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Resume Objectifs Evaluer la manœuvre de Demelin dans la prise en charge d’une dystocie du relevement des bras lors de l’accouchement voie basse (AVB) d’un siege apres echec de la manœuvre de Lovset. Methodes Nous avons realise une etude observationnelle retrospective dans deux maternites francaises (niveaux IIB et III) entre janvier 2013 et juin 2020. Nous avons inclus tous les AVB de nouveau-nes vivants de plus de 32 semaines d’amenorrhee (SA) en presentation du siege necessitant une manœuvre de Demelin pour un relevement des bras persistant malgre la manœuvre de Lovset. Le critere de jugement principal etait la reussite de la manœuvre de Demelin en l’absence de traumatisme neonatal attribuable a cette manœuvre. Resultats Sur 1611 AVB de presentation du siege, 29 ont necessite une manœuvre de Demelin pour un relevement des bras (prevalence de 0,02 %). Il n’y a eu aucun echec de voie basse a la suite de cette manœuvre. Cette manœuvre a concerne 10 patientes nullipares (34,5 %). L’âge gestationnel moyen etait de 38 ± 2,4 semaines d’amenorrhee. Le succes de la manœuvre de Demelin sans traumatisme neonatal lui etant attribuable est estime a 82,8 %. Aucun traumatisme neonatal severe n’a ete mis en evidence. Cinq fractures (17,2 %), une humerale et quatre claviculaires, sans sequelle ont ete diagnostiquees. Le poids moyen du nouveau-ne etait de 2945,5 g et le pH arteriel median de 7,17. Le score d’Apgar median a 5 minutes de vie etait de 10. La morbidite maternelle etait faible avec une (3,4 %) lesion obstetricale du sphincter de l’anus (type III). Conclusion La manœuvre de Demelin semble etre une methode sure pour reduire une dystocie du relevement des bras apres echec de la manœuvre de Lovset lors de l’accouchement voie basse d’une presentation du siege.

During human organogenesis, lung development is a timely and tightly regulated developmental process under the control of a large number of signaling molecules. Understanding how genetic variants can disturb normal lung development causing different lung malformations is a major goal for dissecting molecular mechanisms during embryogenesis. Here, through exome sequencing (ES), array CGH, genome sequencing (GS) and Hi-C, we aimed at elucidating the molecular basis of bilateral isolated lung agenesis in three fetuses born to a non-consanguineous family. We detected a complex genomic rearrangement containing duplicated, triplicated and deleted fragments involving the SHH locus in fetuses presenting complete agenesis of both lungs and near-complete agenesis of the trachea, diagnosed by ultrasound screening and confirmed at autopsy following termination. The rearrangement did not include SHH itself, but several regulatory elements for lung development, such as MACS1, a major SHH lung enhancer, and the neighboring genes MNX1 and NOM1. The rearrangement incorporated parts of two topologically associating domains (TADs) including their boundaries. Hi-C of cells from one of the affected fetuses showed the formation of two novel TADs each containing SHH enhancers and the MNX1 and NOM1 genes. Hi-C together with GS indicate that the new 3D conformation is likely causative for this condition by an inappropriate activation of MNX1 included in the neo-TADs by MACS1 enhancer, further highlighting the importance of the 3D chromatin conformation in human disease.

To evaluate the obstetrical prognosis of term breech delivery in case of asymmetric pelvis. An observational, comparative, retrospective, bi-centric study of 559 patients who had a computer tomography pelvimetry prior to delivery of a term breech presentation was conducted between August 2013 and August 2019. Patients with an attempted vaginal delivery were divided into two groups: a group of asymmetric pelvis (AP) when the difference between the lengths of both oblique diameters was ≥ 1 cm and a group of symmetric pelvis (SP) when the two oblique diameters differed by

Ectopic pregnancies are still the first mortality cause of the first semestre of pregnancy. They are much more frequent in IVF (2-5%) than in the standard population (1-2%). The aim of this study was to compare the rate of ectopic pregnancies following a fresh embryo transfer done whether at an clived embryo stage (day 2 or 3 of the embryo development) or at a blastocyst stage (day 5 or 6 of the embryo development).This is a monocentric retrospective study including all 18 to 43 year-old patients getting pregnant (ßHCG100 UI/L) after a fresh embryo transfer from In Vitro Fecondation with or without Intra-Cytoplasmic Sperm Injection, between January 1st 2014 and December 30th 2020 in the Hospital of Besançon (France). This population has been divided into 2 groups according to the embryo stage on the day of transfer.Nine hundred and twenty two patients have been included. There were statistically more ectopic pregnancies after a blastocyst transfer (n=4; 5.4%) than after a clived embryo transfer (n=14; 1.7%). (P=0.049) CONCLUSION: In our population, there were more ectopic pregnancies from blastocyst(s) transfers than from clived embryo(es).

The aim of our study was to compare the morbidity and long-term efficacy after laparoscopic sacrocolpopexy with and without robotic assistance. We conducted a retrospective chart review of all laparoscopic or robotic sacrocolpopexies for POP-Q stage 2–4 vaginal prolapse performed between September 2015 and October 2018 in 2 Gynecologic Surgery Departments of France. Patients were separated into two groups: a laparoscopic sacrocolpopexy group (LS) and a robotic-assisted sacrocolpopexy group (RAS). The primary outcome measure was reoperation procedures for recurrent pelvic organ prolapse (POP). Two hundred and fourteen patients were included, 160 patients (75%) in the LS group and 54 patients (25%) in the RAS group. After a mean follow-up of 32.8 months, reoperation rate for recurrent POP and the recurrent POP rate were greater in the RAS group (9.2% versus 1.2%, p = 0.01 and 25.9% versus 7.5%, p = 0.0003, respectively). No significant difference was found in terms of immediate intraoperative (3.1% versus 1.8%, p = 1) and postoperative complications (1.9% versus 1.8%, p = 1). On comparing the 2 groups by bivariate analysis, RAS significantly increased the odds of reoperation for POP recurrence (OR = 7.8 CI 95% [1.5–41.6], p = 0.02) and the odds of global reoperation (OR = 3.8 CI 95% [1.4–10.4], p = 0.0095). Similarly, multivariate logistic analysis showed that RAS increased the risks of global reoperation (OR = 3.8 CI 95% [1.3–10.6], p = 0.01) after controlling high-grade prolapse. Robotic sacrocolpopexy does not appear to give long-term clinical benefits. Recurrent POP and reoperation procedures seem to be more frequent in case of robotic-assisted surgery.

Resume Objectif Determiner la place de l’imagerie, des marqueurs tumoraux, le type de traitement et la voie d’abord chirurgicale, la place de la surveillance, la voie d’accouchement, et la restadification des TFO pendant la grossesse, afin d’emettre des recommandations. Methode Analyse systematique de la litterature sur les TFO pendant la grossesse, consultee sur PUBMED, des articles publies entre 1990 et 2019, incluant les mots-cles « borderline ovarian tumor and pregnancy ». Resultats L’echographie pelvienne est l’examen de reference et de premiere intention pour la detection et la caracterisation des masses annexielles durant la grossesse (grade C). L’IRM pelvienne est recommandee a partir de 12 SA en cas de masse annexielle indeterminee et devra etre conclue par un score diagnostique (grade C). L’injection de gadolinium est a limiter au maximum en raison des risques prouves sur le fœtus et devra etre discutee au cas par cas apres information de la patiente (grade C). En l’absence de donnees dans la litterature, il n’est pas possible d’emettre de recommandations quant a l’utilisation de marqueur tumoral pour le diagnostic de TFO pendant la grossesse. En cas de necessite de realiser une chirurgie d’une TFO en cours de grossesse, il n’existe pas d’arguments suffisants pour recommander une kystectomie ou une annexectomie. Pour les TFO, la voie cœlioscopique doit etre privilegiee en cours de grossesse si elle est realisable (grade C). La voie d’abord et le type de traitement chirurgical doivent etre adaptes a la taille de la lesion, au terme obstetrical, et au desir ulterieur de grossesse, apres avis de la RCP. En l’absence de donnees suffisantes dans la litterature, il n’est pas possible d’emettre de recommandations concernant la surveillance d’une suspicion de TFO non operee presumee pendant la grossesse. Il n’existe pas suffisamment d’arguments dans la litterature pour modifier la prise en charge obstetricale en cas de TFO survenant au cours de la grossesse. En cas de stadification incomplete d’une TFO operee en cours de grossesse, une chirurgie de restadification pourra etre discutee selon les memes modalites qu’en dehors de la grossesse (grade C). Conclusion Le diagnostic de TFO survenant au cours de la grossesse reste rare malgre un depistage systematique des masses annexielles au premier trimestre de la grossesse et l’avancee de l’âge maternel. Il existe peu de donnees dans la litterature concernant la prise en charge des TFO pendant la grossesse. L’ensemble des decisions doivent etre prises apres avis en RCP.

Resumen Las presentaciones en extension, que se oponen a la presentacion occipital, de vertex perfectamente flexionada, son tres y se diferencian en funcion del grado de extension cefalica. La presentacion de cara tiene una extension completa de tres tercios, la de frente una extension de dos tercios y, por ultimo, la de bregma una extension de un tercio. Aunque el aumento de los diametros de la presentacion resultante de la extension puede hacer que la situacion sea distocica, es muy distinta la presentacion de frente, que es siempre distocica; la de bregma, que a veces lo es, y la de cara, que en la mayoria de los casos es eutocica. Es a partir del perfecto conocimiento mecanico y obstetrico de estas presentaciones en extension que resulta una indicacion temprana de cesarea antes del enclavamiento en la presentacion de frente o la evitacion de la cesarea en la presentacion de cara en su variedad mentoanterior.

Transgender patients are at increased risk of cancer, sexually transmitted diseases, short- and long-term postoperative complications in patients with vaginoplasty, but also unwanted pregnancy in non-hysterectomized trans men. However, access to care is often difficult for these patients, who often do not benefit from appropriate gynecological monitoring, especially for fear of judgment or discrimination. In view of the health risks of these patients, it is essential to be able to offer them specific and adapted gynecological follow-up. To date, there are no clear recommendations regarding the gynecological follow-up of transgender patients. We relied on the recommendations of the World Professional Association of Transgender Health (W-PATH) and the Endocrine Society Guideline and performed a literature review. We carried out several searches via pubmed in order to explore one by one the different aspects of gynecological follow-up, in particular of non-hysterectomized transgender men and transgender women with a vaginoplasty. It emerges from this a lack of follow-up of transgender people, with a reluctance to consult a gynecologist, associated with the lack of knowledge and experience of health professionals. Due to the risks identical to those of the general population, added to those specific to transgender people, it is important to be able to offer these patients specialized and personalized gynecological follow-up, and to raise awareness and train health professionals on the importance of and the specificities of the gynecological follow-up of these patients.

Objective To assess the incidence of serious complications and reoperations for recurrence after surgery for pelvic organ prolapse (POP) and compare the three most common types of repair. Design Prospective cohort study using a registry. Setting Nineteen French surgical centres. Population A total of 2309 women participated between 2017 and 2019. Methods A multivariate analysis including an inverse probability of treatment weighting approach was used to obtain three comparable groups. Main outcome measures Serious complications and subsequent reoperations for POP recurrence. Results The median follow-up time was 17.6 months. Surgeries were native tissue vaginal repairs (n = 504), transvaginal mesh placements (n = 692) and laparoscopic sacropexies with mesh (n = 1113). Serious complications occurred among 52 women (2.3%), and reoperation for POP recurrence was required for 32 women (1.4%). At 1 year the cumulative weighted incidence of serious complications was 1.8% for native tissue vaginal repair, 3.9% for transvaginal mesh and 2.2% for sacropexy, and the rates for reoperation for recurrence of POP were 1.5, 0.7 and 1.1%, respectively. Compared with native tissue vaginal repair, the risk of serious complications was higher in the transvaginal mesh group (weighted hazard ratio, wHR 3.84, 95% CI 2.43-6.08) and the sacropexy group (wHR 2.48, 95% CI 1.45-4.23), whereas the risk of reoperation for prolapse recurrence was lower in both the transvaginal mesh (wHR 0.22, 95% CI 0.13-0.39) and sacropexy (wHR 0.29, 95% CI 0.18-0.47) groups. Conclusions Our results suggest that native tissue vaginal repairs have the lowest risk of serious complications but the highest risk of reoperation for recurrence. These results are useful for informing women and for shared decision making. Tweetable abstract Laparoscopic sacropexy had fewer serious complications than transvaginal mesh and fewer reoperations for recurrence than vaginal repair.

To evaluate Demelin's maneuver for arm entrapment's dystocia during vaginal breech deliveries after failure of the usual Lovset maneuver.We led a retrospective cohort study in two French maternities. Between January 2013 and June 2020, we included all vaginal breech deliveries of live newborns after 32 weeks of gestation requiring Demelin's maneuver for persistent arm entrapment despite the Lovset maneuver. The primary endpoint was the Demelin's maneuver success without the existence of a neonatal trauma related to the maneuver.Among 1611 vaginal breech deliveries, 29 with Demelin's maneuver for an arm entrapment were enrolled (prevalence 0,02%). No failure of this maneuver was found. There was 10 nulliparous (34.5%). Mean gestational age was 38±2.4 weeks of gestation. The success of Demelin's maneuver without trauma related to it was estimated at 82.8%. No serious neonatal trauma was noticed. Five fractures (17.2%), one humeral and four clavicular, without sequelae were diagnosed. Mean weight of newborns was 2945.5 grams and the median arterial pH was 7.17. The median 5-minutes-Apgar score was 10. Maternal morbidity was low: one case (3.4%) of obstetric anal sphincter injuries (type III).Demelin's maneuver seems to be an effective and safe method to treat an arm entrapment's dystocia during vaginal breech delivery after failure of the Lovset's maneuver.

The Odon Device™ has been described in the literature since 2013 and the World Health Organization supports its development through the Human Reproduction Program. This innovative device could be easier to use than usual instruments and could be an alternative to caesarean section during the second stage of labor, especially in countries where access to obstetric care is limited. The aim of the Odon Device™ is to position an air cuff over the fetal head, past its widest point (around the level of the fetal mouth anteriorly and the nape of the fetal neck posteriorly). Three mechanical principles favor the progression of the fetal head with the Odon Device™: partial propulsion, limited flexion and traction. Preliminary clinical studies on animals and simulators are reassuring and show that an appropriate use is no more at risk than the vaccum or forceps. A phase 1 study was conducted in Argentina and South Africa between 2011 and 2017. The reported failure rate was 29%, of which 77% was secondary to a mechanical failure of one of the components of the device. Improvements concerning the applicator, the handles and the inflatable air cuff have been made to the device. Phase II of the clinical research program began in 2018 and includes two studies in two different centers: The ASSIST Study in Bristol, England, and The BESANCON ASSIST Study, Besancon, France.

International audience; Objectifs : la chirurgie de l’incontinence urinaire d’effort (IUE) par bandelettes sous-urétrales (BSU) fait l’objet d’essais cliniques limités en taille, rapportant peu les complications rares et la qualité de vie (QdV). Les registres permettent de rapporter ces complications rares dans la pratique courante et de mesurer la QdV globale, du point du vue des troubles urinaires et pelviens.Méthodes : l’objectif du registre VIGI-MESH est de spécifier l’incidence de ces complications rares et graves en fonction des différents types de BSU (rétropubiennes, transobturatrices, à incision unique/mini-bandelettes) ainsi que de mesurer cette QdV après la pose de BSU. Entre février 2017 et novembre 2019, chaque chirurgie initiale ou de reprise de BSU dans un des 18 centres participants était colligée sur un formulaire par le chirurgien. Un contrôle était effectué à partir des pharmacies délivrant les dispositifs médicaux implantés et des actes codés par les centres participants. Un questionnaire recherchant une complication était envoyé à toutes les patientes à un an. Il comportait également des questions validées en français sur le bien-être ressenti et l’amélioration des symptômes (WHO, European Quality of life Questionnaire 5 Dimensions [EQ5D], Patient Global Impression of Improvement [PGI-I]) Les complications ont été gradées selon la classification de Clavien–Dindo : arrêt de l’intervention sans pose de matériel (grade III), intervention chirurgicale ultérieure secondaire à une complication (grade III), complication menaçant la vie (grade IV), décès de la patiente (grade V).Résultats : quatre-vingt-deux patientes ont eu des complications de grade ≥ III : 5,7 % (53/923) voie rétropubienne, 4,0 % (21/521) voie transobturatrice et 2,2 % (8/370) mini-bandelette. Dix complications peropératoires ont empêché la pose de BSU. La BSU a été desserrée dans les 48 h dans 6 cas. Le risque de complication était 3 fois plus faible avec une mini-bandellette par rapport à une BSU rétropubienne (RR = 0,36 [0,170,75]), le risque n’était pas significativement différent entre les approches transobturatrice et rétropubienne (RR = 0,67 [0,40–1,11]). Vingt-sept femmes (1,5 %) ont eu une reprise chirurgicale pour échec ou récidive, 15 après BSU rétropubienne (1,6 %), 7 après bandelette transobturatrice (1,4 %) et 5 après mini-bandelette (1,4 % ; p = 0,95) (Fig. 1). La procédure a consisté à retendre la BSU (9 cas), injection de Bulkamid® (2 cas) et mise en place d’une seconde BSU (16 cas). Parmi les 1167 patientes contactées par courrier, 692 réponses (59,3 %) ont été retournées à un an ou plus après la chirurgie. À la question « Que pensez-vous de votre état de santé actuel par rapport à ce qu’il était avant votre chirurgie pour incontinence ou prolapsus ? » 91,4 % (608/665) se sentaient mieux (beaucoup mieux, mieux ou un peu mieux) (PGI-I). L’amélioration ressentie était meilleure en l’absence de complications graves ≥ III (p = 0,008). Parmi les patientes, 96,2 % (630/655) ont évalué leur état de santé général comme étant bon (très bon, bon ou assez bon). L’état de santé général ressenti était similaire qu’elles aient eu ou non des complications. Par rapport à la population française du même âge, les patientes opérées d’une BSU ont déclaré avoir un meilleur état de la santé.Conclusion : les premiers résultats du registre VIGI-MESH montrent que les mini-bandelettes sont une option thérapeutique avec une efficacité à moyen terme similaire aux voies rétropubiennes et transobturatrices avec moins de complications. Ils montrent également que plus de 90 % des patientes rapportent avoir été améliorées par la mise en place d’une BSU pour IUE. Le ressenti de l’état de santé global des patientes opérées était meilleur que celui de la population française féminine du même âge. Néanmoins, une analyse à plus long terme est nécessaire pour confirmer ces premiers résultats.

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

The aim of our study was to compare the morbidity and long-term efficacy after laparoscopic sacrocolpopexy with and without robotic assistance.We conducted a retrospective chart review of all laparoscopic or robotic sacrocolpopexies for POP-Q stage 2-4 vaginal prolapse performed between September 2015 and October 2018 in 2 Gynecologic Surgery Departments of France. Patients were separated into two groups: a laparoscopic sacrocolpopexy group (LS) and a robotic-assisted sacrocolpopexy group (RAS). The primary outcome measure was reoperation procedures for recurrent pelvic organ prolapse (POP).Two hundred and fourteen patients were included, 160 patients (75%) in the LS group and 54 patients (25%) in the RAS group. After a mean follow-up of 32.8 months, reoperation rate for recurrent POP and the recurrent POP rate were greater in the RAS group (9.2% versus 1.2%, p = 0.01 and 25.9% versus 7.5%, p = 0.0003, respectively). No significant difference was found in terms of immediate intraoperative (3.1% versus 1.8%, p = 1) and postoperative complications (1.9% versus 1.8%, p = 1). On comparing the 2 groups by bivariate analysis, RAS significantly increased the odds of reoperation for POP recurrence (OR = 7.8 CI 95% [1.5-41.6], p = 0.02) and the odds of global reoperation (OR = 3.8 CI 95% [1.4-10.4], p = 0.0095). Similarly, multivariate logistic analysis showed that RAS increased the risks of global reoperation (OR = 3.8 CI 95% [1.3-10.6], p = 0.01) after controlling high-grade prolapse.Robotic sacrocolpopexy does not appear to give long-term clinical benefits. Recurrent POP and reoperation procedures seem to be more frequent in case of robotic-assisted surgery.

Episiotomy scar may be the site of complications and result in wound dehiscence in the long term. The aim of this video article was to describe the surgical steps required to repair a right perineal defect after episiotomy using a V-Y advancement flap. Our patient had an episiotomy dehiscence that had already benefited from an end-to-end repair, but the perineal defect recurred. A V-Y advancement flap was performed. The first step of this surgery was to remove the episiotomy scar. A V-shaped flap was then created to fill the perineal defect. Upon advancement, the V flap was transformed in a Y shape and secured using tension-free absorbable sutures. There was no flap necrosis, and the esthetic result was satisfactory.

To evaluate the obstetrical prognosis of term breech delivery in case of asymmetric pelvis.An observational, comparative, retrospective, bi-centric study of 559 patients who had a computer tomography pelvimetry prior to delivery of a term breech presentation was conducted between August 2013 and August 2019. Patients with an attempted vaginal delivery were divided into two groups: a group of asymmetric pelvis (AP) when the difference between the lengths of both oblique diameters was ≥ 1 cm and a group of symmetric pelvis (SP) when the two oblique diameters differed by 1 cm. The primary outcome was the rate of vaginal delivery. Secondary outcomes were a composite variable of neonatal and maternal morbidity and mortality.Of the 370 patients who attempted a vaginal breech delivery, 8% (n = 29) had an AP and 92% (n = 341) had a SP. In the AP group, the vaginal delivery rate was higher (93% versus 78%, p = 0.05). There was no statistically significant difference in neonatal (3% versus 1% in the AP and SP groups, respectively, p = 0.4) and maternal (17% versus 23% in the AP and SP groups, respectively, p = 0.5) morbidity and mortality.When a pelvimetry is performed before an attempt of vaginal breech delivery, a difference of less than two centimetres between both oblique diameters does not seem to reduce the rate of vaginal birth and is not an indication for an elective caesarean section.

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

To determine the place of imaging, tumour markers, type of treatment and surgical route, follow-up, delivery mode, and re-staging in case of BOT during pregnancy, in order to provide guidelines.A systematic bibliographical analysis on BOT during pregnancy was performed through a PUDMED search on articles published from 1990 to 2019 using keywords « borderline ovarian tumour and pregnancy ».Pelvic ultrasound is the gold standard and first-line examination for the detection and characterization of adnexal masses during pregnancy (grade C). Pelvic MRI is recommended from 12 gestational weeks in case of indeterminate adnexal masses and should be concluded by a diagnostic score (grade C). Gadolinium injection should be minimized because of proven risk to the fetus and should be discussed on a case-by-case basis after patient information (grade C). In the absence of data in the literature, it is not possible to recommend the use of any tumour marker for the diagnosis of BOT during pregnancy. In case of a surgical treatment of BOT during pregnancy, there is insufficient evidence to recommend either a cystectomy or an oophorectomy. For BOT, the laparoscopic approach should be preferred during pregnancy if it is feasible (grade C). Surgical route and type of surgery should be chosen after taking into account the tumour size, the obstetrical term, and the subsequent desire for pregnancy, following discussion in a multidisciplinary meeting. In the absence of sufficient data in the literature, it is not possible to make any recommendation on the follow-up of a BOT suspected during pregnancy. There is not enough evidence in the literature to change obstetrical management for delivery in patients with BOT. In case of incomplete staging of a BOT treated during pregnancy, restaging can be discussed as for non-pregnant patients (grade C).The diagnosis of BOT occurring during pregnancy remains rare despite systematic screening of adnexal masses in the first trimester of pregnancy and an increasing maternal age. There is limited data in the literature concerning the management of BOT during pregnancy. All decisions must be taken after discussion in a multidisciplinary meeting.

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

Resume Objectif L’accouchement instrumental (AI) est greve d’un risque de dechirures perineales et notamment de lesions obstetricales du sphincter anal (LOSA) qui sont associees a une morbidite importante et une alteration de la qualite de vie. L’objectif principal de cette etude etait de comparer la proportion de LOSA chez les primipares a terme avec singleton en presentation cephalique en fonction du mode d’accouchement : AI par ventouse versus expulsion spontanee (ES). Methodes Nous avons realise une etude retrospective unicentrique entre le 1er janvier 2010 et le 31 decembre 2014 en incluant toutes les primipares accouchant par voie vaginale a terme, d’un fœtus unique et vivant en presentation cephalique. Les lesions perineales ont ete classees selon la classification de l’OMS. Le critere de jugement principal etait la proportion de LOSA. Resultats 3552 patientes ont ete incluses : 2496 ES et 1056 AI (29,72 %). Vingt LOSA (0,56 %) ont ete diagnostiquees : 7 dans le groupe ES (0,28 %) et 13 dans le AI (1,23 %), p Conclusion Chez ces patientes, le sur-risque de LOSA en cas d’AI est multiplie par 5,10. Le taux eleve d’AI chez ces patientes les expose a un sur-risque reel de LOSA. Cependant, la proportion de LOSA dans ce groupe reste inferieure a celles rapportees dans la litterature et est a peine superieur au taux global national, ceci malgre une politique tres restrictive du recours a l’episiotomie.

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.

To evaluate the impact of a selective use of episiotomy combined with Couder’s maneuver on the incidence of perineal tears in spontaneous term deliveries. A comparative, retrospective, mono-centric study in a university maternity unit was designed and included all primiparous women who delivered spontaneously after 37 weeks of gestation in cephalic presentation. Two cohorts were studied, before and after the practice of Couder’s maneuver. In the first cohort, the ''OSE cohort'' only selective episiotomies were performed from January 2009 to December 2010. In the second cohort, from January 2016 to December 2017, the ''SEC cohort'' selective episiotomies combined with Couder’s maneuver were performed by midwives and obstetricians. The primary outcome was the type of perineal tears, according to the Royal College of Obstetricians and Gynaecologists (RCOG) classification. A total of 2081 patients were included: 909 patients in the OSE cohort and 1172 patients in the SEC cohort. Couder’s maneuver was performed in 59% of the SEC cohort. In the SEC cohort, there were an increase in the number of intact perinea (55% versus 63%, p

Introduction/Background Surgery is the cornerstone of ovarian Granulosa Cell Tumor (GCT). Complete resection with adequate staging is the gold standard in 1st line setting. The aim of this study is to assess the impact of an appropriate surgery according to the guidelines. Methodology This is a nationwide five-year retrospective study, including 463 patients (of the 639 included patients) with a definitive diagnosis of GCT between 2011 and 2016. Medical and surgical practices were analyzed for conformity. Conformity to guidelines was defined by a conservative (unilateral salpingo-oophorectomy) or radical surgery (hysteretomy and bilateral salpingo-oophorectomy) including surgical staging (omentectomy, peritoneal biopsy and peritoneal cytology) according to the FIGO classification. Results Median age at diagnosis was 49 years old (range 10–89). The median size of tumor was 94 mm (range 5–400). Radical surgery was performed in 240 patients (51,8%), while a fertility-sparing surgery was performed in 98 cases (21,2%). A complete surgical staging was performed in only 76 cases (16,4%). 289 (62.4%) patients received an evaluation of the endometrium (hysterectomy or endometrial curettage). Surgery was fully compliant with the guidelines in 65 patients (14%), partially compliant in 213 patients (46%), non-compliant in 137 patients (29,6%) and not assessable in 48 cases (10,4%) respectively. A statistically significant improvement in the surgical management was observed among patients treated after 2012 compared to those treated before 2012. This Improvement included: endometrial evaluation (p=0,026), tumour rupture rate during surgery (p=0,010) and the global compliance of the surgery (p Conclusion Staging surgery provides a better assessment and an appropriate treatment of this rare tumors. According to this study, the implementation of a national network and guidelines dedicated to rare gynaecologic tumors seems to significantly improve the surgical management of the patients with GCT. Disclosure Nothing to disclose.

The Odon Device™ has been described in the literature since 2013 and the World Health Organization supports its development through the Human Reproduction Program. This innovative device could be easier to use than usual instruments and could be an alternative to caesarean section during the second stage of labor, especially in countries where access to obstetric care is limited. The aim of the Odon Device™ is to position an air cuff over the fetal head, past its widest point (around the level of the fetal mouth anteriorly and the nape of the fetal neck posteriorly). Three mechanical principles favor the progression of the fetal head with the Odon Device™: partial propulsion, limited flexion and traction. Preliminary clinical studies on animals and simulators are reassuring and show that an appropriate use is no more at risk than the vaccum or forceps. A phase 1 study was conducted in Argentina and South Africa between 2011 and 2017. The reported failure rate was 29%, of which 77% was secondary to a mechanical failure of one of the components of the device. Improvements concerning the applicator, the handles and the inflatable air cuff have been made to the device. Phase II of the clinical research program began in 2018 and includes two studies in two different centers: The ASSIST Study in Bristol, England, and The BESANCON ASSIST Study, Besançon, France.

The French national rare gynecological tumor network has been established to improve the quality of care through offering expertise in double reading histological diagnosis, reviewing cases and guiding management of these tumors through specialized multidisciplinary tumor boards and online clinical guidelines (www.ovaire-rare.com). The aim of this study is to evaluate the impact of the development and implementation of this network by assessing the conformity of medical practice with the guidelines concerning the granulosa cell tumors (GCTs).This is a French nationwide study, including 463 patients (out of the 639 identified patients) with a definitive diagnosis of GCT between 2011 and 2016. Surgical practices were analyzed for conformity with the current guidelines (www.ovaire-rare.org). Medical records, surgical and pathological reports were systematically analyzed. Total conformity was defined by a conservative (unilateral salpingo-oophorectomy) or radical surgery (hysterectomy and bilateral salpingo-oophorectomy) including surgical staging (omentectomy, peritoneal biopsies and peritoneal cytology) according to the FIGO stage. Partial conformity referred to a conservative or radical surgery without surgical staging and non-conformity was defined as a non-optimal surgery as recommended by the guidelines.Median age at diagnosis was 49 years old (range 10-89). The median size of tumor was 94 mm (range 5-400). Radical surgery was performed in 240 patients (52%); while a fertility-sparing surgery was performed in 98 cases (21%). A surgical staging was performed in 76 cases (16%) and an evaluation of the endometrium in 289 cases (62%). Surgery was fully compliant with the guidelines in 65 patients (14%), partially compliant in 213 patients (46%), non-compliant in 137 patients (30%) and not assessable in 48 cases (10%). A statistically significant difference for compliance was observed in restaging surgery (p 0,001), radical surgery (p = 0,017) and the period (before or after) of the implementation of the network (p 0,001). Survival analyses did not allow us to demonstrate a significant difference in overall survival nor in PFS although there was a trend in favor of optimal surgery compared to incomplete/non optimal surgery.Surgical management's conformity to the guidelines increases over time from 2011 to 2016. According to this study, the implementation of a national network dedicated to rare gynecologic tumors seems to significantly improve the surgical management of the patients with ovarian granulosa cell tumors.

Purpose The first aim was to evaluate feasibility and reproducibility of 2-dimensional ultrasound (2D) shear wave elastography (SWE) of human fetal lungs and liver between 24 and 34 weeks of gestation. The second aim was to model fetal lung-to-liver elastography ratio (LLE ratio) and to assess its variations according to gestational age and maternal administration of corticosteroids. Material and methods 2D-SWE examinations were prospectively performed in fetuses of women with an uncomplicated pregnancy (group 1) and fetuses of women with a threatened preterm labor requiring administration of corticosteroids (group 2). Two 2D-SWE examinations were performed at “day 0” and “day 2” in group 1; before and 24 hours after a course of corticosteroid in group 2. Three operators performed 2 cycles of 3 measurements on the lung (regions A1, A2, A3) and the liver (regions IV, V, VI). Repeatability and reproducibility of measurements were calculated. The fetal LLE ratio was modeled from the most reproducible regions. Results Fifty-five women were enrolled in group 1 and 48 in group 2. For the lung, 8.6% of measurements were considered invalid and 6.9% for the liver. The most reproducible region for the lung was A3 [ICC between 0.70 (95% CI: 0.42–0.85) and 0.78 (95% CI: 0.48–0.90)] and region VI for the liver [ICC between 0.70 (95% CI: 0.40–0.85) and 0.84 (95% CI: 0.60–0.94)]. According to gestational age, a moderate positive linear correlation was found for stiffness values of A3 (R = 0.56), V (R = 0.46) and VI (R = 0.44). LLE ratio values at “day 0” were not different between the two groups but decreased at “day 2” in group 2 (0.2; 95% CI: 0.07–0.34; P Conclusion Quantitative fetal lung and liver stiffness measurements are possible with 2D-SWE with acceptable reproducibility.

The aim of our study was to evaluate the safety and the benefits of manual rotation in the management of Occiput-posterior positions in 2019.A systematic review of literature was performed using the MEDLINE and COCHRANE LIBRARY databases, in order to identify articles concerning maternal and neonatal outcomes after a manual rotation, through January 2019. Information on study characteristics (review, author, year of publication), population, objectives and main neonatal and maternal outcomes were extracted.A total of 51 articles were identified and 12 articles were selected for the systematic review. The rate of successful manual rotation were about 47 to 90%. There were more success if systematic manual rotation, multiparity, engagement, spontaneous labour and maternal age35. The 2nd stage of labour was shorter after an attempt of manual rotation. The randomised controlled trials did not find any statistical difference concerning operative deliveries or neonatal and maternal outcomes.The manual rotation is an obstetrical manoeuvre which must be regulated and only practiced by trained operators. Currently, the state of science is not sufficient to recommend the manual rotation as a systematic practice in 2019.

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

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

El problema de la obesidad de la parturienta se ha convertido en la actualidad en una dificultad frecuente, ya que, por ejemplo en Francia, afecta a casi el 10% de las mujeres. La mecanica obstetrica puede alterarse por una distocia de los tejidos blandos, de forma similar en caso de obesidad. Lo que cambia son las tecnicas obstetricas, que deben adaptarse a esta situacion, y ninguno de los obstetras de los siglos pasados ha descrito principios tecnicos especificos de las obesas. En el manejo del trabajo de parto y de sus diferentes fases se deben tener en cuenta las dificultades inherentes a la obesidad, y el control del bienestar fetal puede tambien complicarse. La decision de practicar una cesarea suele tomarse con demasiada rapidez con base en supuestos fracasos del inicio del trabajo de parto o supuestas distocias dinamicas, incrementando la tasa global en esta poblacion. La propia tecnica de la cesarea debe adaptarse y revisarse, con el fin de facilitar la via de acceso y la extraccion fetal y disminuir la morbilidad postoperatoria. Este articulo evalua los conocimientos actuales del manejo del parto de la mujer obesa y analiza el impacto de la obesidad en el manejo del parto por via vaginal y las especificidades de la cesarea en estas pacientes.

Resume Objectif Evaluer les modalites d’accouchement, les morbidites maternelles et neonatales et le taux de rupture uterine et de dehiscence lors d’une grossesse suivant une cesarienne precoce realisee avant 32 semaines d’amenorrhees (SA) revolues. Methodes Etude retrospective descriptive realisee dans une maternite de type III, sur une periode de 8 ans. Ont ete selectionnees 292 patientes successives cesarisees avant 32 SA sur une grossesse mono-fœtale. Seul l’accouchement suivant directement la cesarienne a ete pris en compte. Les uterus multi-cicatriciels etaient exclus de l’etude. Resultats L’âge gestationnel moyen lors de la cesarienne index etait de 29 SA + 3 jours. Soixante-deux patientes correspondaient aux criteres d’inclusion et d’exclusion. Dix-sept (27,4 %) ont eut une cesarienne programmee apres cesarienne (CPAC) et 45 (72,6 %) ont eut une tentative de voie basse apres cesarienne (TVBAC) dont 71,1 % de succes soit 51,6 % d’accouchement vaginal apres cesarienne precoce (AVAC). Les nouveau-nes du groupe echec de TVBAC avaient un pH arteriel ( p p p p = 0,31) concernant le devenir perinatal en intention de traiter (CPAC versus TVBAC). La seule rupture uterine (1,6 %) fut decouverte a 26 SA + 3 jours en cours de cesarienne chez une patiente initialement incluse dans le groupe TVBAC. Cinq (8,1 %) dehiscences uterines ont ete decouvertes dont 80 % en cours de cesarienne, a un terme moyen de 32 SA + 2 jours. Conclusion Apres une cesarienne realisee avant 32 SA, la TVBAC doit etre encouragee sur conditions locales favorables, les taux de reussite etant comparables a une cesarienne a terme. Le taux de rupture uterine (complete ou sous-peritoneale) semble cependant legerement accru par rapport au risque apres cesarienne realisee a terme, pouvant meme survenir precocement et en dehors de tout travail.

Resume La prescription d’un test HPV en pratique doit permettre au clinicien d’optimiser le suivi et la prise en charge de ses patientes, en particulier dans le cadre du depistage du cancer du col de l’uterus. Un nombre consequent de tests sont disponibles qui presentent des sensibilite et specificite analytiques et cliniques propres. Des recommandations internationales concernant les performances cliniques des tests HPV utilisables pour le depistage ont ete publiees par un groupe d’experts et il convient d’utiliser les tests repondant a ces criteres de performance. Au-dela de la trousse de detection des HPV, c’est l’ensemble du circuit, du prelevement au rendu de resultat, qui doit etre maitrise. Cela implique que les etapes pre-analytique (prise d’echantillon, qualite du milieu de recueil de l’echantillon, condition de stockage et d’acheminement des prelevements…) et post-analytique (qualite du compte-rendu, prestation de conseil…) soient elles aussi normalisees. A cette fin, les laboratoires sont soumis a une accreditation par le COFRAC selon la norme internationale ISO 15189 qui impose un cadre, opposable, definissant les criteres de qualite requis pour la realisation de tout test de biologie medicale, et du test HPV en particulier.

Resume But Analyser l’impact de la version par manœuvre externe (VME) sur le taux de cesarienne dans une equipe a fort taux d’accouchement voie basse du siege. Materiel et methodes Etude retrospective monocentrique portant sur 298 fœtus vivants, diagnostiques en presentation du siege entre 33 et 35 SA suivis dans notre maternite de niveau 3 et ayant accouche apres 35 SA, entre le 1 er janvier 2011 et le 31 decembre 2013. Les patientes ont ete divisees en 2 groupes en intention de traiter : un groupe pour lequel une VME a ete programmee et un groupe pour lequel la VME n’a pas ete programmee. Resultats Notre taux moyen d’accouchement vaginal du siege sur la periode de l’etude etait de 61,1 %. Nous avons pratique 165 VME, avec 21,8 % de reussite. Le terme moyen des tentatives de version etait de 36,7 SA. Le taux de cesarienne n’est pas significativement different chez les femmes ayant eu une VME programmee par rapport a celles qui n’en ont pas eu, avec et sans ajustement sur l’âge, la primiparite et la presence d’un uterus cicatriciel (OR ajuste = 1,67 [0,77–3,61]). La tentative de VME n’a pas permis de reduire le nombre de presentation podalique a l’accouchement (61,1 % versus 61,4 % [ p = 0,55]). Conclusion La pratique de la VME dans notre centre a fort taux d’accouchement vaginal de la presentation du siege n’a pas permis d’obtenir une difference significative sur le taux de cesarienne par rapport aux patientes pour qui la VME n’a pas ete programmee.

Resume But La conisation est le traitement de reference des neoplasies intra-epitheliales. Dans le contexte medico-economique actuel promouvant la simplification des pratiques, la conisation a l’anse diathermique repond parfaitement aux criteres permettant sa realisation en consultation. Nous avons donc evalue la satisfaction des patientes ayant eu recours a une conisation en consultation dediee. Materiel et methodes Nous avons realise une etude observationnelle au CHRU de Besancon. Nous avons inclus toutes les patientes ayant beneficie d’une conisation en consultation durant un an. La satisfaction globale des patientes etait recueillie retrospectivement par questionnaire. Resultats Soixante-dix patientes ont beneficie d’une conisation en consultation et ont repondu au questionnaire. Le taux de satisfaction globale etait de 88,6 %. De plus, 75,7 % des patientes ont declare n’avoir ressenti aucune douleur ou une douleur moderee lors du geste. La majorite des patientes (91,4 %) recommanderaient cette prise en charge a une personne de leur entourage. Les limites d’exerese etaient jugees non in sano pour 31,4 % des prelevements et une hemorragie postoperatoire etait survenue chez 7,1 % des patientes. Conclusion Dans ce souci permanent de reduction des couts, la conisation semble etre un geste parfaitement adapte a une realisation en consultation. Cette prise en charge parait convenir aux patientes sans entrainer d’augmentation du risque hemorragique ou de resection non in sano.