Showing papers in "Journal of gynecology obstetrics and human reproduction in 2019"

Perineal prevention and protection in obstetrics: CNGOF clinical practice guidelines.

Abstract: Introduction The objective of these clinical practice guidelines was to analyse all of the interventions during pregnancy and childbirth that might prevent obstetric anal sphincter injuries (OASIS) and postnatal pelvic floor symptoms. Material and methods These guidelines were developed in accordance with the methods prescribed by the French Health Authority (HAS). Results A prenatal clinical examination of the perineum is recommended for women with a history of Crohn's disease, OASIS, genital mutilation, or perianal lesions (professional consensus). Just after delivery, a perineal examination is recommended to check for OASIS (Grade B); if there is doubt about the diagnosis, a second opinion should be requested (Grade C). In case of OASIS, the injuries (including their severity) and the technique for their repair should be described in detail (Grade C). Perineal massage during pregnancy must be encouraged among women who want it (Grade B). No intervention conducted before the start of the active phase of the second stage of labour has been shown to be effective in reducing the risk of perineal injury. The crowning of the baby's head should be manually controlled and the posterior perineum manually supported to reduce the risk of OASIS (Grade C). The performance of an episiotomy during normal deliveries is not recommended to reduce the risk of OASIS (Grade A). In instrumental deliveries, episiotomy may be indicated to avoid OASIS (Grade C). When an episiotomy is performed, a mediolateral incision is recommended (Grade B). The indication for episiotomy should be explained to the woman, and she should consent before its performance. Advising women to have a caesarean delivery for primary prevention of postnatal urinary or anal incontinence is not recommended (Grade B). During pregnancy and again in the labour room, obstetrics professionals should focus on the woman's expectations and inform her about the modes of delivery.

Anti Müllerian Hormone: More than a biomarker of female reproductive function.

Abstract: Anti-Mullerian hormone (AMH), known for its role during sexual differentiation, is a dimeric glycoprotein that belongs to the transforming growth factor-β (TGF-β) family. AMH has recently been identified as a reliable marker of ovarian reserve that can help predict early ovarian follicle loss and menopause onset. AMH levels also reflect the effects of damaging gynecologic surgeries or gonadotoxic treatments such as chemotherapy on ovarian reserve. Furthermore, AMH participates in the diagnosis of certain diseases such as granulosa cell tumors or Polycystic Ovary Syndrome (PCOS). Currently used to establish patient profiles and predict ovarian response to stimulation, its role in ART techniques is crucial. Nevertheless, AMH appears to be a weak independent predictor of qualitative outcomes such as implantation, pregnancy, and live birth. As the reliability and reproducibility of AMH dosage have raised many doubts due to different existing standards and thresholds, an international consensus is still expected to improve AMH measurement and interpretation.

Maternal and neonatal outcomes of adolescent pregnancy.

Abstract: Objective To examine the maternal and neonatal outcomes of adolescent pregnancies. Methods Deliveries that occurred in a high-volume tertiary center between January 2013 and December 2016 were retrospectively analyzed. We studied pregnant women who were under 19 years of age at the time at which they gave birth, and who underwent regular follow-up. Pregnancies associated with chromosomal abnormalities, early pregnancy losses (before 20 weeks), and ectopic pregnancies were excluded. Results In all, 101 pregnant women aged Conclusion Adolescent pregnancy is a significant issue worldwide. Adverse outcomes differ among study populations, but both preterm delivery and low birth weight are of concern, as are a higher cesarean rate.

Laparoscopic hysterectomy trends in challenging cases (1995–2018)

Abstract: Objective : To investigate the effect of challenging factors on laparoscopic hysterectomy trends within twenty-four years. Population and Method : This was a trend analysis study of 7558 women who underwent hysterectomy for benign indications between 1995–2018 in Bursa Uludag University Hospital, Turkey. A trend analysis of obesity, previous laparotomy (≥3) and uterine specimen weight (≥500 g) was applied for abdominal hysterectomy (TAH), vaginal hysterectomy (VH), and laparoscopic hysterectomy (TLH) rates in this period. The primary outcome was laparoscopic hysterectomy trends throughout the years. We measured the effect of obesity, previous laparotomies and large uterus on TLH trends as secondary outcomes. Results : The ratio of TLHs to all hysterectomies was 2.4% in 1995 and 44.7% in 2018 which increased 33 times higher over 24 years. The percentage of obese patients in TLH cases increased from 1% to 37%, the rate of patients who had three or more previous laparotomy in TLH cases increased from 0% to 32.2%, and the percentage of patients who had more than 500 g uterus specimen in laparoscopic hysterectomy cases increased from 0% to 32.8%. Conclusion : Laparoscopic hysterectomy trends are increasing in challenging cases. Obesity, previous surgeries, and large uteruses are no longer a limiting factor for laparoscopic hysterectomy.

Impact of gestational weight gain on perinatal outcomes after a bariatric surgery.

Abstract: Background Recommendations by the Institute of Medicine (IOM) on gestational weight gain (GWG) for women with histories of bariatric surgery have yet to be studied. Objectives To describe GWG in women with histories of bariatric surgery and to investigate the relationship between GWG and maternal and neonatal outcomes. Study design A bicentric retrospective study on the medical charts of pregnant women with histories of bariatric surgery who delivered between 2003 and 2017 in two level III maternity units. In accordance with IOM guidelines, GWG was classified as insufficient, adapted, or excessive. Results At least 337 pregnancies from 264 patients were included in this study. Of these pregnancies, 154 (45.7%) occurred after gastric banding, 135 (40.1%) after Roux-en-Y gastric bypass, and 48 (14.2%) after sleeve gastrectomy. GWG was adapted in 90 of the pregnancies (26.7%), insufficient in 11 of the pregnancies (35%), and excessive in 129 of pregnancies (38.3%). Gestational age at birth was significantly lower when GWG was insufficient (37.7 ± 4.2 weeks vs. 38.8 ± 2.9 weeks for adequate GWG and 39.4 ± 1.8 weeks for excessive GWG). When compared to normal GWG, insufficient GWG was indicated to be a risk factor for preterm labor (adjusted OR, 3.05, 95% CI 1.30–7.17). When compared to excessive GWG, insufficient GWG increased the rates of small for gestational age (SGA) newborns (OR, 1.96, 95% CI 1.04–3.68), preterm labor (OR, 4.13, 95% CI 1.84–9.24), and preterm delivery (OR, 6.40, 95% CI 2.41–17.0). Conclusion In our study, adequate GWG was associated with better obstetrical outcomes, resulting in the conclusion that IOM recommendations applied to pregnant women who had undergone bariatric surgery. Our findings suggest that the large proportion of women with insufficient GWG may account for increased rates of SGA and preterm birth.

The relation of the vaginal microbiota to early pregnancy development during in vitro fertilization treatment-A meta-analysis.

Abstract: An abnormal vaginal microbiota composition has been shown to lead to pre-term births, miscarriage, and problems with conceiving. Studies have suggested that dysbiosis reduces successful early pregnancy development during IVF. However, conflicting reports exist. This meta-analysis aims to answer the following question: what is the aggregated effect found by studies investigating the influence of the vaginal microbiota composition on early pregnancy rates after IVF treatment? A systematic review was performed using the Medline and EMBASE databases, using search terms for healthy vaginal microbiota, abnormal vaginal microbiota, fertility and pregnancy. The search resulted in six included articles. Of these, all six were used for further meta-analysis. The main outcome measures were the clinical pregnancy rate, determined through ultrasound proven fetal heartbeat and/or hCG results before 10 weeks gestation, in relation to the vaginal microbiota composition. We found a correlation between abnormal vaginal microbiota and lower rates of early pregnancy development after IVF treatment (OR = 0.70, 95% CI = 0.49 - 0.99). One study showed the reverse correlation. However, heterogeneity between study methodologies in various forms was found. In conclusion, women with an abnormal vaginal microbiota are roughly 1.4 times less likely to have a successful early pregnancy development after IVF treatment when compared to women with normal microbiota.

Evaluation of ligament laxity during pregnancy.

Abstract: Objective Pregnancy-related changes in ligament laxity have been shown to be associated with various disorders such as back pain or pelvic floor disorders. The purpose of this study was to assess laxity changes during pregnancy by confronting different methods in order to suggest a simple clinical tool helping to prevent the aforementioned problems. Design Seventeen pregnant women were evaluated at the first, second and third trimesters as cases and 16 non-pregnant women participated as controls. Ligamentous laxity was measured using an extensometer for the metacarpophalangeal joint of the index, a fingertip to floor test and a sit and reach test to assess hip and lumbar flexibility and the Beighton score. Statistical analysis included independent samples t-tests, analysis of variance and Pearson correlation coefficients. Results Laxity of the metacarpophalangeal joint increased by 11% from the first to the second trimester of pregnancy and stabilized until delivery. The Beighton score was significantly higher in the second trimester of pregnancy (p Conclusion Laxity reached its maximum at the second trimester. The combination of an objective measurement by the extensometer and a global evaluation of the laxity by the Beighton’ score for example may be useful for a daily assessment of laxity. However, the chosen clinical tests don’t seem appropriate to be used alone in pregnant women

Hysteroscopic management of cervical pregnancy: Case series and review of the literature.

Abstract: Purpose To evaluate the hysteroscopic management on cervical pregnancy. Materials and methods A case series report and literature review on patients with early first trimester cervical pregnancy (CP) treated by hysteroscopy. The symptoms upon admission, β-hCG levels, hysteroscopy technique, blood loss and operation outcomes were presented. Results Four patients with early CP between 5 and 7 weeks were successfully managed with operative hysteroscopy. Three out of four patients had at least one risk factor for cervical ectopic pregnancy. Two patients were diagnosed on routine examinations and the other two presented with vaginal spotting and pelvic pain. Mechanical hysteroscopy was used in three patients while one case was managed by a 10 mm resectoscope. Three women discharged home on the same day and one patient 24 h after the operation. Literature review revealed 16 publications of cervical pregnancy managed with operative hysteroscopy. 14 articles demonstrated single case reports and two papers were CP case series. Hysteroscopic surgery was successfully reported in 12 cases as a sole treatment, in seven cases after failure of methotrexate treatment and in eight cases as a combined treatment with uterine artery embolization. Conclusions Our case series demonstrated that operative hysteroscopy can be used as a sole treatment in early, less than 8-week CPs with safety. Literature review demonstrated that most of the early first trimester CP cases were treated by hysteroscopy and the rest after failure of methotrexate treatment or in combination with uterine artery embolization.

Management of epithelial cancer of the ovary, fallopian tube, primary peritoneum. Long text of the joint French clinical practice guidelines issued by FRANCOGYN, CNGOF, SFOG, GINECO-ARCAGY, endorsed by INCa. (Part 2: systemic, intraperitoneal treatment, elderly patients, fertility preservation, follow-up)

Abstract: Adjuvant chemotherapy by carboplatin and paclitaxel is recommended for all high-grade ovarian and tubal cancers (FIGO stages I-IIA) (grade A). After primary surgery is complete, 6 cycles of intravenous chemotherapy (grade A) are recommended, or a discussion with the patient about intraperitoneal chemotherapy, according to her risk-benefit ratio. After complete interval surgery for FIGO stage III, hyperthermic intraperitoneal chemotherapy (HIPEC) can be proposed, in accordance with the modalities of the OV-HIPEC trial (grade B). In cases of postoperative tumor residue or in FIGO stage IV tumors, chemotherapy associated with bevacizumab is recommended (grade A).

Update on the contraceptive contraindications.

Abstract: Background The choice of contraceptive methods has considerably increased over recent years. However, all available methods are not appropriate for all women, especially those with medical conditions or individual characteristics in whom any pregnancy, particularly unintended pregnancy, is at higher risk. The safety of contraception is crucial for these women and evidence-based guidance to help healthcare providers choosing a suitable method has been published. The aim of our review is to make an update on the main contraceptive contraindications. Methods The World Health Organisation Medical Eligibility Criteria for Contraceptive Use (WHO-MEC) published in 2015 are referred to throughout this review. The rationale behind the recommendations for women with cardiovascular, rheumatic, neurologic, gynaecological or endocrine disorders was first analysed. The national adaptations of the WHO-MEC, especially the French, British, and American ones, were then scrutinized. Main findings Overall, the MECs considered tend to provide the same recommendations. However, there are some noticeable differences that may be useful to know. Hence, for a given condition, differences in categorisation have been noticed where limited or controversial scientific evidence relating to this condition exists, especially regarding hormonal contraceptives. Some medical conditions or characteristics, included in some MECs but not in others, have also been identified. Conclusion MECs represent valuable tools to help clinicians to prescribe the most acceptable and safe contraceptive method for each individual woman. Although it may be useful to consult different MECs for some complex conditions, prescribers should always bear in mind that these MECs are only guidelines and that their clinical judgment should always prevail.

Management of epithelial cancer of the ovary, fallopian tube, and primary peritoneum. Long text of the Joint French Clinical Practice Guidelines issued by FRANCOGYN, CNGOF, SFOG, and GINECO-ARCAGY, and endorsed by INCa. Part 1: Diagnostic exploration and staging, surgery, perioperative care, and pathology

Abstract: An MRI is recommended for an ovarian mass that is indeterminate on ultrasound. The ROMA score (combining CA125 and HE4) can also be calculated (grade A). In presumed early-stage ovarian or tubal cancers, the following procedures should be performed an omentectomy (at a minimum, infracolic), an appendectomy, multiple peritoneal biopsies, peritoneal cytology (grade C), and pelvic and para-aortic lymphadenectomies (grade B) for all histologic types, except the expansile mucinous subtypes, for which lymphadenectomies can be omitted (grade C). Minimally invasive surgery is recommended for early-stage ovarian cancer, when there is no risk of tumor rupture (grade B). For FIGO stages III or IV ovarian, tubal, and primary peritoneal cancers, a contrast-enhanced computed tomography (CT) scan of the thorax/abdomen/pelvis is recommended (grade B), as well as laparoscopic exploration to take multiple biopsies (grade A) and a carcinomatosis score (Fagotti score at a minimum) (grade C) to assess the possibility of complete surgery (i.e., leaving no macroscopic tumor residue). Complete surgery by a midline laparotomy is recommended for advanced ovarian, tubal, or primary peritoneal cancer (grade B). For advanced cancers, para-aortic and pelvic lymphadenectomies are recommended when metastatic adenopathy is clinically or radiologically suspected (grade B). When adenopathy is not suspected and when complete peritoneal surgery is performed as the initial surgery for advanced cancer, the lymphadenectomies can be omitted because they do not modify either the medical treatment or overall survival (grade B). Primary surgery (before other treatment) is recommended whenever it appears possible to leave no tumor residue (grade B).

Progestin-primed ovarian stimulation is a feasible method for poor ovarian responders undergoing in IVF/ICSI compared to a GnRH antagonist protocol: A retrospective study.

Abstract: Background Poor ovarian response (POR) to ovarian hyperstimulation is one of the biggest challenges in assisted reproduction technology. The objective of this study was to compare the efficacy of progestin-primed ovarian stimulation (PPOS) with a GnRH antagonist (GnRH-ant) in poor ovarian response (POR) patients. Materials and methods This retrospective analysis included a total of 186 cycles of POR patients between 2014 and 2016. The patients were divided into two groups according to the method of stimulation protocol, as follows: 63 cycles were PPOS, and 123 cycles were GnRH-ant. Reproduction-related clinical outcomes in the two groups were compared. Results There were no significant differences in patients’ age, dose and duration of gonadotropin (Gn) treatment, serum luteinizing hormone (LH) and E2 levels on the day of hCG injection, or the number of oocytes retrieved between the two groups. The MII oocyte rates, fertilization rates, good-quality embryo rates were significantly higher in the PPOS group than they were in the antagonist group (p Conclusions Compared with the GnRH-ant protocol, the PPOS protocol may be a better regime for POR that can effectively improve clinical pregnancy and live birth rates.

Comparison of female sexual function in women who underwent abdominal or vaginal hysterectomy with or without bilateral salpingo-oophorectomy

Abstract: Objective To compare the effect of abdominal and vaginal hysterectomy with or without bilateral salpingo-oophorectomy on female sexuality. Methods Perimenopausal, sexually active, aged 45–50 years women who underwent abdominal or vaginal hysterectomy with or without bilateral salpingo-oophorectomy due to benign indications were included in this retrospective study. For the assessment of preoperative and postoperative female sexual function, Turkish validated Female Sexual Function Index form was used. Results Of the study population, 82 women (Group A) underwent hysterectomy + bilateral salpingo-oophorectomy and 78 women (Group B) underwent hysterectomy-only operations. The groups were statistically similar in terms of mean age, number of gravida and parity, body mass index, duration of postoperative evaluation, type of hysterectomy and presence of preoperative female sexual dysfunction. Both in Group A and B, postoperative total Female Sexual Function Index scores increased significantly compared to preoperative total scores. And there were no differences between the groups regarding the total preoperative and postoperative Female Sexual Function Index scores. However, postoperative arousal and orgasm scores were higher while pain score was lower in Group B than in Group A. Conclusion Abdominal and vaginal hysterectomy with or without bilateral salpingo-oophorectomy for benign causes positively affect female sexuality in general. But, premenopausal bilateral oophorectomy may cause more pain during intercourse, decreased libido and orgasm than ovary conservation.

Reliability of IOTA score and ADNEX model in the screening of ovarian malignancy in postmenopausal women.

Abstract: Background The IOTA (International Ovarian Tumor Analysis) group has developed the ADNEX (Assessment of Different NEoplasias in the adneXa) model to predict the risk that an ovarian mass is benign, borderline or malignant. This study aimed to test reliability of these risks prediction models to improve the performance of pelvic ultrasound and discriminate between benign and malignant cysts. Material and methods Postmenopausal women with an adnexal mass (including ovarian, para-ovarian and tubal) and who underwent a standardized ultrasound examination before surgery were included. Prospectively and retrospectively collected data and ultrasound appearances of the tumors were described using the terms and definitions of the IOTA group and tested in accordance with the ADNEX model and were compared to the final histological diagnosis. Results Of the 107 menopausal patients recruited between 2011 and 2016, 14 were excluded (incomplete inclusion criteria). Thus, 93 patients constituted a cohort in whom 89 had benign cysts (83 ovarian and 6 tubal or para-ovarian cysts), 1 had border line tumor and 3 had invasive ovarian cancers (1 at first stage, 1 at advanced stage and 1 metastatic tumor in the ovary). The overall prevalence of malignancy was 4.3%. Every benign ovarian cyst was classified as probably benign by IOTA score which showed also a high specificity with the totality of probably malignant lesion proved malignant by histological exam. The limit of this score was the important rate of not classified or undetermined cysts. However, the malignancy risks calculated by ADNEX model allowed identifying the totality of malignancy. Thus, the combination of the two methods of analysis showed a sensitivity and specificity rates of respectively 100% and 98%. Evaluation of malignancy risks by these 2 tests highlighted a negative predictive value of 100% (there was no case of false negative) and a positive predictive value of 80%. Discussion and conclusion On the basis of our findings, the IOTA classification and the ADNEX multimodal algorithm used as risks prediction models can improve the performance of pelvic ultrasound and discriminate between benign and malignant cysts in postmenopausal women, especially for undetermined lesions.

Luteal phase progesterone supplementation following induced natural cycle frozen embryo transfer: A retrospective cohort study.

Abstract: Introduction The objective of this study was to assess the impact on the clinical pregnancy rate of luteal phase progesterone treatment in patients being prepared for natural cycle frozen embryo transfer (FET) with induced ovulation. Material and methods This retrospective cohort study collect all the FET protocols over a 6-month period at Strasbourg University Hospital fertility unit between December 2016 and May 2017. In total 293 consecutive patients with regular menstrual cycles were prepared for natural cycle FET during this period. All patients had an embryo cryopreservation secondary to in vitro fertilisation (IVF) or by intracytoplasmic sperm injection (ICSI). There were 2 protocols during this period and patients either received or did not received progesterone. Ovulation was routinely triggered in all patients by injection of choriogonadotrophin alfa. Patients in the treated group received vaginal natural micronized progesterone treatment of 400 mg daily, starting on the day of ovulation. The principal assessment criterion was the occurrence of pregnancy. Results In total, 231 patients were analysed: 108 in the group not receiving progesterone and 123 in the group receiving progesterone. Patient characteristics were comparable between groups. A higher clinical pregnancy rate (39% vs. 24.1%, p = 0.02; 95CI [1.10; 3.74]) was recorded in the treated group. Conclusions Our results suggest that luteal phase support with vaginal progesterone statistically increases the clinical pregnancy rate following hCG-triggered natural cycle FET and that it should be used more widely.

Baseline severe constipation negatively impacts functional outcomes of surgery for deep endometriosis infiltrating the rectum: Results of the ENDORE randomized trial.

Abstract: Background Predictive factors of functional outcomes after the surgery of rectal endometriosis are not well identified. Our recent randomized trial did not find significant differences between functional outcomes in patients managed by radical or conservative rectal surgery. Objective To identify preoperative factors which determine functional outcomes of surgery in patients with rectal endometriosis. Study design We performed a cohort study on the population of a 2-arm randomised trial, from March 2011 to August 2013. Patients were enrolled in three French university hospitals and had either conservative surgery by shaving or disc excision, or radical rectal surgery by segmental resection. The primary endpoint was the proportion of patients experiencing one of the following symptoms: constipation, frequent bowel movements, anal incontinence, dysuria or bladder atony requiring self-catheterisation 24 months postoperatively. Secondary endpoints were the values of the Knowles-Eccersley-Scott-Symptom Questionnaire (KESS), the Gastrointestinal Quality of Life Index (GIQLI), the Wexner scale, the Urinary Symptom Profile (USP) and the Short Form 36 Health Survey (SF36). A logistic regression model based on backward selection was used to screen for baseline factors that could impact the primary endpoint. A generalized estimating equations model for repeated measures was used to assess whether a trend could be observed over the follow-up period as regards gastrointestinal and quality of life scores. Results 60 patients with deep endometriosis infiltrating the rectum were managed by conservative surgery (27 cases) and segmental colorectal resection (33 cases). The primary endpoint was recorded in 26 patients (48.1% for conservative surgery vs. 39.4% for radical surgery, OR = 0.70, 95% CI 0.22–2.21). There was a significant improvement in values of all gastrointestinal, quality of life and urinary scores after surgery. Comparing patients with KESS scores 17 (OR = 11.1, 95%CI 2.2–20.5), revealed that the odds to record the primary endpoint are significantly higher in the latter group. Trend analyses suggest that the odds of an elevated KESS score are significantly higher at baseline than at 6 months, but significantly lower after 12 months. Conclusions Patients with severe preoperative constipation are less likely to achieve normal bowel movements after surgery for rectal endometriosis, using either radical or conservative rectal procedures.

Anterior and middle pelvic organ prolapse repair using a six tension-free strap low weight transvaginal mesh: long-term retrospective monocentric study of 311 patients.

Abstract: Introduction Treatment of pelvic organ prolapse is an important public health issue due to the ageing population. The Food and Drug Administration, in 2011, issued a warning on complications after transvaginal insertion of high weight mesh. We evaluated a 6 tension-free straps, light prosthesis made from polypropylene monofilaments. Materials and methods This monocentric, retrospective study included patients undergoing anterior or apical prolapse repair surgery by placement of a six tension-free strap low weight vaginal mesh between 2008 and 2017. The surgical history, concomitant surgery, clinical examination results, pre and postoperative results of the Urinary Symptom Profile questionnaire, and intraoperative and postoperative complications were collected from patients’ medical records. Results 311 patients were included (median follow-up: 33 months). The majority (93%) had stage ≥ III cystocele and 26% had stage ≥ III hysterocele. Postoperatively, there were nine cases (2.9%) of asymptomatic cystocele recurrence and 11 (3.5%) cases of hysterocele recurrence, among them six underwent reoperation. Vaginal comfort was significantly improved in 92% vs. 17% before surgery (p Conclusion Treatment of anterior and/or mid-segment prolapse by transvaginal insertion of a six-strap low-weight mesh is long-term effective, with acceptable morbidity.

Operative hysteroscopy for retained products of conception: Efficacy and subsequent fertility

Abstract: Retained product of conception complicates nearly 1% of pregnancies and can lead to synechiae and compromise ulterior fertility. The aim of this study is to evaluate efficiency of operative hysteroscopy in management of retained products of conception (RPOC). Secondary objectives are assessments of intra-uterine adhesions rate and later fertility. This unicentric retrospective study includes women who undertook an operative hysteroscopy for retained products of conception between January 2012 and March 2014. Assessment of the efficiency of operative hysteroscopy is defined by a complete resection of retained products of conception confirmed by office hysteroscopy. One hundred fourteen women were included in the study. Efficiency of operative hysteroscopy for retained products of conception is 91% for women with a postoperative office hysteroscopy. The authors observed a 7.5% rate of postoperative intra-uterine adhesions. Fertility rate was 83% (30 women out of 36 with a desired pregnancy). Hysteroscopic resection of retained products of conception is an efficient procedure and seems to be a real alternative.

Surgical correction of T-shaped uteri in women with reproductive failure: Long term anatomical and reproductive outcomes.

Abstract: Objective To evaluate the long term anatomical and reproductive outcomes of hysteroscopic treatment for T shaped uterus in patients presenting with reproductive failure. Methods This prospective cohort study included 56 patients with a history of long-standing unexplained infertility, recurrent implantation failure (RIF), and/or recurrent pregnancy loss (RPL) who were eligible for metroplasty by office hysteroscopy. Office hysteroscopy under conscious sedation was performed. Anatomical outcomes were assessed with pre- and postoperative measurements of the transostial, isthmic and myometrial diameters and the uterine volume using three-dimensional transvaginal sonography (3D-TVS). Reproductive outcome was assessed after spontaneous or assisted conception. Results Hysteroscopic treatment significantly increased the volume of the uterus from a mean of 2.5 + 1 mL before surgery to 3.2 ± 1 mL by the end of 1 year as measured by 3D-TVS. According to the main indication to perform metroplasty, 20 of 32 (62.5%) patients with long standing unexplained infertility, 9 of 14 (64%) patients with RIF, and 8 of 10 (80%) patients with RPL conceived either spontaneously or with assisted reproduction. Conclusions Office hysteroscopic metroplasty results in a significant long-term expansion of the uterine cavity and improved reproductive outcomes in women presenting with a T shaped uterus and poor reproductive history.

Gestational pituitary apoplexy: Case series and review of the literature

Abstract: Pituitary apoplexy is an uncommon but potentially life-threatening emergency due to abrupt ischemic infarction or hemorrhage of the pituitary tumor. In many instances, pituitary apoplexy is the initial presentation in patients who were not previously diagnosed to have pituitary adenomas. Variety of precipitating factors have been linked to the occurrence of pituitary apoplexy, which include pregnancy. However, pituitary apoplexy related to pregnancy is limited to isolated case reports and very small case series. The main symptom is headache of sudden onset associated with visual disturbances, signs of meningeal irritation, and/or endocrine dysfunction. In the context of pregnancy the diagnosis of pituitary apoplexy can be challenging and confused with other complex conditions such as pre-eclampsia. Magnetic resonance imaging is the most sensitive sequence to confirm the diagnosis by revealing a pituitary tumor with hemorrhagic and/or necrotic components. Corticotropic deficiency with adrenal insufficiency is a potentially life-threatening disorder for both mother and the fetus if left untreated. The choice between conservative management with dopamine agonists and glucocorticoid, this "wait and see approach" and trans-sphenoidal resection depend on the severity of neuro-ophtalmic signs and the gestational week. In this article, we present three cases of pituitary apoplexy related to pregnancy. Pituitary apoplexy occurred in the third trimester in the three cases. It was the first presentation of an unknown pituitary adenoma in two cases, and complicated a preexisting macroprolactinoma in the other case. All three cases of our patients had sudden onset of severe headache and deterioration of the visual field in two cases. The pituitary MRI performed in our patients was the essential tool confirming the diagnosis of pituitary apoplexy. In all the patients was prompt replacement of deficient hormones especially glucocorticoids with close surveillance. The trans-sphenoidal resection was indicated in two pregnant women; as the first choice treatment in one case presenting with papillary edema, and as the second line after the deterioration of the visual field in one case. In the lack of guidelines of management pituitary apoplexy in case of pregnancy, we review the existing literature with pertinent clinical presentation, radiological findings, management and maternal/fetal outcomes of this rare pathology. The aim is to provide a rational framework for therapeutic management of pituitary apoplexy during pregnancy.

Yolk sac size & shape as predictors of first trimester pregnancy outcome: A prospective observational study.

Abstract: Objective To determine the value of yolk sac size and shape for prediction of pregnancy outcome in the first trimester. Material and methods 500 pregnant women between 6+0 and 9+6 weeks of gestation underwent transvaginal ultrasound and yolk sac diameter (YSD), gestational sac diameter (GSD) were measured, presence/absence of yolk sac (YS) and shape of the yolk sac were noted. Follow up ultrasound was done to confirm fetal well-being between 11+0 and 12+6 weeks and was the cutoff point of success of pregnancy. Results Out of 500 cases, 8 were lost to follow up, YS was absent in 14, of which 8 were anembryonic pregnancies. Thus, 478 out of 492 followed up cases were analyzed for YS shape and size and association with the pregnancy outcome. In our study, abnormal yolk sac shape had a sensitivity and specificity (87.06% & 86.5% respectively, positive predictive value (PPV) of 58.2%, negative predictive value (NPV) of 96.8% in predicting a poor pregnancy outcome as compared to yolk sac diameter (sensitivity and specificity 62.3% & 64.1% respectively and PPV and NPV of 27.3% and 88.7% respectively). The degree of association for both the variables was significant to the level of p Conclusion The presence or absence of yolk sac has a strong predictive value for poor pregnancy outcome. Yolk sac shape was a better predictor of poor pregnancy outcome in terms of higher specificity and negative predictive value as compared to yolk sac diameter.

Double mild stimulation and egg collection in the same cycle for management of poor ovarian responders.

Abstract: Purpose To evaluate the effect of double stimulations during the follicular and luteal phases in women with poor ovarian response (POR) in in-vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) cycles. Basic procedures This prospective clinical study was performed in Royan Institute from October 2014 to January 2016. 121 patients were diagnosed as POR on the basis of Bologna criteria were included. Double stimulations were performed during the follicular and luteal phases by Letrozole, Clomid, hMG and GnRH-agonist. The patients’ present cycle outcomes were compared with those of the previous cycle results using appropriate statistical tests. Main finding The total of 104 (85.9%) patients completed the stimulation stages. The analysis revealed the number of retrieved oocytes after the first and second stimulations did not differ (P = 0.2); however, the fertilization rate and the number of frozen embryos after the first stimulation were significantly higher than those of in the second stimulation (P Principal conclusion Since the intensity of stimulation in both stages was mild, this protocol can be considered a time-efficient and patient friendly regime; however, more studies are required with emphasis on its cost-effectiveness.

Vaginal cleansing prior to caesarian section: To do or not to do?: A randomized trial.

Abstract: Purpose: To evaluate the efficacy of preoperative vaginal cleansing using povidone-iodine solution 10% on rates of post cesarean section (CS) infectious morbidities (endometritis, febrile morbidity and wound infection). Methods: This prospective randomized trial was conducted among 226 pregnant women scheduled for term elective CS. Patients were equally divided into two groups by simple randomization method. The study group had preoperative vaginal cleansing using povidone-iodine solution 10% for about 1 min, while the control group did not. All cases received the prophylactic antibiotics and the usual abdominal scrub. Adverse post CS infectious morbidities such as endometritis, febrile morbidity and wound infection were observed at the time of hospital discharge and weekly for 6 weeks postpartum. Results: Both groups were matched regarding the baseline patients’ characteristics. Overall, post-CS infectious morbidity was significantly reduced from 20.7% in the control group to 7.5% in the intervention group. Marked significant reduction was seen in the incidence of endometritis (11.8% in the control group versus 2.8% in the intervention group). However, maternal fever and wound infection showed no significant difference between both groups. Conclusion: Vaginal cleansing with povidone-iodine solution 10% prior to elective CS appears to be effective in reducing rates of post-CS infectious morbidity mainly endometritis.

Effect of music in reducing patient anxiety during colposcopy: A systematic review and meta-analysis of randomized controlled trials.

Abstract: Background Music therapy has been used greatly in various medical procedures to reduce associated anxiety and pain. Objective to evaluate the evidence from published randomized clinical trials (RCTs) about the effect of music intervention in reducing patient's anxiety during the colposcopy. Search strategy Electronic databases included PubMed, Cochrane Library, Scopus and Web of Science were searched using the relevant MeSH terms. Selection criteria All RCTs assessing the effect of music therapy versus no music in reducing anxiety during colposcopy were considered. Eighty-five studies were identified of which five studies deemed eligible for this review. Data extraction The extracted outcomes were; anxiety, pain during and after the procedure, and satisfaction levels. They were pooled as mean difference in a fixed-effects model, using Review Manager 5.3 software for windows. Main results We found no effect of music therapy in reducing the anxiety levels when compared with the control group (SMD= -0.11, 95% CI [-0.36, 0.14], p = 0.4). No difference between music and control groups regarding pain during and after the procedure respectively (SMD= -0.20, 95% CI [-0.58, -0.18], p = 0.31) and (SMD=-0.10, 95% CI [-0.30, -0.10], p = 0.33). Conclusions Music therapy had no positive effect in reducing anxiety, pain and satisfaction levels during colposcopy.

Bilateral uterine artery ligation plus intravenous tranexamic acid during cesarean delivery for placenta previa: a randomized double-blind controlled trial.

Abstract: Objective To investigate the effect of adjunctive intravenous tranexamic acid (TA) on blood loss during cesarean section (CS) in patients with placenta previa undergone bilateral uterine arteryligation (BUAL). Methods The study was double-blind randomized controlled trial carried out in a tertiary University Hospital between June 2016 to October 2017. We includedpatients scheduled for CS due to placenta previa. They were randomly allocated to group (I) managed by BUAL alone and group (II) managed by intravenous TA plus BUAL. The primary outcome was the amount of totalestimatedblood loss both intra- and post-operative. Results Sixty-two patients were enrolled (n = 31 in each group). Patients received intravenous TA showed great reduction in total estimated blood loss compared with BUAL alone (p = .001). Additionally, the post-operative pulse was significantly higher in group (I) compared with group (II) (p = .002) and post-operative hemoglobin concentration was significantly lower in the same group compared with the other group (p = .034). More additional uterotonics was needed in group (I) than group (II) (29% vs. 3.2%, p = .006). Blood transfusion ≥4 units was required in 17 (54.8%) patients in group (I) versus 4 patients in group (II) (12.9%) (p = .0001). No difference between the study groups regarding the rate of cesarean hysterectomy (p = .27). Conclusion The adjunctive use of intravenousTA in patients undergone BUAL due to placenta previa is associated with decrease blood loss, need for additional uterotonics and blood transfusion during CS compared with BUAL alone.

State of knowledge on smartphone applications concerning contraception: A systematic review.

Abstract: Aim Women's knowledge of contraception is incomplete and a wide variety of information sources are used. Since the advent of smartphones, 325,000 healthcare apps have become available. Our aim is to conduct a literature review on smartphone applications for contraception. Methods 15 databases in English, Spanish and French were examined, which included studies published between 2007 and 2018 that describe or compare mobile applications for reversible contraceptive methods and interventional studies. The quality of the studies was assessed using the Cochrane scale or a scale created by the authors. Results 1786 articles were listed and 22 were included in the main text. In two randomised controlled trials, apps did not influence the choice of a contraceptive method. Two studies showed a significant improvement in knowledge after using an app. Comparative studies reported a large number of apps, the majority of which contained only incomplete information and few interactive features. Conclusion Many applications deal with contraception, but few have reliable and exhaustive information. Further studies are needed to measure the impact of apps on observing compliance.

Does emergency cerclage really works in patients with advanced cervical dilatation

Abstract: Objective To asses the efectivity of emergency cerclage in the patients with advance cervical dilatation and prolapsed membranes. Material methods The patients who have ≥4 cm cervical dilatation with protruding membranes were included in the study. The patients were divided into two groups. Group I was consisted of the patients who had emergency cerclage procedure and group II was consisted of the patients who denied the operation and expectantly managed. The physical examination, pregnancy outcomes and the complications were compared between the groups. The results of the patients with emergency cerclage were analysed. Results 21 patients were referred with a ≥4 cm cervical dilatation with protruding membranes 33.3% of women with emergency cerclage were delivered within one week from the admission. One patient, who was a grand multiparous (G6P4A1), was delivered a healthy infant at 40 weeks of gestation. The remaining five patients were delivered between 21 and 24 weeks, but all the infants were died due to extreme prematurity.Two patients (22.2%) developed chorioamnionitis that necessitated long hospitalization (14–21 days). In group II (expectant management) 83,3% of the patients were delivered within the 48 h from the admission. There were no case of chorioamnionitis in group II. Conclusion Emergency cervical cerclage is not a rationale option for the patients with an advanced cervical dilation (>4 cm) together with protruding membranes in early second trimester because of the short prolongation time and high complication rate.

Prenatal imaging features suggestive of liver gestational allo immune disease.

Abstract: We report prenatal imaging features of four cases of neonatal hemochromatosis due to an alloimmune disease. All cases exhibited intra uterine growth restriction (IUGR) without arguments for a vascular etiology, associated with oligohydramnios. Placental hydrops was present in 75% of cases. Splenomegaly was identified in one case. Other causes of NH have been ruled out during diagnostic workup including karyotype, detection of IGFBP-1 to evaluate a premature rupture of membranes, maternal serologic tests. MRI was performed in two cases and showed an atrophic liver associated with a low signal intensity on T2-sequence in one case. Prenatal NH was suspected in this later case and the fetus was successfully treated with two IVIG (intravenous immunoglobulins) perfusions performed during pregnancy followed by exchange transfusion and IVIG after birth. The child is doing well with normal liver function tests after 17 months of follow up. Our aim was to highlight the importance of suggesting NH-GALD when facing IUGR with oligohydramnios, ascites, placental hydrops, splenomegaly on prenatal ultrasound with negative work up for placental vascular pathologies and infectious fetopathies. MRI might be of a good help, showing an atrophic liver but enhancing iron overload in hepatic and extrahepatic tissue is helpful but not constant.

Elasticity of adenomyosis is increased after GnRHa therapy and is associated with spontaneous pregnancy in infertile patents.

Abstract: Objective To explore the effects of GnRHa on adenomyosis by transvaginal elastography. Methods A prospective observational study included patients who were diagnosed as adenomyosis by conventional transvaginal ultrasound and infertility. The sonographic characters of elastography, the degree of dysmenorrhea and the values of serum CA125 before and following GnRHa (Triptorelin 3.75 mg were administered every 28 days) plus add-back therapy were reviewed and analyzed. Each case had a 6 months follow up and the information of pregnancy were recorded. Results 45 patients who completed the 6 months follow-up were included in the analysis. Twelve cases (group 1) were pregnancy during the follow-up and the other thirty-three cases (group 2) failed their attempts. The numerical rating scale and CA125 of all the cases were both significantly reduced 6 months after therapy. All of enlarged uterus decreased to accessible normal size. In group 1, the mean elasticity score was significantly higher for the uterine after therapy than before (3.6 ± 0.3 vs 2.3 ± 0.5, p = 0.004). In group 2, the mean elasticity score did not change for the uterine after therapy than before (2.2 ± 0.5 vs 2.5 ± 0.6, p = 0.77). Conclusion Elasticity of adenomyosis is increased after GnRHa therapy. And the higher elasticity of adenomyosis after GnRHa therapy is associated with spontaneous pregnancy in infertile patents.

Predictive factors for pregnancy after controlled ovarian stimulation and intrauterine insemination: A retrospective analysis of 4146 cycles.

Abstract: Background The variability in indications and low rate of pregnancy compared to IVF have led many authors to dismiss IUI and offer IVF first-line instead. Objectives To determine what are the predictive factors for clinical pregnancy (CP) and live birth (LB) in intrauterine insemination (IUI) cycles following controlled ovarian stimulation (COS). Methods Retrospective unicentric study, between January 2009 and December 2016. Patients aged 18 to Results 4146 cycles (1312 couples) included. Mean age was 34.7 +/− 4 years. LBR per couple was 39% for anovulatory infertility compared to (p Conclusion We confirm that IUI can be an efficient treatment in selected indications. Young patients with anovulatory infertility seem to be the ideal candidates, with a 39% LBR per couple.