[Risk factors and screening strategy for group B streptococcal colonization in pregnant women: results of a prospective study]

OBJECTIVES

Group B Streptococcus (GBS) continues to be the most important bacterial cause of sepsis, meningitidis in newborns. American consensus guidelines have been published. They recommended the use of either risk-based strategy or screening-based approach for GBS colonization in pregnant women to identify candidates for intrapartum prophylaxis. Screening consists of obtaining vaginal and anorectal specimens for culture at 35 to 37 weeks' gestation. The aim of this prospective study was to assess the usefulness of systematic and concomitant GBS screening by rectal and vaginal swab in pregnant women. A questionnaire designed to determine the risk factors for colonization by GBS was completed.

MATERIALS AND METHODS

We have screened 370 pregnant women with rectal and vaginal swab.

RESULTS

Fifty seven (15.4%) women had positive GBS cultures. Of those women, the rectum and the vagina were the only site of colonization in 16 (4.3%) and 8 (2.2%) women respectively. None of the factors studied was significantly associated with GBS colonization.

CONCLUSION

Detection of GBS is enhanced by 40% by using vaginal and anorectal swabs compared to a vaginal swab alone. No studied factor appeared to predict GBS colonization, which incited us to screen all pregnant women.

[Laparoscopic surgery during the second trimester of pregnancy: indications, technique, and fetal repercussions. Report of nine cases and review the literature]

Non-obstetric abdominopelvic surgery during pregnancy is associated with a considerable materno-foetal complication rate related to the delayed diagnostic and therapeutic management and the severity of the underlying disease. Based on retrospective analysis of 9 laparoscopies performed during the second trimester of pregnancy between the months of January 1994 and October 1996 in the Gynaecology and Obstetrics Department of Hospital Bichat, the authors study the feasibility of this technique. They report 9 cases of abdominopelvic disease, in which laparoscopy allowed a diagnostic and therapeutic approach: 6 cases of adnexal disease, 2 appendicular syndromes and one diagnostic laparoscopy. The maternal and obstetric course was favourable in each case. Several cases of laparoscopic appendicectomy, cholecystectomy, and adnexal surgery during pregnancy have been published since 1990. The main reasons theoretically contraindicating laparoscopy after the first trimester of pregnancy are the risk of uterine injury and the foetal risk during creation of the pneumoperitoneum. Experimental data are limited, but the increased intra-abdominal pressure and the use of CO2 do not appear to have any harmful effects in animals (foetal lambs). By respecting a certain number of technical precautions, laparoscopy during the second trimester of pregnancy can constitute a legitimate diagnostic and therapeutic approach.

[Laparoscopy-assisted hysterectomy and laparoscopic preparation. Apropos of a series of 177 cases]

Our objective was to determine the limits of laparoscopic-assisted vaginal hysterectomy (LAVH) and the value of a preoperative scoring system to determine the operative approach to hysterectomy. Between January 1991 and December 1996, 152 out of 177 patients had LAVH and 25 had laparoconversion. The mean operating time was 163 min. The overall postoperative complication rate was 8.4%. The hospital stay was 4.8 days for LAVH versus 6.2 days for laparoconversion (p < 0.01). For each patient, a preoperative scoring system was established according to uterine size, previous laparotomy, uterine mobility, pelvic adhesions and endometriosis stage. The laparoconversion rate increased according to the score, as it was 7.8% for a score < or = 7 and 80% for a score > 7. LAVH offers a technique to convert some abdominal hysterectomies into vaginal hysterectomies. The use of the preoperative scoring system may help to determine patients who may benefit from the laparoscopic route and those with a high risk of laparoconversion.

[Borderline ovarian tumors: a series of 43 patients]

Our objective was to evaluate the sonographic features, serum tumor markers in a series of 43 patients with borderline ovarian tumors. At sonographic examination, the majority of borderline tumors were multilocular. Serum CA-125 levels were elevated in 32.1%, CA-19-9 in 17.4%. In contrast, ACE levels were constantly normal. Twenty-four out of 43 patients (55.8%) had serous tumors, 18 (41.9%) had mucinous tumors and 1 (2.3%) had endometrioid tumor. Among, the 43 patients, 9 (20.9%) had first laparotomic approach and 34 had first laparoscopic treatment. Seven out of 34 patients treated by first laparoscopic approach had a laparoconversion (2 for presumption of invasive carcinoma and 5 for failure of laparoscopic procedure). Therefore, 27 had exclusive laparoscopic management. Among the 43 patients, 22 had conservative treatment and 21 radical surgery. The mean follow-up of patients was 41 months. Thirty-seven patients (86.1%) were alive without recurrence, 4 had a recurrence (9.3%), 1 patient (2.3%) was lost to follow-up and the last died of intercurrent disease. The mean delay of recurrence was 22 months (range 6 to 36). Three out of 4 recurrences occurred after cystectomy (2 ipsilateral and 1 controlateral). The fourth recurrence occurred after unilateral salpingo-oophorectomy. All 10 second look procedures were negative. Our results point out about the feasibility of laparoscopic management of borderline tumors. However, cystectomy is associated with a high risk of recurrence.

Fertility after laparoscopic myomectomy: preliminary results

We report the limits, complications, subsequent fertility and outcome of pregnancies after laparoscopic myomectomy. From January 1990 to October 1995, 143 patients underwent a first laparoscopic approach to myomectomy. A total of 41 patients (28.7%) had a laparoconversion (12 cases for a number of myomata >5, 15 cases for myoma diameter >7 cm, 12 cases for peroperative haemorrhage and two cases for adenomyosis). Seventy patients (49%) wished to conceive: 26 had undergone laparoconversion and 44 laparoscopic myomectomy. A total of 19 pregnancies were obtained in 17 patients after laparoscopic myomectomy (38.6%): eight vaginal deliveries, three Caesarean sections, four miscarriages, two abortions, one ectopic pregnancy and one therapeutic abortion. The pregnancy rate in patients with unexplained infertility and with multifactorial infertility was 48.2% and 20% respectively. The mean delay to conception was 11.3 months. No uterine rupture was noted. Pelvic adhesions were found in the four patients who underwent second-look procedure. Our preliminary results indicate that laparoscopic myomectomy is a useful technique.

[Laparoscopy and salpingitis. For whom? When? How?]

The apparent decrease of the incidence of pelvic inflammatory disease (PID) in industrial countries comes from the increase of less symptomatic forms. Diagnosis requires more often non clinical diagnostic technics. Laparoscopy remains the gold standard for the diagnosis and grading of PID but its indications should be on an accurate strategy.

[Cervical maturation by repeated applications of prostaglandin E2 gel. 186 cases]

OBJECTIVE

A prospective clinical trial of cervical ripening with intracervical prostaglandin E2 gel in repeated administrations was performed.

STUDY DESIGN

One hundred eighty-six patients were enrolled in this prospective trial between 01/01/89 and 31/12/93. these patients with unripe cervix (Bishop score < 5) required induction of labor because of pregnancy disorders. Mean patient age was 28.2 years (range 15 to 43), mean gestational age was 39.2 week's gestation (range 33 to 43) and mean parity was 1.8 (range 1 to 10). Our exclusion criterias were as follow: twin pregnancies, breech presentation and premature rupture of membranes. A 0.5 mg prostaglandin E2 gel was administered into the cervix every four hours maximal of three doses before induction of labor with oxytocin. Maternal and neonatal results were reviewed.

RESULTS

Patients required a single dose of gel in 19.9% of cases, two doses in 26.3% and three doses in 53.8%. Induced labor during cervical ripening occurred in 55.4% of patients. A cesarean section was necessary in 22% of cases. This rate was both significantly related to the initial Bishop score and to the Bishop score at the end of the procedure. Patient with induced labor during the cervical ripening had a significantly lower cesarean section rate compared to these who needed induction with oxytocin (10.7% versus 33.8%; p < 0.01). The uterine hyperstimulation rate was 1.6%. A 1 min Apgar score less than 7 occurred in 1.1% of neonates.

COMMENTS

Our results do not demonstrate benefit of repeated administration comparison to a single administration described in literature. Maternal and neonatal morbidity is low in this study but cervical ripening should be used only when pregnancy disorders require prompt delivery within twenty-four hours.

[Upper genital tract infections in women infected with HIV: epidemiologic, diagnostic and therapeutic aspects]

Fifty seven women hospitalized in the gynecological department of Bichat-Claude Bernard hospital in Paris for pelvic inflammatory disease (PID) proven by laparoscopy from sept. 1992 to nov. 1994 had a serological diagnosis of HIV infection. Three of them (5,2%) were positive (HIV+). Previous publications have shown from 4% to 17% in the USA and as much as 32% in Abidjan. However this prevalence is arising each year. PID in HIV+ seems to have more often a poor symptomatology but require more surgical treatments. Postpartum endometritis in HIV+ were also studied. From 1989 to 1994, we observed 109 delivery in HIV+ patients. Numerous infectious diseases occurred but endometritis were not significantly elevated. Three american studies in HIV+ failed to show an increased risk of postpartum endometritis but a fourth larger study achieved in Abidjan, showed a significantly higher risk of endometritis, associated with decreasing levels of CD4. HIV+ women are at increased risk of upper genital tract infection and could profit from obstetrical antibioprophylaxis.

[Clinical comparison of different replacement milk formulas in children with allergies to cow's milk proteins. 24-month follow-up study]

The elective treatment for allergy to cow's milk protein is the elimination of these proteins from the diet. The present study with a follow-up of over two years took the form of a comparison between different replacement formulas based on soya (group A), hydrolysate of soya and bovine collagen (group B), and hydrolysate of casein (group C), randomly administered to 55 children (30 males and 25 females, aged between 2-48 months) with documented allergy to cow's milk proteins, but with different clinical symptoms. Tests to evaluate the acquisition of clinical tolerance to cow's milk proteins were performed using a day-hospital regime every 6 months. Sensitivity reactions were observed in 22% of cases in group A, 8% in group B and 37.5% in group C. It is worth underlining that 5 of the 6 children with reactions to soya protein then showed an excellent tolerance to hydrolysate of soya when it was administered subsequently until tolerance was achieved. Weight and statutory growth was uniformly good in all three groups. A high percentage of children achieved tolerance after 24 months (72%); the mean time taken to acquire clinical tolerance was 11.6 +/- 4.8 in group A, 11.6 +/- 6.02 in group B, and 14 +/- 5.6 in group C. No correlation was found between the type of initial symptoms, age at onset, method of response to first challenge and the time taken to acquire tolerance.