[Molecular diagnosis of human papillomaviruses (HPV): What test(s) in clinical practice?]

Prescription of an HPV test in practice will enable the clinician to optimize the monitoring and the management of patients, especially in the context of cervical cancer screening. Numerous HPV tests are available that present different analytical and clinical sensitivity and specificity. International recommendations on clinical performance of HPV tests used for cervical cancer screening have been published by a group of experts, and tests that meet these performance criteria should be used. Apart from the HPV detection kit, the whole circuit from sampling to report of the results must be considered. This implies that the pre-analytical (sampling, quality of sample collection medium, storage condition and sample transportation…) and post-analytical steps (quality of result reporting, providing expert advices…) are also standardized. For this purpose, medical-biology laboratories are subjected to a COFRAC certification, as defined by the international standard ISO 15189 providing quality criteria for any clinical laboratory test and HPV test in particular.

[Evaluation of satisfaction after in-office conization under local anesthesia]

OBJECTIVES

Treating cervical intraepithelial neoplasia is essential in cervix carcinoma prevention and conization is the standard treatment. In the current medical and economic context, which advocates the simplification of procedures, loop excision conization is well adapted to an in-office procedure. Therefore, we evaluated the patient satisfaction after an in-office conization.

METHOD

We conducted an observational study at the Besançon University Medical Centre. Between November 2013 and October 2014, all patients treated by an in-office conization were included. Global satisfaction of patient was retrospectively collected by answering a telephone questionnaire.

RESULTS

Seventy patients were treated by in-office conization and answered the questionnaire. Global satisfaction was 88.6%. Moreover, 75.7% of patients declared to have felt no pain or moderate pain during the conization. Most of the patients (91.4%) would advise this in-office care to their relatives. The rate of positive margins for dysplasia was 31.4% and postoperative haemorrhage occurred in 7.1%.

CONCLUSION

In this context of medical care cost reduction, conization seems to be perfectly adapted to in-office surgery. It was also found to be well accepted by patients without raising neither positive margins rate nor postoperative haemorrhage risk.

[Impact of the external cephalic version on the obstetrical prognosis in a team with a high success rate of vaginal delivery in breech presentation]

OBJECTIVES

To analyse the impact of external cephalic version (ECV) on caesarean section rate in a team with a high success rate of vaginal delivery in breech presentation.

MATERIALS AND METHODS

Retrospective monocentric study including 298 patients with a breech presentations between 33 and 35weeks of amenorrhea followed at our university hospital and delivered after 35weeks, between 1st January 2011 and 31st December 2013. Patients were divided into 2 groups: planned ECV (n=216 patients) versus no planned ECV (n=57 patients).

RESULTS

Our rate of successful vaginal breech delivery over the period of the study was 61.1%. We performed 165 ECV, with a 21.8% success rate. The average term of the attempt of ECV was 36.7weeks of amenorrhea. The caesarean section rate was not significantly different in the planned ECV group, even after adjustment on age, parity and previous caesarean delivery (adjusted OR=1.67 [0.77-3.61]). Attempt of ECV did not reduce the number of breech presentation at delivery (61.1% versus 61.4% [P=0.55]).

CONCLUSION

Planned ECV in our center with a high level of breech vaginal delivery did not significantly impact our cesarean section rate.

Endoscopic lithotripsy and vaginal excision of a calcified bladder-mesh extrusion

INTRODUCTION AND HYPOTHESIS

Synthetic meshes have proven to increase efficacy of pelvic organ prolapse (POP) repair, but associated complications are not rare. Bladder mesh extrusion is one of the most serious adverse events following POP surgery with mesh. The aim of this video was to describe endoscopic and vaginal approaches for treating a bladder-mesh extrusion.

METHODS

A 52-year-old female patient with a history of vaginal POP surgery with mesh was referred for severe pelvic and perineal pain, dyspareunia, and dysuria. She was found to have a bladder calculus on a mesh extrusion. The calculus was removed by endoscopic lithotripsy before vaginal mesh excision was performed.

CONCLUSIONS

With the use of synthetic vaginal mesh, the incidence of bladder-mesh extrusion could increase. This didactic video will be helpful to surgeons required to manage such cases using a minimally invasive treatment.

[Can we decrease cesarean rate at a university hospital treating high risk pregnancies?]

OBJECTIVE

To determine which clinical practice changes were responsible for a decrease in cesarean rate from 19.2% in 2003 to 15.5% in 2012 at our university hospital treating high risk pregnancies, while verifying the absence of any increase in neonatal morbidity and death.

MATERIALS AND METHODS

A descriptive retrospective study was undertaken at our labour ward including all patients delivering in 2003 and in 2012. Maternal, obstetrical and neonatal characteristics of the two populations were compared. Cesarean rates were analysed following : (1) Robson classification, (2) some maternal and obstetrical characteristics, and (3) indications for cesarean.

RESULTS

Mean age, BMI and rate of scarred uterus significantly increased in 2012. The two populations remained comparable in terms of other criteria studied. The main cause responsible for decrease in cesarean rate was breech presentations (p<0.05). Furthermore, significantly less cesareans were performed after labour induction (p=0.04). We also significantly decreased our elective cesarean rate by more than 3% without increasing cesarean sections during labour, showing a rise in successful vaginal delivery trials. The impact of in utero transfers on the global rate of cesarean is highly significant since the latter has been divided by half in 10 years in this population considered to be of high risk for cesareans.

DISCUSSION

These significant decreases reflect our experience in allowing vaginal deliveries in breech presentations, and also a better selection of patients for labour induction. Furthermore, it should be noted that increasing vaginal delivery trials in various obstetrical situations participated in this decrease. We clearly found that some indications for elective cesarean can be avoided, such as multiple pregnancies and scarred uterus, thus showing the importance of restricting the first indication for cesarean. Finally, the decrease in cesarean rate had no negative effect on neonatal outcome.

CONCLUSION

Decreasing cesarean rate is possible in a university hospital treating high risk pregnancies. It requires daily obstetrical case by case critical analysis, allowing wide acceptance of vaginal delivery trials, and continuously evaluating clinical practices.

Twin pregnancy in each half of a didelphys uterus with delayed delivery and review of literature

Didelphys uterus results from an incomplete fusion of mullerian ducts and corresponds to the class III of mullerian abnormalities of the American Fertility Society. We describe the case of a spontaneous twin pregnancy developed in each cavity of a didelphys uterus. At 29 weeks of gestation and 6 days, the patient had preterm rupture of membranes in the right horn. She went into spontaneous labor and delivered vaginally the first “right” twin. Delivery was complicated with post-partum hemorrhage on uterine atonia treated with a Bakri balloon. She was tocolyzed to pursue the fetal lung maturity of the second twin. She had a rupture of the second membranes at 30 weeks and 3 days and had a preterm vaginal delivery at 32 weeks and 1 day of the second twin. Twin pregnancy in both horns of a uterus is extremely rare, about 1 in 1,000,000. Pregnancies on congenital abnormalities of the paramesonephric duct present frequently poor obstetrical outcomes and many complications. There are no guidelines about the follow-up of these high-risk patients or the mode of delivery.

[Evaluation of satisfaction after hysteroscopic tubal ligation. About a study from the CHU of Besançon]

OBJECTIVE

The Essure(®) system is a hysteroscopic sterilization method. The purpose of our study was to retrospectively evaluate the sterilization procedure with Essure(®) devices without anesthesia.

PATIENTS AND METHODS

The descriptive study included all tubal sterilizations with Essure(®) devices performed without anesthesia, with MEOPA, from January 1st, 2013 till February 28th, 2014 in the CHU of Besançon. The evaluation of the global satisfaction of the patients was collected by telephone survey.

RESULTS

A hundred and forty-three patients benefited from Essure(®) without anesthesia during the period of study in the CHU of Besançon and among them, 120 patients answered the telephone survey questionnaire. The average age was of 41.3 years. As regards the satisfaction and the tolerance, 89.2% of the patients declared to be globally satisfied by this procedure and 95.8% would recommend it to a friend. Indeed, 66.6% of the patients declared to have felt no pain or moderate pain. Furthermore, the MEOPA was well tolerated at 79.9% of the patients. As regards the procedure of Essure(®) inserts without anesthesia the rate of failure was 9.2% and at 3 months the radiological control was satisfactory in 94.5% of the patients.

DISCUSSION AND CONCLUSION

The tubaire sterilization by implants Essure(®) is a fast and effective procedure. Our study shows, that at present, this technique can be realized without anesthesia, during a dedicated consultation, with an important rate of global satisfaction of the patients. It thus allows to decrease the number of hospitalization in ambulatory surgery and to decrease the cost of this intervention.

Screening of human papillomavirus infection in women with systemic sclerosis

OBJECTIVES

High risk human papilloma-viruses (HR HPV) are associated with risk of cervical dysplasia and carcinoma. The risk is increased in patients with immune deficiency or auto-immune disease as systemic lupus erythematosus. Currently, no data are available about the human papillomavirus status in women with systemic sclerosis (SSc).

METHODS

Thirty-one women with SSc were evaluated for cervical HPV infection and dysplasia, and compared to fifty age-matched control. Cervical swabs were tested by the INNO-LiPA assay®. Serum antibodies against HPV 16 and 18 were assessed using enzyme-linked immunosorbent assay in the SSc group.

RESULTS

The overall HPV frequency was comparable between SSc and controls (32% vs. 38%), as well as the HR HPV frequency (28% vs. 34%), but infection by ≥2 HPV was two times more frequent in the SSc group (50% vs. 26% of the HPV positive samples). The most prevalent genotype was 52 in the SSc group (12%), and 52/53 in the control group (8% for both). Pap smears were within the normal range. Seropositivity for HPV 16 and 18 was 13% and 6.5%, respectively. A diffuse systemic sclerosis and a younger age at first intercourse were more frequent in cases of overall HPV positivity. Current smoking and a higher number of sexual partners were only observed in cases of seropositivity.

CONCLUSIONS

This is the first study to evaluate HPV status in women with SSc. HR HPV52 was the most common genotype with a greater multi-HPV infection rate. This result needs to be confirmed in a larger study.

Changes in maternal blood inflammatory markers as a predictor of chorioamnionitis: a prospective multicenter study

PROBLEM

To evaluate the inflammatory pattern in maternal circulation from women with preterm premature rupture of membranes (PPROM) considering the occurrence of histologically confirmed chorioamnionitis (HCA).

METHOD OF STUDY

A prospective study was conducted in 121 women with PPROM between 24 and 34 + 0 weeks of gestation. Association between white blood cells (WBC) count, plasma CRP, IL-6, MCP-1 and IP-10 levels, and HCA was assessed.

RESULTS

The rate of HCA was 44.7% (54/121). During the 5 days preceding delivery, median CRP, WBC, and IL-6 levels were significantly higher in the HCA than in no-HCA group (P < 0.001). Variations in IL-6, IP-10 levels, during the 24-72 hr before delivery, were predictors of the occurrence of HCA, but the diagnostic accuracy was low [Receiver Operating Characterictic (ROC) curve, area under the curve (AUC) = 0.56].

CONCLUSION

An increase in IL-6, CRP, IP-10 maternal plasma levels was confirmed in PPROM women with HCA. Longitudinal follow-up of these markers did not add valuable information regarding HCA.

[Birth weight discordance in dichorionic twins: diagnosis, obstetrical and neonatal prognosis]

OBJECTIVE

To describe neonatal and obstetrical prognosis in dichorionic (DC) twins with a birth weight discordance under 20% and evaluate the influence of intrauterine growth restriction on the management.

PATIENTS AND METHODS

We studied retrospectively 67 DC twins birth between July 2002 and July 2012 at our university labour ward. Birth weight discordance was considered slight between 20-25%, moderate between 25-30%, and severe over 30%.

RESULTS

Prevalence of birth weight discordance in DC twins is estimated at 11.4% in our study. Eighty percent of severe discordance was diagnosed before delivery, 41% for moderate discordance and 20% for slight discordance. We note 30% of pre eclampsia in our population with 44% in the severe discordance group. Mean gestational age was 35.1 weeks for slight and moderate discordances, and 33 weeks for severe discordance. Caesarean section rate was 48% for severe discordance and only 36% for slight discordance. Vaginal delivery rate is 56.7%. More than half of patient with a severe discordance gave birth vaginally. Intrauterine growth restriction rate under the 10th percentile was 18.7%. Prevalence of IUGR was 24% in sever discordance group, 23.5% in the moderate discordance group and 10% in the slight group. Neonatal morbidity rate was 20.8% mainly in children with IUGR.

DISCUSSION AND CONCLUSION

Neonatal mortality and morbidity rate are mainly increased in severe discordant twins. These pregnancies are at high risk of maternal morbidity. Vaginal delivery must be preferred for slight and moderate discordances. In case of severe discordance, vaginal delivery should be considered depending on the degree of intrauterine growth retardation.

Anatomy of the pubovisceral muscle origin: Macroscopic and microscopic findings within the injury zone

AIMS

The levator ani muscle (LA) injury associated with vaginal birth occurs in a characteristic site of injury on the inner surface of the pubic bone to the pubovisceral portion of the levator ani muscle's origin. This study investigated the gross and microscopic anatomy of the pubic origin of the LA in this region.

METHODS

Pubic origin of the levator ani muscle was examined in situ then harvested from nine female cadavers (35-98 years). A combination of targeted feature sampling and sequential sampling was used where each specimen was cut sequentially in approximately 5 mm thick slices apart in the area of known LA injury. Histological sections were stained with Masson's trichrome.

RESULTS

The pubovisceral origin is transparent and thin as it attaches tangentially to the pubic periosteum, with its morphology changing from medial to lateral regions. Medially, fibers of the thick muscle belly coalesce toward multiple narrow points of bony attachment for individual fascicles. In the central portion there is an aponeurosis and the distance between muscle and periosteum is wider (∼3 mm) than in the medial region. Laterally, the LA fibers attach to the levator arch where the transition from pubovisceral muscle to the iliococcygeal muscle occurs.

CONCLUSIONS

The morphology of the levator ani origin varies from the medial to lateral margin. The medial origin is a rather direct attachment of the muscle, while lateral origin is made through the levator arch.

[Active management of the second twin for vaginal delivery: ruptured versus intact membranes. Apropos a series of 182 patients]

AIM

The vaginal management of the second twin (T2) differs throughout our country. In 2009, the French National College of Gynecologists and Obstetricians released practice guidelines, with low-level evidence, encouraging active management of the second twin, using maneuvers with intact membrane.

PATIENTS AND METHODS

In our level III labour ward, these maneuvers are systematically performed when the second twin is in a breech or transverse presentation and after ruptured membranes in most cases. We studied 182 twin pregnancies with active management of the T2 at more than 28 weeks of gestation, from 1st January 1996 to 31st December 2010, by comparing the membrane status during delivery of T2.

RESULTS

The results did not show any significant differences between the two groups of patients concerning the neonatal or maternal results. The technique is feasible, even by residents. Our results show that total breech extraction of the second twin with ruptured membranes is feasible, which allows for reappraisal of the national recommendations.

CONCLUSION

In our practice, it is possible to actively deliver the T2 with ruptured membranes without altering maternal and fetal prognosis and thus simplifying learning for young doctors.

[Satisfaction with obstetrical care: development and validation of a scale on quality of care]

OBJECTIVES

To develop and validate a subjective and multidimensional scale to measure satisfaction in obstetrical care (SSO) during labour, delivery and two hours postpartum, which is relevant to the French-speaking context.

PATIENTS ET METHODS

Forty partially directed patient interviews during the 48 hours after delivery and four care-giver interviews were conducted to build up the questionnaire. After a prior feasibility study on 40 patients, the psychometric validity of the questionnaire was evaluated by calculating the Cronbach coefficient of reliability for 432 patients.

RESULTS

Hundred and eighty items were initially obtained after content analysis of the patient interviews. Expert meetings finally selected 49 items classified within 5 dimensions. The feasibility study showed that the questionnaire was easily accepted and understood with a mean time of 15 minutes to answer it. Cronbach coefficients were respectively at 0.941, 0.949, 0.808, 0.814 et 0.869 for the 5 dimensions.

DISCUSSION AND CONCLUSION

SSO questionnaire is a reliable and relevant scale to measure immediate postpartum quality of care in French.