et ano-rectal au decours d’un traumatisme du bassin n’est a ce jour que peu explorees dans la litterature. De futures etudes prospectives sont a mener pour ameliorer la prise en charge des patientes.

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

Background: The COVID-19 pandemic has shaken the world by imposing unprecedented health measures, including in the postpartum period. Objectives: We aim to assess the impact of maternal isolation in the immediate postpartum period on the rate of postpartum depression (PPD) in a tertiary center. Study Design: We conducted a prospective cohort study, between 22 April and 29 October 2020, using anonymous questionnaires on 265 participants (129 during lockdown and 135 outside). The Edinburgh Postnatal Depression Scale (EPDS) was used as screening for PPD. We used a univariate logistic regression model to analyze the association between risk factors and PPD. Results: There was no difference between the two groups for PPD assessed by an EPDS score >10.5 on day 30 and/or day 60 (23.1% vs. 29.3%, p = 0.661) but on day 3 it was higher (31% vs. 17.8%, p = 0.015) during the lockdown period and partners were more impacted psychologically (48.3% vs. 10.5%, p < 0.001). Parity ≥1 was a protective factor for PPD (OR = 0.2, 95% CI [0.1–0.6], p = 0.003). Risk factors of PPD were: history of psychological abuses (OR = 6.4, CI 95% [1.1–37.6], p = 0.04), stressful life event (OR = 4.5, CI 95% [1.6–12.6], p = 0.004), and bad birth experience (OR = 5.1, CI 95% [1.4–17.8], p = 0.012). Conclusion: Maternal isolation in the immediate postpartum period is associated with an increased rate of moderate to severe symptoms of postpartum blues. The well-known long-term consequences of PPD must be balanced against the expected benefits of partner’s restrictive access to maternity ward.

Objectives Preterm labour is the leading cause of hospitalization during pregnancy. In France, it results in more than 60,000 births before 37 weeks of gestation every year. Recent studies suggest that detection of placental α-microglobulin-1 (PAMG-1) in vaginal secretions among women presenting symptoms of preterm labour with intact membranes has good predictive value for the onset of spontaneous preterm delivery within 7 days. The test is especially interesting, in that the repetition of antenatal corticosteroids for foetal lung maturation is no longer recommended in France and the effect of the initial administration is most beneficial in the 24 h to 7 days afterwards. Methods We included all studies listed in PubMed and clinicaltrials.gov with the terms “PAMG-1” and either “preterm labor” or “preterm labour”, while excluding all studies on the subject of “rupture of the membranes” from 2000 through 2017. Ten studies were thus included. Results In women who had both the PAMG-1 and foetal fibronectin test, the PAMG-1 test was statistically superior to the measurement of cervical length for positive predictive value (p Conclusions The use of PAMG-1 may make it possible to target the women at risk with a shortened cervix on ultrasound (

Sacropexy is a reference surgical treatment for pelvic organ prolapse in women. The great variability in surgical techniques for this procedure is a source of bias that complicates analysis of the results of trials assessing it. Using the French guidelines issued in 2016 by the SCGP, AFU, SIFUD-PP, and CNGOF as a reference, we sought to inventory the surgical practices of the surgeons who perform these procedures. In November 2018, a questionnaire about the technical aspects of this procedure was distributed by email to the French physicians performing it. It was distributed to members of several professional societies (CNGOF, SCGP, and SIFUD) and to gynecologists practicing in clinics owned by the ELSAN group. Of the 273 responders, 92% reported that they perform most operations laparoscopically. Overall, 83% of gynecologic surgeons used polypropylene prostheses (mesh); 38% routinely placed a posterior mesh, while the rest did so only in cases of clinical rectocele with anorectal symptoms. A concomitant hysterectomy was performed by 51% of respondents when the uterus was bulky and/or associated with substantial uterine prolapse. Finally, half the surgeons suggested the placement of a suburethral sling for women with stress urinary incontinence. Although practices are largely consistent with the most recent guidelines, surgical techniques vary widely between surgeons, both in France and internationally.

Uterine fibroids are often associated with lower urinary tract symptoms (LUTS), the exact prevalence of which has been underexplored. Our main objective was to evaluate the effect of surgical treatment of fibroids on LUTS. Our secondary objectives were to assess the prevalence of LUTS in women undergoing fibroid surgery and to analyze the relationship between the characteristics of fibroids and the severity of symptoms.This was a prospective study of women conducted between 2019 and 2021. The main endpoint was the change in the total UDI-6, IIQ7, ICIQ-SF and CONTILIFE scores preoperatively and 6 weeks postoperatively.Of the 55 included women, 63.6% had frequency and 60% had urgency. Six weeks postoperatively, urinary symptoms had significantly improved for all scores. The presence of an anterior fibroid was significantly associated with higher urinary symptom scores for the UDI-6 (p = 0.007) and ICIQ-SF scores (p = 0.04). The size of the uterus or dominant fibroid was not significantly associated with the severity of urinary symptoms.Fibroids are often associated with symptoms of overactive bladder. An anterior location of the fibroid appears to be associated with greater severity scores. Surgical treatment appears to reduce urinary symptoms 6 weeks postoperatively.

Resume Objectif Evaluer l’impact de la realisation d’une hysterectomie en cas de cure de prolapsus sur les resultats anatomiques, fonctionnels, les complications per et postoperatoires par rapport a la conservation uterine. Materiels et Methodes Nous avons realise une revue de la litterature sur Pubmed, Medline, Embase et Cochrane en utilisant les termes et MeSH (Medical Subject Headings of the National Library of Medicine) suivants : uterine prolapse ; genital prolapse ; prolapse surgery ; vaginal prolapse surgery ; abdominal prolapse surgery ; hysterectomy ; hysteropexy ; sacrocolpopexy ; surgical meshes ; complications ; sexuality ; neoplasia ; urinary ; incontinence ; cancer. Resultats Parmi les 168 resumes etudies, nous avons retenu 63 articles. Il n’existait pas de difference significative en termes de resultats anatomiques et fonctionnels en cas de promontofixation (OR = 2,21 [IC95 % : 0,33–14,67[) et en cas de chirurgie vaginale sans pose de prothese (OR = 1,07 [IC95 % : 0,38–2,99]). Il n’y avait pas non plus de difference en termes de symptomatologie urinaire ou de sexualite au decours quel que soit la voie d’abord. L’hysterectomie etait associee a une morbidite plus importante (saignements, allongement du temps operatoire, allongement de la duree d’hospitalisation), un risque augmente d’exposition prothetique en cas d’hysterectomie totale (8,6 % IC95 % : 6,3–11). Conclusion En l’absence de preuve de superiorite en termes de resultats anatomiques et fonctionnels, avec une augmentation du taux de complications, l’hysterectomie concomitante en cas de cure de prolapsus ne doit probablement pas etre realisee de maniere systematique.

Miscarriage is a frequent problem that requires dilation and curettage in 30% of cases. This routine surgery may lead to intrauterine adhesions and severe infertility. Hyaluronic acid gel is known to reduce intrauterine adhesions after hysteroscopic surgery.This study aimed to evaluate the rate of intrauterine adhesions after dilation and curettage for miscarriage with and without hyaluronic acid gel.This was a multicentric (9 hospitals in France), prospective, open-label randomized trial. Patients who had a miscarriage between weeks 7 and 14 of gestation, required dilation and curettage, and wanted another pregnancy were eligible for the study. Women were randomly assigned in a 1:1 ratio to surgery alone (control group) or surgery with intrauterine instillation of hyaluronic acid gel (gel group). An office hysteroscopy was planned at 6 to 8 weeks after surgery. The primary endpoint was the rate of intrauterine adhesions during this office follow-up hysteroscopy. Two different follow-up fertility surveys were sent at 6 months and 1 year after the end of the intervention, respectively.Among the 343 patients who had curettage, 278 had hysteroscopy. After multiple imputation, the rate of intrauterine adhesions was lower in the gel group than in the control group (9.1% vs 18.4%, respectively; P=.0171). Among the 110 responders to the surveys, the overall pregnancy rate at 12 months after surgery was 64.5% (71/110), and similar in both groups (57.4% [27/47] in the control group vs 69.8% [44/63] in the gel group; P=.1789).Intrauterine instillation of hyaluronic acid gel reduces the rate of intrauterine adhesions in women treated with dilation and curettage for miscarriage.

Non-tubal ectopic pregnancies (NTEP) in France constitute approximately 5% of ectopic pregnancies (EP). A NTEP can be abdominal, ovarian, cervical, interstitial, on a caesarean scar, or cornual. These pregnancies, which are sometimes difficult to diagnose and are often diagnosed late, carry a high risk of complications, particularly haemorrhages. Many treatments have been described for treating these NTEP. Our objective is to assess how they are cared for in terms of diagnosis, treatment and monitoring.An online questionnaire was sent out to all members of the French Society of gynecologic and Pelvic Surgery (SCGP) in September 2020. The questionnaire was in the form of two clinical cases on interstitial and caesarean scar pregnancies.141 SCGP members responded (36%). For diagnosis, 58% of respondents enlisted the help of a specialist sonographer. MRI is rarely used for diagnosis to the extent that it was only requested in 7% of cases for interstitial pregnancy and 23.6% of cases for caesarean scar pregnancy. In the case of stable interstitial pregnancy without signs of complications, treatment is predominantly medical (90%), with the use of methotrexate (MTX) by intramuscular injection in 33.3% of cases, by in situ injection in 30.7% of cases, or a combination of the two in 36% of cases. If there were signs of pre-rupture, the majority of respondents performed laparoscopic surgical treatment (79.3%). In terms of caesarean scar pregnancies, the treatment was predominantly medical (78.2%) with the use of MTX only, as an intramuscular injection in 23.3% of cases, in situ in 36% of cases, and as a combination of intramuscular and in situ in 37.2% of cases.Non-tubal ectopic pregnancies are sometimes difficult to diagnose in the first trimester and constitute a significant haemorrhage risk for patients. In France, there is currently no specific recommendation on this subject and there is huge disparity in practice.

To implement a vaginal delivery of the second twin simulation program for obstetric and gynecology residents, to reduce maternal-fetal mortality in the management of twin pregnancies in the delivery room.A prospective education program. The session consisted of a theoretical part, a practical part on a mannequin and an evaluation. The model was designed in a simple and reproducible way. The simulation evaluation was done at several levels according to the validated Kirkpatrick model.A tertiary level university maternity hospital.Ten obstetric and gynecology residents participated.The resident's personal feelings about their ability to perform the maneuvers increased significantly after participation in the simulation session. Their technical skills in performing the maneuvers were assessed in a second step. The majority of the participants considered the model realistic and the session useful. All agreed that the simulation was an essential part of their learning process.A simulated vaginal delivery of the second twin session allows residents to be safely trained in these obstetrical maneuvers, which can be difficult to teach and perform.

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

Resume Introduction Le diastasis des muscles droits de l’abdomen est frequent au cours de la grossesse et du post-partum. Objectif Determiner la prevalence de cette pathologie, les methodes de diagnostic, l’association avec les troubles pelvi-perineaux et les therapeutiques pouvant etre proposees. Methodes Revue de la litterature sur Pubmed, Medline, Embase et Cochrane en utilisant les mots et MeSH suivants : diastasis, diastasis and pregnancy, diastasis of the rectus abdominis muscle, increase of the inter-recti distance. Resultats Parmi les 124 articles que nous avons trouves, 61 ont ete retenus. L’echographie abdominale semble etre l’examen de choix tant sur le plan de la faisabilite que de la reproductibilite pour le diagnostic de cette pathologie (coefficients de correlation intra-classe (ICC) eleves 0,81 a 0,94). Les facteurs de risque mis en evidence sont variables selon les etudes : port de charge lourde (OR = 2,18 (IC 95 % 1,05 a 4,52) p = 0,04), prise de poids. Les resultats des etudes sont discordants concernant l’association entre le diastasis et les douleurs lombaires (RR = 1,39 (IC 95 % 0,91–2,14), p = 0,17), l’incontinence urinaire (RR = 0,86 (IC95 % 0,55–1,33) p > 0,65) et le prolapsus (OR = 2,25 (IC 95 % 1,51–3,37) p Conclusion Les connaissances sur les facteurs de risque, les consequences des diastasis et leur prise en charge sont encore limitees a ce jour. Il est donc necessaire d’etablir des etudes prospectives sur de plus grands effectifs afin d’ameliorer les connaissances sur les diastasis des muscles droits.

Resume Objectifs Evaluer l’impact d’une formation theorique a partir du programme « CLEAR » (Cervical Length Education And Review) sur les competences echographiques des internes de gynecologie obstetrique. Methode Il s’agit d’une etude prospective monocentrique menee au CHU de Nantes de mai a novembre 2017. Nous avons recueilli 5 cliches d’echographie de col par interne realises chez des patientes consultant pour des contractions uterines ou un col modifie au toucher vaginal entre 24 et 34 SA. Un enseignement theorique a ensuite ete dispense sur 2 heures avec explication des criteres du programme « CLEAR ». A l’issue de cette formation, 5 nouveaux cliches par interne ont ete collectes, chaque cliche etant cote par 2 evaluateurs ayant obtenu la certification « CLEAR » en aveugle du statut pre- ou post-formation. Resultats Dix internes de gynecologie obstetrique ont participe a l’etude. Nous avons montre une amelioration statistiquement significative du score CLEAR moyen global post-formation vs preformation : 6,6 ± 0,9 vs 4,3 ± 2,1, difference positive de 2,3 ± 2,3 (p Conclusion Ce programme pedagogique avec apprentissage des criteres de qualite d’une echographie de col selon les criteres CLEAR a permis de noter une progression significative des internes, meme si cela peut aussi etre correle a la progression des internes au cours du semestre. Il serait interessant d’evaluer la mise en place de maniere systematique d’une formation en e-learning type « CLEAR » en debut d’internat pour standardiser l’enseignement theorique des internes.

Aims Our purpose was to explore the involvement of cognition in voluntary and involuntary pelvic floor muscle (PFM) contraction in stress urinary incontinent women. Methods PFM contraction monitored by surface electromyography (EMG) was measured without a mental distraction task (DT), and with a DT called "paced auditory serial additional test" (PASAT). Forty stress incontinent women performed voluntary contractions of the external anal sphincter (EAS), and reflex EAS contractions induced by means of coughing were studied using the external intercostal muscle (EIC) EMG pattern. Results A DT altered PFM pre-activation when coughing: the reaction time between EIC muscle contraction and EAS contraction (called RT3) was respectively -54.94 ms (IQR -87.12; 3.12) without the PASAT and -3.99 ms (IQR: -47.92; 18.69) with a DT (P = 0.02, Wilcoxon's test). Concerning voluntary contraction, women activated their PFM sooner without than with a DT. Conclusion The PASAT altered voluntary and reflex contractions of the PFM in stress urinary incontinent women. Our study suggests that cognition plays a role in urinary pathophysiology. Future studies should investigate rehabilitation programs that consider the role of cognition in stress urinary incontinent women.

International audience; Introduction: The impact of a hysterectomy on urinary incontinence is a controversial subject in the literature.Objective: To evaluate the prevalence and incidence of urinary incontinence after a hysterectomy as well as associated risk factors such as the type of hysterectomy, the surgical approach, urodynamic criteria and uterine disease.Study design: We conducted a systematic review in Pubmed database with the following keywords and MeSH term: hysterectomy, urinary incontinence.Results: A total of 1340 articles were retrieved, 42 articles were selected for the final text analysis. The results of the different studies were heterogeneous. Hysterectomy seemed to increase the rate of sphincter deficiency (VLPP

Introduction Endometrial cancer, one of the most frequent pelvic gynecologic cancer worldwide, currently has no biomarker used to assess it in daily practice. Nonetheless, human epididymis 4 (HE4) appears to offer the best prospects, alone or combined with CA125. This study sought to systematically review the work on HE4 from the first publications in 2008 until now. Material and methods Two independent reviewers searched the PubMed database with the terms “HE4″, ”endometrial cancer“, ”endometrial carcinoma“, and HE4 or human epididymis protein 4. Only original clinical research articles and meta-analyses, published in English, were included, with literature reviews and case reports excluded. Results Studies were organized into 3 categories: diagnosis, prognosis, and recurrence/survival. Overall we identified 117 articles dealing with HE4 and endometrial cancer and selected 52 relevant texts: 46 articles, 6 meta-analyses. The sensitivity of HE4 for the diagnosis of endometrial cancer varied from 44.2% to 91% and its specificity from 65.5 to 100%, versus 24.1 to 71.5% and from 65.6 to 100% for CA125. Two meta-analyses of their combination produced areas under the curve (AUC): 0.83 and 0.86. Two available algorithms — the REM (risk of endometrial malignancy) and REM-B (risk of endometrial malignancy associated with BMI) scores — require more study. HE4 is also strongly associated with prognostic factors such as myometrial invasion, tumor grade, FIGO stage, and lymph node involvement. It also predicts recurrence and can serve as a monitoring tool, as reported by a 2018 meta-analysis with a hazard ratio of 2.15 (P Conclusion HE4, alone or associated with CA125, appears to be an important tool in the management of endometrial cancer, initially for diagnosis, but for assessing prognosis and survival. Other prospective and multicenter studies are necessary to confirm these hopes and be able to recommend the use of HE4 in regular practice.

Resume Introduction Les douleurs pelvi-perineales postchirurgie du prolapsus genital sont des complications postoperatoires graves et frequentes dont le diagnostic et le traitement peuvent etre complexes. Materiels et methodes Nous avons realise une revue de la litterature sur la base de donnees Pubmed en utilisant les mots et MeSH suivants : genital prolapse, pain, dyspareunia, genital prolapse and pain, genital prolapse and dyspareunia, genital prolapse and surgery, pain and surgery. Resultats Parmi les 133 articles trouves, 74 ont ete retenus. Les douleurs pelvi-perineales chroniques evoluent depuis plus de 3 mois selon l’International Association for the Study of Pain, et peuvent etre de type nociceptif, neuropathique ou dysfonctionnel. Leur definition est avant tout clinique. Leur incidence varie de 1 a 50 % et les facteurs de risques suspectes sont un âge jeune, des comorbidites, un antecedent de chirurgie de prolapsus, un stade eleve de prolapsus, des douleurs preoperatoires, une voie d’abord chirurgicale invasive, la pose simultanee de plusieurs protheses, une moindre experience de l’operateur, une duree importante d’intervention et des douleurs postoperatoires precoces. La voie vaginale peut favoriser une modification de la compliance ou de la longueur vaginale, des lesions des nerfs pudendaux, sciatiques ou obturateurs ou un syndrome myofascial pelviens ; la voie cœlioscopique est a risque de lesion des nerfs parietaux ; la chirurgie prothetique implique des complications liees aux modifications de prothese. La prise en charge therapeutique est complexe et doit etre multimodale et pluridisciplinaire. Conclusion Les connaissances sur les douleurs pelvi-perineales apres chirurgie du prolapsus genital sont encore limitees a ce jour.

Sacropexy is a reference surgical treatment for pelvic organ prolapse in women. The great variability in surgical techniques for this procedure is a source of bias that complicates analysis of the results of trials assessing it. Using the French guidelines issued in 2016 by the SCGP, AFU, SIFUD-PP, and CNGOF as a reference, we sought to inventory the surgical practices of the surgeons who perform these procedures.In November 2018, a questionnaire about the technical aspects of this procedure was distributed by email to the French physicians performing it. It was distributed to members of several professional societies (CNGOF, SCGP, and SIFUD) and to gynecologists practicing in clinics owned by the ELSAN group.Of the 273 responders, 92% reported that they perform most operations laparoscopically. Overall, 83% of gynecologic surgeons used polypropylene prostheses (mesh); 38% routinely placed a posterior mesh, while the rest did so only in cases of clinical rectocele with anorectal symptoms. A concomitant hysterectomy was performed by 51% of respondents when the uterus was bulky and/or associated with substantial uterine prolapse. Finally, half the surgeons suggested the placement of a suburethral sling for women with stress urinary incontinence.Although practices are largely consistent with the most recent guidelines, surgical techniques vary widely between surgeons, both in France and internationally.

Objective To study changes in the reasons for third-trimester termination of pregnancy (TOP) for fetal anomalies over a 20-year period in France. Study design We compared a consecutive series of third-trimester TOPs from a single centre in 2005–2014 to those performed by Dommergues et al. in a similar centre in 1986–1994, using the same criteria. Main outcome measures The process leading to late TOP, using the same categories in both studies. Results In the present series, 205 of 1409 TOPs were performed in the third trimester, vs. 305/956 in the historical series. There were 33 (16.1 %) diagnoses missed at the screening before the third trimester, 55 (26.8 %) cases in which the anomaly was impossible to diagnose until the third trimester, 86 (42 %) cases in which fetal prognosis could not be established until the third trimester despite earlier diagnosis, 31 (15.1 %) TOPs postponed to allow more time for the women/couples to contemplate, versus respectively 113 (37 %), 55 (18 %), 122 (40 %), and 15 (5%) in the historical series. Conclusion There was a significant drop in the rate of anomalies missed earlier. The increase in late TOP due to couples requiring additional time for contemplation might result from changes in counselling processes.

Objectives The main objective was to assess the reliability of the patient's measurement of diastasis. The secondary aims were the estimation postpartum diastasis prevalence, of diastasis-associated pelvic floor symptoms and quality of life immediately after childbirth and at 3−6 months postpartum. Study design Using a prospective observational design, women who gave birth in a French university hospital were eligible. After a learning phase, both clinician and patient conducted a clinical evaluation of diastasis. Then, patients were asked to complete the HerQLes, the FPFQ and a general questionnaire. Three to 6 months later, patients completed the same questionnaires online and performed a clinical evaluation of diastasis at home, as learned previously. Results Of 253 patients included in the study, 139 (54.9 %) completed the questionnaires at 3–6 months of follow-up. There was good correlation between clinician and patient evaluations of diastasis (kappa coefficient 0.76 [95 % CI, 0.5−0.7]). Immediately after childbirth, 210 (83 %) of the women presented diastasis including 116/210 (55 %) cases of severe diastasis and 51 (42 %) of those had persistent diastasis at 3−6 months of follow-up. Cesarean section (p = 0.05) and multiparity (p = 0.04) were factors of persistent diastasis. Severe diastasis had a significant impact on quality of life (HerQLes score) at birth (p = 0.001) and at 3−6 months (p = 0.01), but no effect on pelvic floor symptoms according the FPFQ. The occurrence and severity of diastasis did not significantly impact lumbar or pubic symphysis pain. Furthermore, the aesthetic discomfort felt by patients was significantly increased by the presence of diastasis on a numerical scale at 3−6 months (p = 0.03). Conclusion Good agreement between clinician and patient evaluations of postpartum diastasis indicated that the evaluation method is reliable. Persistent diastasis was associated with impaired quality of life.

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

Introduction To classify persistent perineal and pelvic postpartum pain using the classification usually employed in chronic pelvic pain. Material and method Prospective observational study including all women who have consulted an algologist or gynecologist at one of the six French centers for a chronic pain (superior or equal to 3 months) spontaneous linked by the mother with her childbirth were included. During semi-directed interviews, a questionnaire regarding sociodemographic factors and detailed questions about pain were collected. Then, pelvic and perineal pain were classified into 7 pain syndromes: pelvic sensitization (Convergences PP criteria), complex regional pain syndrome (Budapest criteria), pudendal or cluneal neuralgia (Nantes criteria), neuroma, thoraco-lumbar junction syndrome, myofascial pain (muscle trigger zone), fibromyalgia (American College of Rheumatology criteria). The principal objective of this study is to assess the prevalence of each painful disorder. The secondary aims were the description of socio-demographic factors and clinical characteristics of this population, identify the related symptoms and the impact on daily function associated with the chronic pelvic or perineal postpartum pain. Results 40 women with chronic pelvic or perineal pain spontaneously linked with childbirth were included. 78 % experienced pain for more than 12 months. A large majority had a vaginal birth (95 %) with perineal suture (90 %) and severe acute pain within the first week postpartum (62 %). Postpartum pain impacted participant’s sexual activity (80 %), micturition (28 %) and defecation (38 %). In the sample, 17 cases of neuroma, 6 patients with pudendal or cluneal neuralgia, 13 patients with pelvic sensitization and 2 cases of fibromyalgia were identified. Complex regional pain syndrome was diagnosed in 8 patients, and myofascial pain in 11 women, and only 1 patient had thoraco-lumbar junction syndrome. Neuropathic pain was found in 31 participants (77.5 %) according to DN4 criteria. Discussion The classification scheme proposed in this study may be a very useful tool to investigate postpartum pelvic and perineal pain and to propose a treatment.

Introduction The breech presentation represents 4,7% of deliveries at term. There is a method of external cephalic version (ECV) performed from 36 weeks of gestation. French guidelines for the clinical practice of ECV were published in 2020. Objective To evaluate the national practices of ECV in French maternity units, especially on the use of tocolysis, 1 year after publication of the French clinical recommendations guidelines by the French national college of obstetricians and gynecologists (CNGOF). Methods Data self-reported for this national descriptive study were collected from March to May 2021 by an online questionnaire distributed to all French maternities. The 25 items of the questionnaire collected information of maternity units, the general practice of ECV, use or not of tocolysis for ECV attempt and the relevance of a prospective study. Results Of the 517 French maternity units, 150 (29%) responded to the online survey. 95,3% systematically performed ECV. A Kleihauer test was routinely performed in 71 units (49.7%). A tocolysis was associated with ECV attempt in 52.4% of cases. The drugs used were intravenous atosiban (30,7%), mainly in levels 2b and 3 maternity units, intravenous salbutamol (24%), other mode of administration of salbutamol (14,7%) and oral nifedipine (22,6%) mainly in levels 1 and 2a maternity units. Adverse effects were described in 20%, mainly with the use of salbutamol (73,3%). Conclusions 52.4% of the French maternity units surveyed used tocolysis for the ECV attempt, although it is systematically recommended. The choice of tocolytic drug differed according to the maternity units.

Resume Les troubles de la statique pelvienne constituent un enjeu de sante publique frequent, influant de maniere considerable sur la qualite de vie. Les symptomes sont multiples et peuvent etre associes : pesanteur pelvienne (prolapsus), troubles urinaires, troubles sexuels, troubles rectaux. Une approche unitaire de la physiopathologie du plancher pelvien requiert un diagnostic global incluant les trois compartiments : anterieur (urinaire), moyen (genital) et posterieur (recto-anal). Le diagnostic clinique, fondamental, s’appuie sur les modalites d’imagerie, qui doivent etre dynamiques : la colpocystodefecographie, l’IRM pelvienne et l’echographie dynamiques. L’imagerie a toute sa place dans l’exploration preoperatoire, mais egalement dans l’evaluation du plancher pelvien des patientes operees (complications, recidives). Les radiologues doivent etre conscients des implications cliniques et therapeutiques de leur diagnostic radiologique et connaitre les erreurs potentielles afin de les minimiser.

Existen numerosas tecnicas de rehabilitacion perineal, empleadas con mucha frecuencia de forma conjunta. Durante el embarazo, se puede prescribir rehabilitacion perineal a las mujeres con incontinencia urinaria. En el posparto, se recomienda rehabilitacion perineal en la incontinencia urinaria o anal persistente a los 3 meses del parto (al menos tres sesiones dirigidas por un terapeuta), que debe incluir ejercicios de contraccion voluntaria de los musculos del piso pelvico. La rehabilitacion del posparto mejora la incontinencia urinaria y anal a corto plazo (1 ano), pero no a largo plazo (entre 6-12 anos). Para la incontinencia urinaria del posparto, se deben rehabilitar de seis a siete mujeres con incontinencia para que una de ellas sea continente al ano. La prevalencia de la incontinencia anal al ano del posparto es del 7% en las pacientes que han recibido rehabilitacion a los 3 meses del posparto frente al 13% en el grupo control. En las mujeres, con excepcion del embarazo y del posparto, la rehabilitacion perineal ha demostrado eficacia a corto plazo en el caso del tratamiento de la incontinencia urinaria de esfuerzo, la vejiga hiperactiva, los prolapsos genitales de estadio 1 o 2 (eficacia sobre la anatomia y los sintomas), los trastornos anorrectales (incontinencia anal, disquecia) y los trastornos sexuales (incontinencia urinaria coital, orgasmo, libido). No se ha demostrado beneficio alguno a largo plazo de esta rehabilitacion.

International audience; Objectifs : le prolapsus des organes pelviens (POP) de la femme est une situation fréquente qui mène dans 19 % des cas à un traitement chirurgical. Le registre VIGI-MESH a permis de collecter les interventions chirurgicales de POP dans 19 centres et à surveiller les complications et les révisions chirurgicales. Nous présentons ici les premiers résultats à moyen terme de notre registre.Méthodes : l’analyse comprend 2 341 patientes dont la chirurgie prévue était une promontofixation par laparoscopie avec prothèse (n = 1 143), une chirurgie transvaginale avec prothèse (n = 694) ou sans prothèse (n = 504). La promontofixation a été converti dix fois (0,9 %) : 5 par laparotomie, 2 fixations latérales par laparoscopie, 3 voies transvaginale dont 2 avec prothèse. Les patientes étaient plus jeunes, avec moins de comorbidités dans le groupe promontofixation, et avec plus d’antécédents chirurgicaux chez les patients opérés par voie vaginale. Il y a une majorité de chirurgie avec prothèse en cas de prolapsus antérieur ou apical.Résultats : avec 15 mois de suivi médian, nous avons observé des complications Clavien–Dindo grade III ou plus chez 48 patientes (2,05 %). L’incidence de complications graves à 12 mois est significativement supérieure pour la réparation vaginale prothétique soit 3,71 % [2,28–5,13] versus 1,27 pour la réparation vaginale non prothétique [0,25–2,29] et 1,44 pour la promontofixation [0,71–2,167] avec p = 0,005 (Fig. 1). Il y a 29 réinterventions (1,24 %) en raison d’échec ou de récidive du prolapsus : 11 après promontofixation (0,96 %), 6 après prothèse vaginale (0,86 %) et 12 après réparation vaginale autologue (2,38 %). La réparation vaginale native comporte un risque de reprise chirurgicale pour prolapsus récidivé trois fois plus élevé qu’en cas de promontofixation (RR 0,34 [0,15–0,77]) ou de prothèse vaginale (RR = 0,29 [0,11–0,76]) .Conclusion : dans notre registre, la promontofixation présente le meilleur ratio bénéfice/risque par rapport à la réparation vaginale. Cette dernière expose à un faible risque de complications en cas de réparation autologue mais avec un risque de récidive 3 fois plus élevé et à l’inverse à un faible risque de récidive en cas de chirurgie prothétique mais avec un risque de complication grave 3 fois plus élevé.

Introduction Approximately 4% of singleton pregnancies at term are in breech presentation. External cephalic version (ECV) can reduce the risks of noncephalic birth and cesarean delivery, but this maneuver can be painful. Our aim was to analyze the effect of administering inhaled nitrous oxide for analgesia on the ECV success rate. Material and methods This prospective, randomized, single-blind, controlled trial included women with singleton pregnancies in breech presentation at term who were referred for ECV in a tertiary care center. Women were assigned according to a balanced (1:1) restricted randomization design to inhale either nitrous oxide (N2 O) in a 50:50 mix with oxygen or medical air during the procedure. The main outcomes reported are the ECV success rate, degree of pain, adverse event rate, and women's satisfaction. Trial registration ClinicalTrials.gov Identifier: NCT01948115. Results The study included 150 women (nitrous oxide group: n = 74; medical air: n = 76). Inhaled nitrous oxide was not associated with a higher ECV success rate than medical air (24.3 vs 19.7%, P = 0.51). Among parous women (n = 34 in each group), the ECV success rate appeared higher in the nitrous oxide group, respectively 47.1% (n = 16) vs 23.5% (n = 8) (P = 0.042). Neither the median pain level nor adverse event rates differed significantly in women with inhaled nitrous oxide compared with medical air. Conclusions Use of an equimolar mixture of oxygen and nitrous oxide during ECV appears safe. Although it does not seem to change the overall success rate, it may increase success in parous women.

Objective Precise data are lacking concerning laparoscopic sacropexy in the elderly population. The purpose of this study was to compare the outcomes and complications associated with laparoscopic sacropexy (colpopexy or hysteropexy) in women aged under 70 and 70 or over. Study design Retrospective review of data on patients who underwent laparoscopic sacropexy in two tertiary centers. Peri- and postoperative complications were recorded and described using the IUGA classification. Surgery was considered successful if the patient was symptomatically satisfied or very satisfied and if the POP-Q (Pelvic Organ Prolapse-Quantification) stage score at the follow-up visit was below stage 2 for all compartments. Results Among the 191 women studied, 47 (24.6%) were aged 70 or more. According to the ICS/IUGA classification of POP complications, perioperative and postoperative complication rates were similar in the older versus younger groups (bladder injuries (0 vs. 1.39%, p = 1) (4A T1 S2), rectal injuries (0% vs. 0.69%, p = 1) (5BT1S5), vaginal injuries (2.13% vs. 0%, p = 0.246) (2A T1 S1)). No laparotomy conversion was required in either group. At two months of follow-up, the success rate was 97.9% and 95.1% in the older and younger groups, respectively (p = 0.68). At 24 months of follow-up, the overall reoperation rate was 12.8% for the older group versus 11.8% in the younger group (p = 0.80). Conclusions Our findings suggest that laparoscopic sacropexy is a valid option in elderly women presenting with genital prolapse.

Background Threatened preterm delivery (TPD) is the leading cause of inpatient admissions during pregnancy. The ability to predict the risk of imminent preterm delivery is thus a major priority in obstetrics. The aim of our study is to assess the diagnostic performance of the test to detect the placental alpha microglobulin 1 (PAMG-1) for the prediction of delivery within 7 days in women with TPD. Methods This is a prospective multicenter diagnostic study. Inclusion criteria are singleton pregnancy, gestational age between 24 + 0 and 33 + 6 weeks inclusive, cervical measurement 25 mm or less assessed by transvaginal ultrasound (with or without uterine contractions), clinically intact membranes and cervical dilatation According to the current protocol, when a women presents with TPD and the diagnosis is confirmed by transvaginal ultrasound, a vaginal sample to test for genital infection is performed. At the same time, the midwife will perform the PartoSure® test. To perform this analysis, a sample of cervicovaginal secretions is taken with the vaginal swab furnished in the test kit. The primary outcome is the specificity of the PartoSure® test of women who gave birth more than 7 days after their hospitalization for TPD. The secondary outcomes are the sensitivity, PPV, and NPV of the Partosure® test and the factors associated with false positives (with a univariate logistic regression model). Starting with the hypothesis of an anticipated specificity of 89%, if we want to estimate this specificity with a confidence interval of ± 5%, we will require 151 women who do not give birth within 7 days. We therefore decided to include 400 women over a period of two years to have a larger number of events (deliveries within 7 days). Discussion The different tests already used such as fetal fibronectin and phIGFBP-1, are not sufficiently relevant to recommend their use in daily practice. The different studies of PAMG-1 described above thus provide support for the use of this substance, tested by PartoSure®. Nonetheless, other larger studies are necessary to validate its use in daily practice and our study could answer this question. Trial registration NCT03401255 (January 15, 2018)

The diastasis of the rectus abdominis muscles is common during pregnancy and post-partum.To determine the prevalence of this pathology, methods of diagnosis, association with pelvic-perineal disorders and therapies that may be proposed.Review of Pubmed, Medline, Embase and Cochrane literature using the following words and MeSH: diastasis, diastasis and pregnancy, diastasis of the rectus abdominis muscle, increase of the inter-recti distance.Among the 124 articles found, 61 were selected. Ultrasound seems to be the exam of choice both in terms of feasibility and reproducibility for the diagnosis of this pathology (intra-class correlation coefficients (ICC) high 0.81 to 0.94). The risk factors identified vary from one study to another: heavy load bearing (OR=2.18 (95 % CI 1.05 to 4.52) P=0.04), weight gain. Studies are discordant regarding the association between diastasis and low back pain (RR=1.39 (95 % CI 0.91-2.14), P=0.17), urinary incontinence (RR=0.86 (95 % CI 0.55-1.33) P0.65) and prolapse (OR=2.25 (95 % CI 1.51-3.37) P0.001), but the diastasis seems to play a role in the alteration of the quality of life for these patients.Knowledge about risk factors, consequences of diastasis and management is still limited today. It is therefore necessary to establish prospective studies on larger numbers in order to improve knowledge on the diastasis of the rectus abdominis muscles.

Objectives: To assess the methods used to manage Bartholin gland abscesses and cysts in French university hospitals. Method: Data for this descriptive, cross-sectional study with self-reported data were collected between January and March 2018 by an online questionnaire. The 11 items of the questionnaire assessed the surgical techniques known and used, the type of hospitalization, and the non-surgical management to treat Bartholin gland abscesses and cysts. Results: Overall, 116 obstetrics-gynecology residents responded to the online questionnaire. The three best-known techniques were incision and drainage, marsupialization, and excision of the Bartholin gland. Only 3% of the physicians knew about other techniques. Most participants reported that their unit treated 2–6 Bartholin gland abscesses monthly and fewer than 2 cysts. The most frequent treatment for abscess was incision-drainage (87%), followed by marsupialization (13%). The most widely used treatment for the cysts was gland excision (68.5%) followed by marsupialization (22.5%). In both cases, management generally took place on an outpatient basis (92.9%). Conclusion: This study showed that 87% of the respondents used incision-drainage for Bartholin gland abscesses, although the recurrence and complication rates of this technique have never been evaluated.

Background: Presumed benign ovarian tumours (PBOT) are defined by the International Ovarian Tumour Analysis (IOTA) group, without suspected sonographic criteria of cancer, without ascites or metastasis. The aim is to evaluate the efficacy of human epididymis protein 4 (HE4), cancer antigen 125 (CA125), the risk of malignancy index (RMI) and the risk of ovarian malignancy index (ROMA) to predict ovarian cancer in women with PBOT. Methods: It is a prospective, observational, multicentre, laboratory-based study including women with PBOT in four hospitals from 11 May 2015 through 12 May 2016. Preoperative CA125 and HE4 plasma levels were measured for all women. The primary endpoint was the specificity of CA125 and HE4 for diagnosing ovarian cancer. The main secondary endpoints were specificity and likelihood ratio of RMI, ROMA and tumours markers. Results: Two hundred and fifty patients were initially enrolled and 221 patients were finally analysed, including 209 benign ovarian tumours (94.6%) and 12 malignant ovarian tumours (5.4%). The malignant group had significantly higher mean values of HE4, CA125, RMI and ROMA compared to the benign group (p &lt, 0.001). Specificity was significantly higher using a combination of HE4 and CA125 (99.5%) compared to either HE4 or CA125 alone (90.4% and 91.4%, respectively, p &lt, 0.001). Moreover, the positive likelihood ratio for combination HE4 and CA125 was significantly higher (104.5, 95% CI 13.6&ndash, 800.0) compared to HE4 alone (5.81, 95% CI 2.83&ndash, 11.90) or CA125 alone (6.97, 95% CI 3.91&ndash, 12.41). Conclusions: The combination of HE4 and CA125 represents the best tool to predict the risk of ovarian cancer in patients with a PBOT.

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

Postpartum pelvic floor disorders. Postpartum pelvic floor disorders are frequent but most of the time, decrease spontaneously. Even if 40% of pregnant women suffer from urinary incontinence, 85% of them are cured 3 months after delivery. In case of persistent urinary incontinence, postpartum rehabilitation improves short-term urinary incontinence. Six weeks after delivery 4% to 39% women suffer from anal incontinence. Most of the time anal symptoms decrease spontaneously. Postpartum rehabilitation seems to improve short-term anal incontinence. 15 to 20% of pregnant women have a genital prolapse stage 2 during the third trimester and 20 to 50% in the immediate postpartum. Even if most of the women (90%) have genital prolapse (stage 1 for most of them) one year after delivery, only 10% are bothered. Expectative management with a clinical evaluation 12 months after delivery is sufficient. In case of persistent symptoms, pelvic floor rehabilitation can be proposed.Troubles pelvi-périnéaux du post-partum. Les troubles pelvi-périnéaux du post-partum sont fréquents mais régressent spontanément la plupart du temps. L’incontinence urinaire dont la prévalence est proche de 40 % au cours de la grossesse régresse spontanément dans 85 % des cas à 3 mois du post-partum. En cas de persistance des symptômes, la rééducation périnéale semble améliorer les symptômes au moins à court terme. L’incontinence anale, dont la prévalence varie de 4 à 39 % à 6 semaines du post-partum régresse aussi spontanément la plupart du temps. La rééducation périnéale semble également être efficace à court mais pas à long terme. La prévalence des prolapsus de stade 2 est de 15 à 20 % au 3e trimestre de grossesse et elle varie de 20 à 50 % dans le post-partum immédiat. Même si la majorité des patientes (90 %) ont encore une petite composante de prolapsus à 1 an, seules 10 % en sont gênées. L’expectative avec une réévaluation de la gêne à 1 an du post-partum semble être préférable et, en cas de persistance des symptômes, une rééducation périnéale est alors préconisée.

STUDY QUESTION Were spontaneous miscarriages more frequent in women with histologically proven endometriosis when compared with endometriosis-free controls? SUMMARY ANSWER Endometriosis-affected women display a significantly higher rate of previous spontaneous miscarriages than endometriosis-free controls. WHAT IS KNOWN ALREADY The association between endometriosis and miscarriages has long been debated without reaching a consensus. STUDY DESIGN, SIZE, DURATION We conducted a retrospective cohort study comparing exposed women (endometriosis) and control (without endometriosis) regarding the incidence of miscarriages. All study participants underwent surgery for benign gynaecological conditions in a tertiary-care university hospital between January 2004 and March 2013. After thorough surgical examination of the abdominopelvic cavity, 870 women with histologically proven endometriosis were allocated to the endometriosis group and 981 unaffected women to the control group. Only previously pregnant women were finally included for the study analysis: 284 women in the endometriosis group and 466 in the control group. PARTICIPANTS/MATERIALS, SETTING, METHODS Data were collected preoperatively using a structured questionnaire. Among women with at least one pregnancy before the surgery, the type and number of the different previous first trimester pregnancies outcomes were studied. Previous history of miscarriage was studied according to the existence of previous infertility history and the disease severity (revised American Fertility Society and surgical classification). MAIN RESULTS AND THE ROLE OF CHANCE Four hundred and seventy-eight pregnancies in endometriosis-affected women and 964 pregnancies in controls were analysed. The previous miscarriage rate was significantly higher in women with endometriosis compared with the controls (139/478 [29] versus 187/964 [19%], respectively; ITALIC! P < 0.001). After a subgroup analysis, the miscarriage rates of women with endometriosis and the controls were, respectively: 20 versus 12% ( ITALIC! P = 0.003) among women without a previous history of infertility and 53 versus 30% ( ITALIC! P < 0.001) for women with a previous history of infertility. After using a random-effects Poisson regression and adjusting for confounding factors, we found a significantly increased incidence rate ratio (IRR) for miscarriages in women with endometriosis (adjusted IRR: 1.70, 95% confidence interval: 1.34-2.16). LIMITATIONS, REASONS FOR CAUTION There is a possible selection bias due to the specificity of the study design which included only surgical patients. In the control group, certain of the surgical gynaecological conditions, such as fibroids, ovarian cysts or tubal pathologies, might be associated with higher spontaneous miscarriage rates. In the endometriosis group, asymptomatic women were less likely to be referred for surgery and might therefore be underrepresented. WIDER IMPLICATIONS OF THE FINDINGS This study opens the doors to future, more mechanistic studies to establish the exact link between endometriosis and spontaneous miscarriage rates. STUDY FUNDING/COMPETING INTERESTS No external funding was used for this study. The authors have no conflicts of interest to declare.

El diagnostico de incontinencia urinaria (IU) es clinico: la anamnesis diferencia una incontinencia urinaria de esfuerzo (IUE), una incontinencia urinaria de urgencia (IUU) (hiperactividad vesical) y una incontinencia urinaria mixta (IUM). Esta distincion es esencial, porque las estrategias terapeuticas son diferentes. La fisiopatologia es compleja y multifactorial. Es cierto que el embarazo, el parto, la edad, un cierto grado de predisposicion genetica tisular y el sobrepeso son factores de riesgo demostrados, pero todavia no se conocen los mecanismos precisos que conducen a la genesis de uno u otro tipo de incontinencia. Aparte de los raros casos en que se sospecha una enfermedad organica subyacente (neurologica o uroginecologica) y despues de haber descartado una infeccion urinaria y un residuo posmiccional, puede proponerse un tratamiento de primera linea sin exploracion urodinamica previa. En la IUE, se recomienda la reeducacion (ejercicios de contraccion voluntaria de los musculos perineales) de entrada, en ocasiones asociada a una reduccion ponderal. En la hiperactividad vesical, la reeducacion (tecnicas conductuales, ejercicios de contraccion muscular y electroestimulacion) y los anticolinergicos (con o sin estrogenos topicos despues de la menopausia) constituyen los tratamientos de primera linea, en ocasiones asociados a una reduccion ponderal. En caso de fracaso de un tratamiento de primera linea, esta indicada una exploracion urodinamica. En la IUE, tras el fracaso de la reeducacion, se propone una intervencion quirurgica con colocacion de un cabestrillo suburetral (CSU). En caso de fracaso, se discuten otras alternativas: inyecciones/balones parauretrales y esfinter artificial. En la hiperactividad vesical, en caso de fracaso de los anticolinergicos, se puede proponer a la paciente una neuromodulacion (sacra o del ciatico popliteo interno) o inyecciones intradetrusorianas de toxina botulinica. Sea cual sea el tipo de incontinencia, se puede proponer a las mujeres que presentan una IU durante el embarazo o en el posparto una reeducacion, que se ha mostrado eficaz en estas dos indicaciones. En cambio, esta reeducacion no parece tener un efecto protector de larga duracion.

Objective Although placement of a retropubic mid-urethral slings (MUS) is one of the gold standard surgical treatments for stress urinary incontinence, new devices are poorly evaluated before marketing. We compared TVT-EXACT™ (TVT-E), a new device expected to reduce bladder injuries, with the historically described bottom-to-top TVT™ (TVT). Study design This retrospective study compared TVT-E ( n = 49) and TVT ( n = 49). The main outcomes were the prevalence of complications (bladder injuries, immediate postoperative pain, perioperative complications, etc.) and the short-term success rate (no reported urinary leakage and negative cough test) of both MUSs. Results Minimum follow-up was 12 months. The characteristics of the two groups were comparable. The prevalence of bladder injury for TVT-E and TVT was 8% and 6%, respectively ( p = 1). The intensity of immediate postoperative pain (VAS/100) was lower following TVT-E than after TVT (8.0 vs. 15.9, p = 0.01). The first post-void residual was increased in the TVT-E group (153.9 vs. 78.9 mL, p = 0.045), and there were more postoperative bladder outlet obstruction (BOO) symptoms in the TVT-E group (24% vs. 6%, p = 0.02). However, there was no difference when considering only de novo BOO (14% vs. 4%, p = 0.16). The prevalence of peri- and post-operative complications was equal in the two groups. The success rate was similar at 12 months of follow-up (80 vs. 82%, p = 1). Conclusion The prevalence of bladder injury was unchanged with TVT-EXACT™ compared with TVT™, but post-operative pain was decreased. The success rate of both retropubic MUSs was similar at 12 months of follow-up.

Resume Objectif Etablir des recommandations concernant la reeducation perineale et abdominale du post-partum. Materiel et methode Revue exhaustive de la litterature concernant la reeducation perineale et abdominale du post-partum, etablissement de niveaux de preuve (NP) et de grades de recommandation selon la methodologie des recommandations pour la pratique clinique. Resultats La reeducation perineale par des exercices de contraction des muscles du plancher pelvien est recommandee pour traiter une incontinence urinaire persistante a 3 mois du post-partum (grade A), quel que soit le type d’incontinence. Au moins 3 seances guidees par un therapeute sont recommandees, associees a des exercices realises au domicile. Cette reeducation du post-partum ameliore l’incontinence urinaire a court terme (1 an), mais pas a long terme (6–12 ans). La reeducation perineale precoce (dans les deux mois suivants l’accouchement) n’est pas recommandee (grade C). La reeducation perineale du post-partum chez les femmes presentant une incontinence anale est associee a une prevalence moindre de symptomes d’incontinence anale a court (1 an) (NP3) mais pas a long terme (6 et 12 ans) (NP3). La reeducation perineale du post-partum est recommandee pour traiter une incontinence anale du post-partum (grade C) mais ses resultats ne sont pas maintenus a moyen ou long terme. Aucun essai randomise n’a evalue la reeducation perineale chez des femmes asymptomatiques dans le but de prevenir une incontinence urinaire ou anale a moyen ou long terme. Elle n’est donc pas recommandee (accord professionnel). La reeducation perineale guidee par un therapeute n’est pas plus efficace (tant sur le plan anatomique que symptomatique) que de simples conseils de contraction volontaire des muscles du plancher pelvien pour prevenir/corriger a court terme (6 mois) un prolapsus persistant a 6 semaines du post-partum (NP2), qu’il existe ou non un defect du levator ani (NP3). La reeducation perineale du post-partum n’est pas associee a une diminution de la prevalence des dyspareunies a 1 an (NP3). La reeducation perineale du post-partum guidee par un therapeute n’est donc pas recommandee pour traiter ou prevenir un prolapsus (grade C) ou des dyspareunies (grade C). Aucun essai randomise n’a evalue l’effet de la reeducation perineale apres un episode de retention ou dysurie du post-partum, ni dans la prevention primaire de l’incontinence anale en cas de perinee complet, ni chez des patientes presentant une incontinence anale dans les suites d’un perinee complet. La reeducation n’est donc pas recommandee dans ces situations. Les appareils d’electrostimulation utilises isolement n’ont pas ete evalues dans ce contexte du post-partum (que la femme soit symptomatique ou non) ; ils ne sont donc pas recommandes (accord professionnel). Conclusion Une reeducation perineale du post-partum est recommandee en cas d’incontinence urinaire (grade A) ou anale (grade C) persistant a 3 mois de l’accouchement.