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OBJECTIVES The delivery of breech presentations remains controversial. Our study analysed the impact of a service protocol on the proportion of planned vaginal delivery and its success. Immediate neonatal morbidity and factors that may influence the success of vaginal delivery were studied. METHODS Retrospective study, between 2009 and 2020 at the CHRU of Limoges, type 3 maternity hospital, on patients with a breech foetus at term. The proportion of planned vaginal delivery and the rate of effective vaginal delivery were compared before/after 2015. Neonatal morbidity was compared for planned vaginal delivery and planned cesarean delivery groups. RESULTS We included 923 patients. The rate of planned vaginal delivery was significantly higher after 2015 from 5.2% to 19% (P

Resume Objectif Le score de FullPIERS permet de predire la survenue d’evenements maternels graves secondaires a une pre-eclampsie. L’objectif de cette etude est de tester la validite externe de ce score a partir d’une population issue d’une maternite francaise. Methodes Nous avons realise une etude retrospective monocentrique dans une maternite de type 3 de 2014 a 2018 a Limoges incluant les patientes ayant fait une pre-eclampsie quelle que soit sa severite. La performance du score a ete evaluee a 48 h et au cours des 7 jours apres l’admission via des courbes ROC. Resultats Au total, 276 patientes repondaient aux criteres d’inclusions, 217 patientes ont ete incluses. Parmi elles, 61 ont fait une complication soit 28 % des patientes. Huit patientes ont presente deux evenements maternels a deux moments distincts (48 h puis au cours des 7 jours). Le score FullPIERS predisait la survenue d’evenements maternels a 48 h avec une aire sous la courbe a 0,80 (IC95 % [0,74–0,85]). Pour un seuil a 4,2, la sensibilite etait a 71 % et la specificite etait a 88 %. A 7 jours, l’aire sous la courbe etait a 0,74 (IC95 % [0,67–0,79]). En prenant un seuil a 3,4, la sensibilite etait a 59 % et la specificite a 85 %. Conclusion Notre etude valide l’utilisation du score FullPIERS dans une maternite francaise. Ce score parait etre un outil performant pour predire la survenue d’evenements maternels graves secondaires a une pre-eclampsie. L’utilisation de ce modele en pratique clinique pourrait permettre d’envisager une optimisation de la prise en charge de ces patientes a risque.

The delivery of breech presentations remains controversial. Our study analysed the impact of a service protocol on the proportion of planned vaginal delivery and its success. Immediate neonatal morbidity and factors that may influence the success of vaginal delivery were studied.Retrospective study, between 2009 and 2020 at the CHRU of Limoges, type 3 maternity hospital, on patients with a breech foetus at term. The proportion of planned vaginal delivery and the rate of effective vaginal delivery were compared before/after 2015. Neonatal morbidity was compared for planned vaginal delivery and planned cesarean delivery groups.We included 923 patients. The rate of planned vaginal delivery was significantly higher after 2015 from 5.2% to 19% (P0.001), with a success rate increasing from 60% to 82.1% (P=0.06). The rate of vaginal breech deliveries significantly increased from 3.8% to 17% (P0.001). We found significantly more newborns with moderate acidosis when a vaginal delivery was attempted (P0.001). The success of vaginal delivery was correlated to the Magnin index (P=0.044), to gestational age (P=0.037), and to multiparity (OR 3.78 95% CI [1.42-10.03] P=0.006).Our study demonstrates the benefits of setting up a service protocol for the practice of breech vaginal delivery.

The main difficulty of ovarian tissue autograft (OTA) is to preserve as many follicles as possible because the ovarian tissue undergoes warm ischemia during grafting until revascularisation, resulting in significant follicular loss. We describe a two-stage grafting technique to stimulate new vascularisation in order to enhance the revascularization process to reduce the ischemic injuries. Furthermore we performed ovarian patchwork in the laboratory and then grafting with robotic laparoscopy to facilitate surgery and increase precision. This technique is used in the DATOR study with promising results, such as a 40% delivery rate.

Additional file 1. SPIRIT 2013 Checklist: Recommended items to address in a clinical trial protocol and related documents.

Native tissue cystocele repair has been the cornerstone of prolapse surgery, especially since the learned societies warned clinicians and patients about serious mesh related complications and recommend a vaginal route without prosthesis in first intention. Surgical techniques mainly consist in anterior colporraphy, vaginal patch plastron and para vaginal repair. However, in case of vaginal patch plastron, the vagina left in contact with the bladder is a material of much better quality than colporraphy alone. The multiplication of native tissues, generating post-operative fibrosis, associated with anchorage on a strong ligamentous structure, allows to expect better outcomes compared to anterior colporraphy. Indeed, vaginal plastron corrects median cystoceles with a vaginal strip as well as lateral cystoceles thanks to bilateral paravaginal suspension. Thereby, vaginal patch plastron appears to be a good compromise between the 3 autologous techniques with median and paralateral repair We aimed to describe the surgical technique of the vaginal patch plastron for vaginal native tissue repair for cystocele.

Resume Objectifs En cas de cancer du sein volumineux, une chimiotherapie neoadjuvante (CNA) peut etre realisee afin de diminuer la taille de la tumeur et ainsi realiser une chirurgie conservatrice. La place du ganglion sentinelle (GS) en cas de CNA est encore debattue. L’objectif principal de cette etude est d’evaluer le risque de recidive axillaire apres GS negatif avant CNA. Methodes Il s’agit d’une etude retrospective, observationnelle et uni centrique. Nous avons inclus les patientes âgees de 18 a 80 ans, ayant un cancer du sein unilateral necessitant la realisation d’une CNA et ayant un GS negatif avant CNA. Notre critere de jugement principal etait la recidive axillaire. Resultats Entre aout 2006 et octobre 2016, 64 patientes ont eu un GS negatif avant realisation d’une CNA et n’ont pas beneficie de curage axillaire post CNA. La duree moyenne de suivi etait de 37 mois. Au cours de notre suivi, nous n’avons releve aucun cas de recidive axillaire. Conclusion Cette etude est en faveur de la fiabilite de l’evaluation du statut ganglionnaire par la technique du GS avant CNA.

Background: Adjuvant chemotherapy decisions are relatively simple using clinicopathological parameters (Goldhirsch et al. 2007), some cases require the addition of biomarkers as in patients with node negative or micrometastatic (N0), grade II (GII) breast cancer. The objective of this study was to evaluate the impact of uPA/PAI-1 compared to classical criteria +/- KI67 in adjuvant treatment decision-making in this population. Methods: This retrospective study included patients, treated from March 2008 to May 2016 in the Department of Medical Oncology at Limoges University Hospital (France). Ki67 and uPA/PAI-1 were analyzed on the initial specimen tumor. Optimal cut-off of Ki67 was defined at 20% (Coates et al. 2015). The positivity thresholds of uPA and PAI-1 were 3 ng/mg and 14 ng/mg respectively (Look et al. 2002). A positive uPA/PAI-1 level was defined as the elevation of at least one of these markers above the positivity threshold. All clinicopathological parameters were recorded prospectively. Results: 2364 patients with breast cancer were screened. Among these patients, 256 N0, GII breast cancer patients were included with a median age of 62 years (32-87). Discordance between the two markers uPA/PAI-1 and KI67 was observed in 58% of tumors. Adding KI67 to the other classical clinicopathological parameters, 143 cases were defined as high risk versus 111 cases without KI67; low risk were defined in 113 cases versus 145 cases without KI67. Considering Ki67 status, the indication to perform adjuvant chemotherapy was increased by 29% compared to clinicopathological parameters. uPA/PAI-1 level was positive in these 143 high risk tumors in 93 cases and negative in 50 cases; in the 113 low risk tumors uPA/PAI-1 was positive in 72 cases and negative in 41 cases. uPA/PAI-1 increased indication to perform adjuvant chemotherapy by 15% compared to St Gallen criteria (including KI67) and by 49% compared to St Gallen criteria (excluding KI67). Using these two markers the final decision of chemotherapy by the multidisciplinary board was increased by 3% compared to St Gallen criteria (including KI67). Conclusions: This study highlighted that uPA/PAI-1 and Ki67 assessment provides additional information for adjuvant chemotherapy decision-making. This study confirms the difficulty to assess the level of importance (weighting) of these biomarkers in adjuvant chemotherapy decision-making. The use of uPA/PAI-1 was feasible, cost-effective in N0, GII breast cancer's patients. Citation Format: Deluche E, Venat-Bouvet L, Leobon S, Fermeaux V, Aubard Y, Saïdi N, Jammet I, Tubiana-Mathieu N. uPA/PAI-1 and adjuvant chemotherapy decision-making in early breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P2-05-26.

Resume Objectifs En France, la prevalence de l’uterus cicatriciel parmi les parturientes est proche de 20 %. La methode ideale de declenchement du travail en cas d’uterus unicicatriciel reste debattue. A travers notre experience et une revue de la litterature, nous avons evalue l’efficacite et la morbimortalite maternofœtale d’une methode de maturation cervicale par dinoprostone en cas d’uterus cicatriciel. Materiels et methodes Il s’agit d’une etude retrospective monocentrique realisee de 2010 a 2014 au centre hospitalo-universitaire de Limoges, de 269 patientes ayant un uterus unicicatriciel declenchees pour raisons medicales par dinoprostone (Propess ® et/ou Prostine ® ) avec un score de Bishop inferieur a 6. Resultats Le taux d’accouchement voie basse etait de 62 %. Les patientes ont beneficie de l’application de plus d’une prostaglandine dans 19 % des cas, le taux de cesarienne etait significativement plus eleve 55,6 % versus 44,4 % d’accouchement voie basse ( p = 0,0043), dans ce cas. Une hemorragie de la delivrance et une rupture uterine sont survenues respectivement chez 4 % et 0,7 % des patientes. Une acidose severe (pH arteriel Conclusion Le declenchement par dinoprostone sur uterus cicatriciel est une procedure efficace et associee a une morbidite comparable aux autres methodes de declenchement.

Introduction Au cours du syndrome des antiphospholipides (SAPL), le HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets), est une complication rare mettant en jeu le pronostic vital maternel et fœtal. Nous presentons le cas d’une patiente avec SAPL primaire, presentant un HELLP syndrome a j4 post-partum. Observation Cette patiente de 34 ans, G2P0 (interruption volontaire de grossesse et fausse couche spontanee precoce), est porteuse d’un SAPL avec triple positivite (anticardiolipine et anti-beta-2-GP1 a taux moderes, anticoagulant circulant de type lupique), revele par une thrombophlebite cerebrale en 2015, sans lupus associe, sous warfarine au long cours (INR entre 2 et 3). Elle presente une obesite (IMC a 32,5 kg/m2). Elle debute une grossesse en septembre 2018 et recoit un traitement prophylactique par aspirine 100 mg/j, et enoxaparine 0,7 mL × 2/j a dose curative (activite anti-Xa correcte a 0,5 UI/mL), en relais de la warfarine. Les echographies fœtales de suivi retrouvent un petit fœtus avec apparition de notchs des arteres uterines a 21 SA + 5 et a 25 SA + 5, justifiant l’ajout de l’hydroxychloroquine a 400 mg/j a partir de 25 SA + 5. A 27 SA + 5, devant un retard de croissance intra-uterin avec inversion du rapport ombilico-cerebral et souffrance fœtale chronique, une maturation pulmonaire du fœtus est indiquee, suivie d’une cesarienne. L’enoxaparine curative est suspendue le soir precedant la cesarienne, sans relais HNF, puis reprise a dose preventive le soir de la cesarienne (j0 post-partum) ; la dose curative n’est reintroduite qu’a j1 post-partum au matin, soit un delai de 36 heures sans anticoagulation curative efficace. A j4 de la cesarienne, la patiente decrit une douleur epigastrique violente avec irradiation sous costale droite resistante aux antalgiques de palier 3. La tension arterielle est a 120/70 mmHg. L’ECG est normal. Le bilan biologique retrouve une cytolyse sans cholestase avec ASAT a 62 UI/L (N Discussion Le HELLP syndrome associe au SAPL est souvent severe. Le HELLP peut etre incomplet et le diagnostic differentiel avec une complication thrombotique du SAPL evoque. Il se manifeste habituellement au cours du 3e trimestre de grossesse mais est possible en post-partum [1] . Chez notre patiente, le contexte d’accouchement premature et la fenetre therapeutique d’anticoagulants possiblement trop longue sans relais HNF ont pu precipiter l’evenement. Par ailleurs, les facteurs predictifs de complications obstetricales etaient la triple positivite initiale, dans un contexte d’obesite favorisant les complications thrombotiques [2] . Les infarctus hepatiques sont une complication rare du HELLP syndrome, du fait de la double vascularisation hepatique arterielle et portale mais semblent plus frequents en cas de SAPL associe [3] . Le traitement du HELLP associe au SAPL n’est pas encore bien codifie ; en pre-partum, l’accouchement permet souvent la resolution des symptomes. Les autres traitements possibles sont les anticoagulants IV et les corticoides, les echanges plasmatiques, les transfusions de plasma frais congele, les immunoglobulines IV, le cyclophosphamide [1] . Conclusion Le HELLP syndrome dans le cadre du SAPL est une complication rare mais a anticiper d’autant plus chez des patientes triple positives avec facteurs de risque cardiovasculaires associes. L’ajout d’emblee de l’hydroxychloroquine, une cible anti-Xa plus haute a 1 UI/mL et l’augmentation de l’aspirine a 150 mg/j peuvent se discuter. Par ailleurs, la fenetre therapeutique sans anticoagulation doit etre imperativement la plus courte possible.

Reduction of maternal mortality remains a major public health issue worldwide. In France, the latest national confidential enquiry regarding maternal mortality (2010-2012) stated a ratio of 10 /100 000 livebirths whereas the goal was 5/100 000. The risk of death among pregnant women from Subsaharan Africa (SSA) was 3 times higher. We performed a monocentric observational retrospective study from 01/01/2009 to 01/09/2016 in order to better understand the factors of maternal morbidity among SSA pregnant women. Demographic characteristics as well as pregnancy outcomes were collected. Antenatal clinics attendance was scored (+1 if positive, +1 if done following the recommended schedule). A total 1 489 (7%) out of 20 755 pregnancies were registred among SSA women. Mean age was 29 years (14-48), mean gestity/parity were respectively 3.5 and 1.8. About 38% of pregnancies occured in overweight or obese women. Obstetrical complications were seen in 542 (36%) pregnancies: gestational diabetes (n = 206, 36,4%), hypertensive disorders (n = 122, 8,2%), 19 had both. Pre-eclampsia represented 4%, sepsis 5%, premature rupture of membrane 5% and post partum haemorrhage 3%. Livebirths was high (97%) with a mean gestational age of 37(22-41), a mean birth weight of 3150g (500-5000). The unique maternal death in this cohort was due to amniotic fluid embolism. Complication risk factors were age (30 versus 28 years; p < 0.0001), BMI (26 versus 25 kg/m2; p < 0.0001), past history of chronic hypertension and pregestational diabetes (p < 0,001). Furthermore, the score of antenatal care attendance was low in those who presented pregnancy morbidities (p = 0.0006) (adjusted with age, BMI> 25 and chronic hypertension). Higher risk of maternal morbidity among SSA women is not only explained by individual risk factors but also by a lack of compliance to the recommended antenatal care even if they live in France. Further investigations including sociological studies are therefore needed. Key messages Maternal mortality and morbidity are higher among migrant women from Subsaharan Africa. Our study highlights a non compliance to the recommended antenatal care surveillance among risk factors.

Background Native tissue cystocele repair has been the cornerstone of prolapse surgery, especially since the learned societies warned clinicians and patients about serious mesh-related complications. Surgical techniques mainly consist in anterior colporraphy and vaginal patch plastron. However, success rates of native tissue cystocele repair are heterogeneous, depending on the design of studies and definition of outcomes. To date, high-quality data comparing vaginal native tissue procedures are still lacking. Methods Herein we aimed to describe the design of the first randomized controlled trial (TAPP) comparing anterior colporraphy (plication of the muscularis and adventitial layers of the vaginal wall) and vaginal patch plastron (bladder support anchored on the tendinous arch of the pelvic fascia by lateral sutures) techniques. Our aim is to assess the effectiveness of vaginal native tissue repair at 1 year for cystocele with a combined definition of success—anatomic and functional. The primary endpoint will be the success rate 1 year after surgery with a composite of objective and subjective measures (Aa and Ba points Discussion A prospective study has found a success rate at 35% for anterior colporraphy based on a combined definition, both anatomic and functional, as recently recommended. However, the definition of anatomic was strict (POP-Q Trial registration CHU LIMOGES is the sponsor of this research (n°87RI18_0013). This research is supported by the French Department of Health (PHRC 2018-A03476-49) and will be conducted with the support of DGOS (PHRC interregional – GIRCI SOHO). The study protocol was approved by the Human Subjects Protection Review Board (Comité de Protection des Personnes) on May 16, 2019. The trial is registered in the ClinicalTrials.gov registry (NCT03875989).

FullPIERS score (Pre-eclampsia Integrated Estimate of RiSk) is built in order to predict maternal outcomes among women with preeclampsia. Our objective is to assess external validity of this score among a population of French women.A retrospective study was conducted for all patients with pre-eclampsia (severe or not) admitted to a tertiary hospital center. A receiver operating characteristic (ROC) curve was constructed to determine accuracy of the model at 48 hours and 7 days after admittance and area under the curve (AUC) was calculated.In total, 276 patients meet inclusions criterion. Among them, 217 were included and 61 (28 %) had one or more complication. Only 8 patients had two complications at two different moments (one at 48 hours and one at 7 days). The FullPiers score predicted maternels events at 48 hours with an area under the curve at 0.80 (IC95 % [0.74-0.85]). At 4.2 cut off, the sensitivity was 71 % and specifity 88 %. At 7 days, the area under the curve was 0.74 (IC95 % [0.67-0.79]), admiting a cutoff point for FullPIERS probability of 3.4, sensitivity was 59 % and specificity 85 %.Our study show utility of FullPIERS score in french maternity. This model might be a useful tool for predicting complications in women with pre-eclampsia. Using of this score in clinical practice might help improving optimization of patient's care.

AIM To describe class I and II human leucocyte antigen (HLA) expression using different uterine tissues in the perspective of uterus transplantation. METHODS Human uterine tissues were obtained from 12 women who had undergone hysterectomy for the treatment of benign disease. HLA class I and HLA-antigen D related (DR) expression were assessed via immunochemistry. HLA class I expression in the uterus was compared with expression in other organs and tissues, including kidney and myocardium samples. RESULTS HLA class I expression was strong in the endometrial glands and mild in the myometrium. Staining of endometrial glands was similar to glomerular staining in the kidney. The myometrium seems to express HLA class I similarly to hepatocytes and myocardial cells. HLA class I expression in the uterus did not differ in younger or post-menopausal women. HLA-DR was expressed in the endometrial glands, but not in the myometrium. A lack of HLA-DR expression seemed to be correlated with cell proliferation. CONCLUSION HLA expression in the endometrium and myometrium is different. The endometrium should be the major target of alloreactive response. As for other transplanted organs, assessment of HLA unacceptable antigens and multiple immunosuppressive treatments is necessary in uterus transplantation.

Introduction et but de l’etude Le cancer du sein est la premiere cause de deces par cancer chez les femmes. Le surpoids et l’obesite, evalues a l’aide de l’indice de masse corporelle (IMC), sont associes a un risque accru de cancer du sein post-menopausique, en particulier de cancers a recepteurs hormonaux positifs. Quel que soit le statut menopausique, l’IMC est associe a un cancer du sein plus agressif ou plus developpe, mais le lien avec les facteurs pronostiques classiques du cancer du sein est inconnu. Les objectifs de notre etude etaient : – comparer les facteurs pronostiques initiaux de cancer du sein et leur evolution chez les femmes en fonction de l’IMC et du statut menopausique, – etudier la survie selon l’IMC, – pour rechercher les facteurs associes a la recidive de cancer du sein. Materiel et methodes Nous avons inclus toutes les femmes atteintes de cancer du sein localise, diagnostique entre 2004 et 2013. Le statut menopausique, l’IMC au moment du diagnostic, les caracteristiques de la tumeur (type histologique, activateur d’urokinase-plasminogene et inhibiteur de l’activateur de plasminogene-1, recepteurs d’œstrogenes, recepteurs de progesterone positifs), le traitement et l’evolution des patientes ont ete recueillis. Nous avons compare deux groupes d’IMC (> 25 et Resultats et analyse statistique Au total, 1638 femmes ont ete incluses. Les femmes non menopausees ayant un IMC ≥ 25 kg/m2avaient plus souvent des cancers positifs a l’activateur d’urokinase du plasminogene et d’activateur du plasminogene-1 (77,8 % vs 47,1 %, p = 0,009). De plus, le pourcentage de recidives metastatiques etait plus important (93,3 % vs 53,6 %, p = 0,008) par rapport aux patients ayant un IMC Conclusion Les resultats des biomarqueurs peuvent expliquer les differents pronostiques chez les patientes atteints de cancer du sein invasif en fonction de l’IMC et du statut menopausique. L’etat nutritionnel des femmes est un parametre important a prendre en compte au cours du cancer du sein. L’exces de poids doit etre depiste au moment du diagnostic et au cours du suivi afin de permettre les soins nutritionnels appropries en plus des traitements habituels du cancer du sein.

Absolute uterine factor infertility affects several thousand young women in France. The first healthy child delivered to a uterus transplant recipient took place in 2014, and uterus transplantation is developing rapidly in many countries. The French College of Gynaecologists and Obstetricians (CNGOF) formed a uterus transplantation committee (CETUF) in 2015 to advance this technology in France. The CETUF sets out the criteria for the designation of Uterus Transplantation Centres. The objectives, requirements, operation and responsibilities of these centres have been described. Their responsibilities for organizing geographical coverage, continuity of care, communication, training, research and evaluation have been defined. This document will serve as a guide for the authorities concerned, to ensure that the means are provided to adequately manage patients with absolute uterine factor infertility who require uterus transplantation.

In case of large breast cancer, neoadjuvant chemotherapy (NAC) can be performed to reduce the size of the tumor and thus perform a conservative surgery. The place of the sentinel lymph node biopsy (SLNB) in case of NAC is still debated. The main aim of this study is to assess the risk of axillary recurrence after negative SLNB before NAC.It is a retrospective, observational and uni-centric study. We included 18 to 80-year-old patients with unilateral breast cancer requiring a NAC and with a negative SLNB before NAC. Our primary endpoint was axillary recurrence.Between August 2006 and October 2016, 64 patients had a negative GS performing before a NAC and did not benefit from axillary dissection after NAC. The average duration of follow-up was 37 months. During our follow-up, we did not find any cases of axillary recurrence.This study supports the reliability of lymph node status assessment using the SLNB before CNA.

Q fever is an ubiquitous zoonosis caused by Coxiella burnetii. Its tropism for the uterus is a potential source of obstetric complications. We describe the obstetric consequences of Q fever diagnosed during pregnancy from a series of cases. When an antenatal diagnosis was made, antibiotic therapy with roxithromycin (Rulid®) was started until delivery. Between 2007 and 2012, 30 patients were treated for Q fever diagnosed during pregnancy, i.e. 1.9 cases per 1000 people. The most common reasons for performing serology was intrauterine growth retardation, preterm labor and oligoamnios. Q fever was diagnosed as acute and chronic in 26 and 4 cases, respectively. Progression to chronic disease occurred in 8 % of acute forms of the diseases. The prevalence of obstetric complications was 66 %, including 10 % foetal deaths, 31 % preterm delivery and 27 % low birthweight

Resume Objectif La transplantation uterine (TU) est un traitement potentiel de l’infertilite uterine (IU). La demande concernant ce traitement est toutefois meconnue. Patientes et methode En raison de l’absence de traitement actuel de l’IU et de la mediatisation des travaux concernant la TU, nous avons ete en contact avec l’association des patientes atteintes du syndrome MRKH et d’autres patientes atteintes d’une IU. Un questionnaire leur a ete envoye. Le but du questionnaire etait de connaitre la position des patientes vis-a-vis de la TU mais egalement vis-a-vis de l’adoption et de la GPA. Les donnees concernant leur âge, leur vie de couple, leur pathologie et leurs traitements eventuels ont ete recueillies. Une analyse de discours qualitative a ete egalement realisee par une psychologue clinicienne. Resultats Soixante patientes ont repondu au questionnaire. L’âge median etait 26 ans [18–53]. Cinquante-cinq residaient en France, 3 en Belgique et 2 dans le continent africain. Trente-huit (63,3 %) patientes etaient mariees ou en couple et heterosexuelles. Vingt (33,3 %) etaient celibataires. Sept patientes (11,7 %) avaient eu une hysterectomie dont 4 pour hemorragie de la delivrance, 1 pour pathologie benigne et 2 pour cancer. Cinquante et une (85 %) patientes etaient atteintes d’une agenesie utero-vaginale partielle ou totale. Leur âge median de diagnostic etait 16 ans [1–27]. Trente-deux (53,3 %) ont eu une chirurgie vaginale dont 6 sigmoido-colpoplasties. Parmi les 60 patientes, l’adoption et la gestation par autrui ne seraient pas envisagees respectivement par 19 (31,7 %) et 21 patientes (35 %). Onze patientes n’envisageraient pas ces 2 solutions (18,3 %). Trente-cinq (58,3 %) patientes seraient volontaires pour une etude clinique sur la TU malgre l’incertitude des resultats et le risque potentiel de la procedure. Parmi elles, 23 (38,33 %) etaient en couple, heterosexuelles et ≤ 35 ans. Discussion et conclusion La TU semble etre un espoir pour une partie de ces patientes malgre la complexite et le risque de la procedure. Il parait important de poursuivre les travaux de recherche, les patientes nous en seront reconnaissantes. En cas de projet de TU, l’information et la selection des patientes seront des problematiques majeures etant donne la vulnerabilite engendree par l’IU.

Introduction Congenital human cytomegalovirus (HCMV) infection is a major public health problem due to severe sequelae in the fetus and newborns. Currently, due to their toxicity anti-CMV treatments cannot be administered to pregnant women. We thus developed an ex vivo model of 1st trimester placental CMV infection to observe the route of infection across the placenta and to test the efficacy of various new drugs targeting different stages of viral cycle. Methods After validation of the viability of floating villi explants by ELISA β-HCG, the kinetics of placental infection were determined by immunochemistry and qPCR in this ex vivo model. Antiviral susceptibility was determined in vitro using focus reduction assay and by qPCR in the ex vivo model. Results The ex vivo model showed viral infection in trophoblasts and mesenchymal space of floating villi. In vitro, antiviral combinations of maribavir with baicalein or artesunate inhibited viral infection by more than 90%. On the other hand, in ex vivo model, infection was reduced by 40% in presence of maribavir and artesunate. The synergistic effect observed in vitro was not observed ex vivo. Discussion This model allowed us to understand the CMV spread in 1st trimester floating villi better and to analyze the anti-CMV efficacy and toxicity of new drugs that could be administered to pregnant women, either alone or in combination. Conclusions Such an ex vivo model could be applied to other viruses such as rubella or parvovirus B19 and in new drug development.

Prenatal diagnosis of cystic fibrosis (CF) is difficult and is mainly considered upon identification of digestive sonographic signs. Although such an association has never been described until now to our knowledge, we report two cases of fetal arrhythmia associated with cystic fibrosis. This association may be explained by the physiopathology of heart in the context of CF, but nevertheless needs to be confirmed by other reports. The prenatal diagnosis of CF is important in order to implement early appropriate care, with better prognosis. The finding of possibly new associated prenatal signs may then improve the global management of the disease.

The aim was to evaluate the agreement between and the reproducibility of transperineal and transvaginal ultrasound cervical length measurements performed by the duty obstetrical team in case of preterm labor. The acceptability of transperineal ultrasonography was also assessed. Pregnant patients between 25 and 34 weeks of gestation with contractions and a clinically modified cervix were included. Order of ultrasonography examination (transperineal or transvaginal first) and rank of operator (resident or senior) were allocated randomly. Agreement was assessed using the intraclass correlation coefficient (ICC) and the Bland and Altman plot. The patient’s discomfort and preference for either method were assessed with a questionnaire. 62 patients admitted for preterm labor between 25 and 34 weeks of gestation were included. Six seniors and nine residents took part in the study. Among the 51 patients with an interpretable transperineal ultrasound scan, median cervical length measurements with the transperineal and the transvaginal technique were, respectively, 25 mm (0–53) and 27 mm (4–51). Concordance was good with an ICC of 0.83 [IC 95 % = (0.73–0.90)]. Transperineal ultrasonography was preferred in 56.5 % of cases. In case of preterm labor, cervical length measurement with transperineal ultrasonography seems reproducible and can be performed by the obstetric team on duty.

Aim of no residual macroscopic disease has to be the objective of the gynecologist oncologist surgeon. It can require extensive surgical procedures in all the abdomen area. We report 2 rare cases of cytoreductive surgery with iliac vessels resection and use of vascular prosthesis. We discuss the opportunity of this surgery with high morbidity.

We reviewed the studies about fertility-sparing in young patient presenting a benign ovarian tumor. It appears that more than the histologic nature of the ovarian cysts, it is the surgical treatment of the cyst which may decrease fertility. Some good practice of surgical procedures must be kept in mind when one manages a benign ovarian tumor in a young patient wishing to preserve her fertility: surgery should be avoided as much as possible; kystectomy is better than oophorectomy; no radical surgery should be done without pathological certitudes; electrocoagulation must be avoided on the cyst walls. In some situations, fertility is specially endangered: bilateral ovarian cysts, recurrence or strong probability of recurrence (endometriomas), poor ovarian reserve (previous chemo- or radiotherapy, age>35, premature ovarian failure). In these situations, a pre-operative assessment of the ovarian reserve could be useful. Beside the surgical 'good procedures', gamete cryopreservation procedures could be used. Cryopreservation of mature oocytes (after ovarian hyperstimulation) or in vitro mature oocytes (after antral follicle retrieval) can be proposed. Ovarian tissue cryopreservation is another option. Oocyte (or embryos) cryopreservation can be proposed before or after the surgery. The global management of benign ovarian tumors in young patients should be decided between surgeons and specialists in reproductive biology.

International audience; Objective - Uterine infertility (UI), which can be caused by a variety of congenital or acquired factors, affects several thousand women in Europe. Uterus transplantation (UTx), at the current stage of research, offers hope for these women to be both the biological mother and the carrier of their child. However, the indications of UTx still need to be defined. The main aim of the study was to describe the different etiologies of UI and other data as marital and parental status from women requesting UTx who contacted us in the framework of a UTx clinical trial. Secondarily, we discussed the potential indications of UTx and their feasibility. Study design - This is an observational study. Results - Of a total of 139 patients with UI, 105 patients (75.5%) had uterine agenesis, making it the leading cause of UI in this sample. Among the patients with uterine agenesis, 25% had a solitary kidney and 44.7% had undergone vaginal reconstruction. Peripartum hysterectomy, hysterectomy for cancer, and hysterectomy for benign pathologies accounted for 9.4%, 7.2% and 5% of cases, respectively. Less common causes of UI included complete androgen insensitivity syndrome (2.2% of patients) and prenatal diethylstilbestrol exposure (0.7%). Approximately 14% of the women already had at least one child and 66% were in a couple living together for at least 2 years. Conclusion - UTx is still under evaluation and further research is under way. Nulliparous patients with no major medical or surgical history and with normal ovarian function, who meet the legal criteria for medically assisted reproduction, represent the best indications for UTx at this stage of its development.

Primary Sjögren's syndrome (pSS) is one of the most common autoimmune diseases, mainly affecting women during the fourth decade of life. During pregnancy, the presence of anti-Ro/SSa and anti-La/SSb antibodies increases the risk of congenital heart block (CHB). Foetal and pregnancy outcomes in pregnant women with pSS compared with the general population are difficult to evaluate because of confounding factors including age and body mass index (BMI).The aim of this case-control study was to analyse the impact of pSS in pregnant women on foetal and pregnancy outcomes.We enrolled 19 women with pSS (54 pregnancies) matched by age and BMI to 216 controls. Patients with pSS delivered significantly earlier (38 weeks + 3 days vs. 39 weeks + 2 days) and experienced more spontaneous abortions [22 weeks of gestation (WG)] than the controls [n = 16/54 (30.0%) vs. n = 1/216 (0.4%); p 0.00001]. Preterm delivery (≤ 37pSS is responsible for an increased risk of spontaneous abortion. The duration of pregnancy is lower in patients with than without pSS, with more premature deliveries. Pregnancies that occur after the onset of the disease result in lower birthweight percentile children than when pSS is not clinically overt.

Except adoption, absolute uterine factor infertility lacks solution in case of motherhood desire. Gestational surrogacy is still not approved in France. Over the last decade, uterus transplantation experimentation made advances. Data from animal research, progress in immunosuppressive treatment and knowledge about pregnancy after transplantation provide a scenario in which a human allotransplantation project can become reality.

Resume Introduction Le traitement de reference de la maladie de Paget extramammaire (MPEM) est la chirurgie mais celle-ci est parfois mutilante et incomplete, avec un taux eleve de recidive. La phototherapie dynamique topique (PDT) offre une alternative therapeutique avec des taux de remission complete interessants, sans limitation de dose ni sequelle fonctionnelle ou esthetique. L’objectif de notre etude etait d’evaluer l’efficacite et la tolerance de la PDT dans le traitement de la MPEM. Patients et methodes Il s’agit d’une serie monocentrique de cas consecutifs traites entre le 1er decembre 2005 et le 31 decembre 2010. Tous les patients ayant une MPEM confirmee histologiquement etaient inclus dans l’etude. Les patients etaient traites par un cycle de deux seances PDT espacees de trois semaines. Un deuxieme cycle etait realise a S6 si la reponse etait partielle. D’autres seances etaient programmees en cas de rechute. Le protocole de traitement consistait en l’application d’une creme a l’aminolevulinate de methyle (MAL) suivie trois heures plus tard d’une illumination de dix minutes en lumiere rouge (570–670 nm) avec une fluence de 37 J/cm2. Resultats Huit patients (sept femmes, un homme) d’âge moyen 69 ans ont ete inclus consecutivement et traites pour MPEM vulvaire (n = 6), perianale (n = 1) ou axillaire (n = 1). Apres deux cycles de deux seances, sept patients etaient en remission clinique complete a M3 et une en remission partielle. Cinq patients etaient toujours en remission a M6. Tous les patients ont rechute apres une moyenne de 8,6 mois (quatre a 14 mois). Le facteur limitant parait etre la douleur pendant l’illumination. Les patients etaient satisfaits, avec une disparition des symptomes et une amelioration notable de leur qualite de vie. Discussion Le taux de remission clinique complete a six mois, apres deux cycles de PDT, etait proche de celui de la chirurgie. Le taux de rechute reste eleve mais le traitement peut etre repete sans consequence esthetique ou fonctionnelle, a l’inverse de la chirurgie. La PDT permet d’obtenir pendant six mois une disparition des symptomes douloureux lies a la maladie et contribue ainsi a l’amelioration de la qualite de vie des patients.

International audience; BACKGROUND: We investigated a novel allotransplantation model using an aortocava patch in ewes. METHODS AND RESULTS: We carried out 10 uterine orthotopic allotransplantations in ewes with end-to-side anastomosis of the aortocava donor patch on the left external iliac vessel recipient. The immunosuppressive protocol was a combination of cyclosporine (10 mg/kg/day) and mycophenolic acid (3 g/day). An estimation of the immunosuppressive therapy exposure was performed by measuring the area under the curve (AUC) of immunosuppressive plasma concentrations. The graft was assessed by vaginoscopy, magnetic resonance imaging (MRI) and second look laparotomy at 6, 8 and 10 weeks, respectively. The median (range) times for cold and warm ischemia were 95 min (75-130) and 91 min (55-165), respectively. All the vascular anastomoses were patent at the end of the surgery. The median AUC of cyclosporine and mycophenolic acid were 1.24 mg h/l (0.34-3.85) and 18.40 mg h/l (3.76-42.35), respectively. Of the 10 ewes receiving a transplant, 6 could be assessed. Cervical biopsies showed signs of necrosis in all six ewes. The MRI results correlated with the macroscopic observations of the 'second look' laparotomy. The aortocava vascular pedicles were thrombosed, adding to the peripheral neovascularization. Graft histology showed endometrial tissue in two out of six ewes. CONCLUSIONS: Mobility of the transplant within the pelvis, the length of the vascular pedicle and rejection can explain the high rate of transplant necrosis. The particular digestive anatomy and physiology of ruminants makes it difficult to administer an optimal immunosuppressive treatment. MRI appears to be a good non-invasive examination for graft estimation.

Introduction L’appartenance au groupe sanguin non-O est un facteur de risque (FR) de la maladie thromboembolique veineuse (MTEV), dans la population generale avec un Odd Ratio (OR) de 2,09 [1] ainsi que pendant la grossesse et le post-partum avec un OR de 2,4 pour le groupe A [2] . Cependant, ces etudes menees pendant la grossesse et le post-partum n’ont pas evalue l’impact des antecedents personnels de thrombose veineuse et des anomalies du bilan de thrombophilie qui constituent des FR importants de la MTEV. L’objectif de ce travail est de comparer les FR usuels de la MTEV chez des patientes ayant presente un evenement thromboembolique veineux (ETV) au cours de la grossesse ou du post-partum en fonction de leur appartenance au groupe sanguin O ou non-O. Patients et methodes Etude de cohorte, monocentrique, retrospective incluant des patientes ayant presente un ETV au cours de la grossesse et dans le puerperium entre 2004 et 2015. Quarante-cinq patientes ont ete incluses, 23 FR de la MTEV ont ete recherches, 16 ont pu etre compares entre les patientes des groupes sanguins O et non-O. Les evenements thromboemboliques veineux etudies comprenaient la thrombose veineuse profonde des membres inferieurs ou de localisation pelvienne, la thrombose veineuse superficielle des membres inferieurs, l’embolie pulmonaire et la thrombophlebite cerebrale. Resultats L’analyse de 45 patientes montre un âge moyen de 30,9 ans (SD ± 6,2). Vingt-trois (51,1 %) patientes etaient du groupe O et 22 (48,9 %) du groupe non-O. Trois grossesses (6,6 %) ont ete obtenues par procreation medicalement assistee dont une ayant donne lieu a une grossesse triple. Le suivi des 45 grossesses a conduit a 42 naissances vivantes : 35 (81,4 %) naissances a terme et 7 (16,6 %) naissances prematurees, une mort fœtale in utero, 2 interruptions volontaires de grossesse. Quarante-six ETV sont survenus dont 33 (71,7 %) episodes de thrombose veineuse profonde des membres inferieurs ou pelvienne, 3 (6,5 %) embolies pulmonaires, et 2 (4,3 %) thrombophlebites cerebrales. Quatorze patientes presentaient un antecedent de thrombose veineuse avec 5 patientes (35,7 %) dans le groupe O et 9 (64,3 %) dans le groupe non-O. Trente-six (78,3 %) ETV sont apparus pendant la grossesse avec un terme moyen de 23 SA + 5 jours (SD ± 9 SA + 4 jours) et dix (21,7 %) en post-partum avec un delai de survenu moyen de 12,3 jours (SD ± 12,7). Deux patientes (4,4 %) ont presente une hemorragie de la delivrance. Deux patientes, une dans chaque groupe, etaient suivies pour un lupus systemique et deux autres patientes, une dans chaque groupe, avaient un syndrome des antiphospholipides selon les criteres cliniques et biologiques de Sydney. Deux patientes dans le groupe O et une dans le groupe non-O avaient un deficit en antithrombine, une patiente dans le groupe non-O avait un deficit en proteine C, une patiente dans chaque groupe avait un deficit en proteine S, 3 patientes du groupe O et 2 patientes du groupe non-O presentaient une mutation du facteur V, 2 patientes dans chaque groupe presentaient une mutation du facteur II. Il n’y avait pas de difference significative entre les groupes concernant : l’âge maternel (p = 0,6), l’antecedent personnel de thrombose veineuse (p = 0,2), la survenue d’un episode infectieux (p = 0,2), l’antecedent d’obesite (p > 0,9), de dyslipidemie (p = 0,2), de tabagisme actif (p = 0,5), de grossesse multiple (p > 0,9), de recours a la procreation medicalement assistee (p = 0,2), de lupus systemique (p > 0,9), de deficit en antithrombine (p = 0,8), de deficit en proteine C (p = 0,8), de deficit en proteine S (p > 0,9), de mutation du facteur V Leiden (p = 0,6), de mutation du facteur II (p > 0,9), d’anticorps antiphospholipides (p > 0,9). Discussion La comparaison des FR usuels de la MTEV pendant la grossesse et le puerperium n’a pas retrouve de difference significative entre les patientes du groupe O et du groupe non-O dans notre population. La repartition des patientes selon leur groupe sanguin ABO et l’incidence des ETV dans notre etude etaient comparables aux donnees de la litterature [3] . Les limites de l’etude sont liees a l’analyse retrospective des donnees et la petite taille de l’echantillon. Conclusion Devant la comparabilite des facteurs de risques usuels entre les deux groupes, les perspectives de l’etude sont de montrer une difference significative sur la prevalence des ETV dans le groupe non-O en appariant les cas avec deux temoins sur les facteurs de risques etudies afin de completer les donnees existantes [2] .

La quimioterapia y la radioterapia provocan alteraciones irreversibles de la reserva y de la funcion ovarica que pueden dar lugar a una insuficiencia ovarica prematura en las mujeres adultas y jovenes que padecen un cancer. La radioterapia pelvica ocasiona tambien modificaciones morfologicas uterinas que tambien comprometen la fertilidad. La quimioterapia basada en agentes alquilantes, la intensificacion terapeutica antes de un injerto de celulas madre hematopoyeticas y la radioterapia pelvica conllevan un alto riesgo de infertilidad. La congelacion de embriones y la transposicion ovarica son los unicos metodos reconocidos y establecidos de conservacion de la fertilidad, aunque existen nuevas estrategias. La crioconservacion de tejido ovarico con foliculogenesis in vivo mediante autoinjerto ortotopico o heterotopico es una alternativa prometedora y debe proponerse en la actualidad en caso de tratamiento muy gonadotoxico. Hasta el momento, se han descrito varias gestaciones obtenidas por esta tecnica. Al contrario que la congelacion embrionaria, la crioconservacion de tejido ovarico tiene la ventaja de poder plantearse tanto en las mujeres jovenes como las de edad prepuberal y ademas no requiere una estimulacion previa que retrase el tratamiento. La proteccion farmacologica con analogos de la hormona liberadora de gonadotropinas (GnRH) tambien parece ser una alternativa util. La foliculogenesis in vitro es una tecnica experimental por el momento. Cuando se obtiene una gestacion, los antecedentes de radioterapia son mas perjudiciales que los de quimioterapia. La vigilancia obstetrica clasica debe asociarse a un protocolo para la deteccion de una recidiva o de otro cancer. Tambien conviene tranquilizar a la pareja ante los temores justificados que surgen por el riesgo mutageno de los tratamientos antioncologicos.

Resume Objectif Etant donne l’heterogeneite des pratiques anatomopathologiques dans la litterature, il est difficile d’apprecier le risque d’atteinte du curage axillaire en cas de nanometastases (atteinte inferieure a 0,2 mm = pN0i+) et de micrometastases (atteinte comprise entre 0,2 et 2 mm = pN1mi) detectees lors du prelevement du ganglion sentinelle dans le cancer du sein. Nous proposons d’evaluer ce risque en respectant les clarifications de la classification tumor-node-metastasis (TNM) par l’ European Working Group for Breast Screening Pathology (EWGBSP). Patientes et methodes Parmi les patientes ayant eu une detection du ganglion sentinelle entre fevrier 2001 et avril 2008 dans notre structure, nous avons repris les dossiers de celles presentant une atteinte du ganglion sentinelle inferieure a 2 mm. Toutes les lames de ces patientes ont fait l’objet d’une relecture anatomopathologique selon les recommandations de l’EWGBSP. Un curage axillaire a ete realise chez chacune des patientes. Resultats Parmi les 608 patientes ayant eu une detection du ganglion sentinelle dans le cadre d’un cancer du sein, 72 (11,84 %) ont eu une atteinte du ganglion sentinelle inferieure a 2 mm (27 pN0i+ et 45 pN1mi). Le taux d’atteinte des ganglions non sentinelles lors du curage a ete de 8,89 % pour les pN1mi et de 0 % pour les pN0i+. Discussion et conclusion En realisant une interpretation rigoureuse de l’envahissement minime du ganglion sentinelle selon les recommandations restrictives de l’EWGBSP, nous avons reduit notre taux de nanometastases. Aucun envahissement non sentinelle, en cas de nanometastases detectees lors du prelevement du ganglion sentinelle, n’a ete retrouve.

Resume But de l’etude La detection des papillomavirus humains (HPV) a haut risque oncogene est devenue un complement indispensable du depistage par frottis cervicovaginal pour les lesions de type ASCUS. La trousse Hybrid Capture® 2 (HC2, Digene) a montre son efficacite depuis plusieurs annees dans ces indications. Nous avons donc souhaite la comparer a deux techniques de detection par PCR-hybridation : HPV Consensus kit® (HPVC, Argene), non commercialisee et Amplicor HPV test® (AHPV, RocheDiagnostics), disponible en routine. Materiel et methodes Les echantillons cervicaux de 88 patientes ont ete testes en parallele par les trois techniques. Les resultats de l’ensemble des echantillons ont ete confirmes par PCR nichee et sequencage des produits amplifies. Resultats Parmi les 88 echantillons, seuls 86 resultats etaient comparables. L’analyse de ces resultats a montre les performances assez proches des techniques HC2 et AHPV. Malgre la sensibilite de la methode HPVC, 13 echantillons n’ont pu etre classes en haut ou bas risque par cette technique (resultats « generique ») et ont donc du etre ecartes pour calculer les performances de la technique. Conclusion Malgre une selection d’echantillons presentant souvent une faible charge virale et/ou des discordances cytovirologiques, nos resultats tendent a montrer une bonne sensibilite de detection de l’infection a HPV aussi bien par les techniques d’amplification du signal (HC2) que par les techniques d’amplification de la cible (HPVC et AHPV). Cependant, une etude complementaire sur un panel plus large de patientes avec un diagnostic cytologique d’ASCUS et une biopsie sous colposcopie permettrait de valider ces techniques pour une indication clinique.

Thanks to a superior resolution and contrast, MRI allows recognizing the post therapeutic modifications of female pelvis, often very subtle and nonvisible by the other imaging modalities. The main surgical or medical therapies in the female pelvis will be described as well as the normal post therapeutic anatomical aspects. The main complications and failures will be mentioned and informed. Finally the keys that will allow to understand these complications and failures will be boarded.

The aim of this study was to evaluate with a long follow-up the efficacy of concomitant chemoradiotherapy in non-metastatic inflammatory breast cancer (IBC) and to evaluate the breast conservation rate. Between 1990 and 2000, 66 non-metastatic patients with IBC were treated with chemotherapy and concomitant irradiation. The induction chemotherapy consisted of epirubicine, cyclophosphamide and vindesine, in association with split-course bi-fractionated irradiation to a total dose of 65 Gy with concomitant cisplatin and 5-fluorouracil. Maintenance chemotherapy consisted of high-dose methotrexate and six cycles of epirubicine, cyclophosphamide and fluorouracil. Hormonal treatment was given if indicated. Mastectomy was not systemic. Among 65 evaluable patients, 57 (87.6%) achieved a complete clinical response and had a breast conservation. Only six loco regional relapses were noted in six patients with a delay of 20 months and with concomitant metastatic dissemination in four cases. Median disease-free survival (DFS) was 28 months. Median overall survival (OS) was 63 months and median follow-up was 55.5 months. Induction chemotherapy and concomitant irradiation is feasible in patients with IBC, permitting a breast conservation with a high rate of local control with an OS comparable to that of the best recent series.

Primary ovarian abscess is a rare infection. A new case has led us to carry out a literature review in order to optimize the treatment. Exceptionally isolated, primary ovarian abscess usually belongs to the postoperative complications. Nevertheless, its etiopathogenies are numerous. The symptoms are often poor; therefore the diagnosis is difficult to establish. The curative treatment must associate surgery and antibiotherapy. Even if laparoscopic surgery is the first line treatment in many cases, laparotomy remains the choice procedure. Ultrasonographically-guided evacuation has to be further evaluated. Preventive treatment is of major importance.