Les stimulations ovariennes modérées pour fécondation in vitro constituent-elles un réel progrès en assistance médicale à la procréation ?

Growing evidence indicates that mild ovarian stimulation for in vitro-fertilization-embryo transfer may be an interesting approach to reduce the incidence and severity of complications, the number of treatment days, cost, patient discomfort and number of patient drop-outs. However, the heterogeneity of FSH-sensitive follicles, presumably requires multiple follicular growth to improve oocyte-embryo selection. In addition, whether the acceptability probably is similar between standard ovarian stimulation and mild stimulation, per-treatment pregnancy rates with conventional stimulation is superior to mild stimulation in unselected populations. Hence, some specific indications tend to emerge such as alterations of the ovarian follicular reserve in women of less than 38 years, bad embryo qualities and implantation failure after conventional stimulation, patients with previous history of hyperstimulation syndrome or contraindications to hyperoestrogenia (estrogeno-related cancers and thromboembolic diseases). However, no randomized trials have ever been performed to compare the results of mild versus conventional stimulation in young patients and good responders. Therefore, there is insufficient scientific evidence to shift from standard stimulation to mild stimulation for all patients. Cultural standards have to be considered in the choice of the type of stimulation.     

Impact sur la survie de la procédure du ganglion sentinelle dans le cancer de la vulve : analyse de la SEER database

ObjectivesVulvar cancer is usually treated with vulvectomy and bilateral groin lymphadenectomy, which result in serious morbidities while only 30% of patients have positive nodes. The sentinel node technique has good sensitivity and specificity for detecting lymph node involvement while minimizing postoperative morbidity. The aim of this study was to evaluate the specific and overall survival impact of sentinel lymph node procedure versus inguinofemoral lymphadenectomy in patients with vulvar cancer.Patients and methodsThis is a retrospective study from the Surveillance, Epidemiology, and End Results (SEER) database on patients with vulvar squamous cell carcinoma, T1 or T2 stage, metastatis-free, followed between 2004 and 2008.ResultsOne thousand and thirty eight patients had a systematic groin lymphadenectomy and 56 a sentinel node technique (including 22 with an associated lymphadenectomy because of a positive sentinel node). There is no significant difference in overall or specific survival between the two groups. In multivariate analysis, age, T stage and nodal status are prognostic factors for overall and specific mortality (P < 0.05).Discussion and conclusionSentinel node technique is not associated with an excess risk of mortality or recurrence.     

Risques cardiovasculaires de la contraception orale estro-progestative : au-delà de la polémique…

Combined hormonal contraceptive is the most used contraceptive method in France among childbearing-aged women. Following the temporary delisting of oral contraception containing a 3rd generation progestin and following the market withdrawal of oral pills containing cyproterone acetate in combination with ethynil-estradiol (35 μg), the impact of these events on our prescribing practice remains to determine. We will especially discuss the cardiovascular risk associated with combined hormonal contraceptives in the light of the most recent publications either with epidemiological or biological data.     

Ensayo clínico,aleatorizado y controlado para evaluar la eficacia y la seguridad de la administración de 25 μg de misoprostol vaginal frente a 50 μg de misoprostol sublingual para la inducción del trabajo del parto

Objectives

To compare the safety and efficacy of 25 μg of vaginal misoprostol versus 50 μg of sublingual misoprostol for induction of labor.

Patients and methods

Four hundred fifty women were randomly assigned to receive 25 μg of vaginal misoprostol or 50 μg of sublingual misoprostol every 4 h for up to four doses. The main outcome assessed was the number of vaginal deliveries in 24 h.

Results

A total of 155/225 (68.9%) patients in the sublingual group and 154/225 (68.4%) women in the vaginal group delivered vaginally (p = 0.920; RR = 1.021; 95% CI for RR, 0.685-1.521). The mean time (± standard deviation) for starting labor was 2.75 ± 2.20 h in the sublingual group and 3.8 ± 2.77 h in the vaginal group (p < 0.001). The mean number (± standard deviation) of doses was 1.9 ± 0.8 in the vaginal group and 1.6 ± 0.8 in the sublingual group (p = 0.010). Indications for cesarean section and the frequency of tachysystole were similar in both groups. There was a greater need for oxytocin in the vaginal group (22.7%) than in the sublingual group (14.7%) (p = 0.020).

Conclusions

No statistically significant differences were found between the 2 treatment groups in the main variable: the number of vaginal deliveries in 24 h.     

Vers une simplification de la technique de césarienne : suture péritonéale ou non ?

Objectives

To assess the postoperative morbidity of a technique for caesarean section without closing the visceral and parietal peritoneum.

Patients and methods

We conducted a prospective cohort study randomized 252 patients over a period of four months (from March 1 to June 30, 2009). We studied the early postoperative morbidity.

Results

Among the 252 patients, 137 were included in the group “with peritonisation” and 115 in the group “without peritonisation”. Clinical and hematology maternal characteristics were comparable in both groups. The duration of intervention was reduced significantly in the absence of peritonisation (31.1 instead of 41.4 minutes; P < 0.001). The postoperative pain was less but not significant between h0 and h12, however it is significant at h18, h24and h30 in the absence of peritonisation (respectively 2.37 versus 2.81; P = 0.030; 1.98 versus 2.37; P < 0.001 and 1.38 versus 1.72; P = 0.018). Resumption of transit was significantly faster “without peritonisation” (24.3 versus 24.7 hours; P < 0.001). However, there is no significant difference between the two groups as regards the immediate postoperative complications.

Conclusion

The absence of visceral and parietal peritoneum shortens the operative time and favors an earlier resumption of transit. It also decreases pain symptoms. We therefore recommend not to suture the parietal and visceral peritoneum during cesarean section.     

Étude de la distribution anatomique des lésions endométriosiques : un argument majeur en faveur de la participation de la théorie de la régurgitation dans la physiopathologie de l’endométriose

Endometriosis is a common disease in gynecology. Many theories were proposed to explain the endometriosis pathogenesis. The distribution of the endometriosis lesions seems to be interesting in order to understand the endometriosis pathogenesis. This distribution is asymmetric. This asymmetric distribution of endometriosis is explained by the anatomy of the peritoneal cavity and by the intraperitoneal fluids. It strongly confirms the role of menstrual regurgitation and peritoneal fluid in the endometriosis genesis. The similar asymmetric distribution for all types of endometriosis (superficial lesions, ovarian endometriosis cyst, deep endometriosis) is an argument in favor of a unique origin for the different types of lesions.     

Utilisation de la colle chirurgicale dans la promontofixation laparoscopique. Étude comparative à propos de 32 cas

AimTo study the impact of the use of glue instead of some laparoscopic sutures, on the operative time, the morbidity, and the short-term anatomical and functional results in the laparoscopic sacrocolpopexy (LSCP).Patients and methodsThirty-two patients underwent a LSCP at Poissy-St-Germain-en-Laye University Hospital. The fixation of prostheses was made either exclusively by sutures (Group S), or by associating sutures (on traction sites) and biological glue (Group C). Comparison was made after pairing on the number of prostheses associated surgery. Patients’ satisfaction was assessed thanks to the validated PGI-I questionnaire.ResultsThe mean operative time (178.7 [Group S] vs 173.1 minutes [Group C]) and the mean hospital stay (3.94 [Group S] vs 3.31 days [Group C]) were not significantly different. Anatomical results (POP-Q) and the mean satisfaction rate in the short-term were similar in both groups (1.67 [Group S] vs 1.30 [Group C]. Morbidity was also similar in both groups; no serious complications have been experienced.Discussion and conclusionThe use of the glue in the LSCP did not significantly reduce the operative time. However, the use of glue for the adhesion of prostheses in addition to sutures has shown its safety and efficacy compared to the conventional technique (sutures exclusively) since the morbidity, the anatomical results and satisfaction rate are identical in the short-term. A study involving a larger number of patients with a longer follow-up seems necessary.     

Le choriocarcinome : une face cachée de la pemphigoïde gestationnelle

Gestationis pemphigoid is an autoimmune subepidermal blistering dermatosis occurring predominantly in pregnancy, more seldom in early puerperium, and exceptionally in post-abortion. The association of gestationis pemphigoid with choriocarcinoma is extremely rare. We report this association in a patient of 35 years in which the diagnosis of gestationis pemphigoid was made on clinical, histological and immunological criteria, and the one of choriocarcinoma was made on clinical, biological radiological and histological criteria. Through this article, we put the item on this association reported for the first time in post-abortion.     

Tumeur de la Granulosa de l’ovaire : étude rétrospective à propos de 17 cas

Granulosa cell tumors of the ovary are rare tumor of ovary, included in the sex cord-stromal tumor category, hormone secreting. Seventeen patients with adult-type granulosa cell tumor were identified between 1995 and 2012. All have received surgical treatment first at stage I. Thirty-three percent of the patients relapsed with peritoneal nodules in 68% of the cases, treated surgically and sometimes with complementary therapies, such as chemotherapy, radiotherapy, hormonal treatment. Overall survival and recurrence-free survival were 100% and 58.3%, respectively at 10 years with median time to recurrence of 6 years (4–27). These tumors have therefore a good prognosis and require long-time follow-up. Finally, the prognostic factors of recurrence identified in the literature are FIGO stage, the presence of residual tumor and tumor size.