[Determinants of group B streptococcus maternal colonization and factors related to its vertical perinatal transmission: case-control study]

OBJECTIVES

To investigate the determinants of Group B streptococcus (GBS) maternal colonization, as well as factors associated with its vertical transmission.

PATIENTS AND METHODS

Case-control study on all singletons pregnancies delivered beyond at least 24 weeks of amenorrhoea in Southern Reunion maternities for which GBS screening was known. Multiple logistic regression analysis using 2004-2007 dataset of South Reunion birth registers.

RESULTS

Out of 17,430 women delivered between 1st January 2004 and 31st December 2007, 2911 (16.7%) carried GBS. In a model adjusted on antenatal care, risk groups for GBS carriage were the women indigenous from another island of the Indian Ocean than Reunion (OR: 1.29, CI95%: 1.05-1.57) and obese women (body mass index ≥ 30, OR: 1.19, CI95%: 1.03-1.18). Protective factors included birthplace in mainland France (OR: 0.82, CI95%: 0.69-0.97) and underweight (OR: 0.81; CI95%: 0.69-0. 95). In a model controlling for a composite obstetrical variable delineating the protective roles of C-section and antibioprophylaxis as well as the putative role of meconium-stained fluids (thin, thick or fetid), all previously found in our setting, three key factors were independently associated with GBS vertical mother-to-child transmission: obesity (OR: 1.48, CI95%: 1.05-2.09), fetal tachycardia (OR: 4.92, CI95%: 2.79-8.68) and late preterm birth (35 to 36 wks, OR: 2.14, CI95%: 1.32-3.45).

CONCLUSION

These findings strengthen the putative roles of corpulence and ethnicity in GBS acquisition previously found in the United States, while confirming an authentic role of obesity in its vertical transmission, independently of other classical cofactors lighted by our study.

[Nipple sparing mastectomy: an update]

In order to decrease the psychological impact and the mutilating feeling of surgical treatments of the breast cancer when the mastectomy is indicated, authors described and propose the nipple sparing mastectomy (NSM). The only opposable criticism would be the increase of recurrence rate. The study of the recent literature allows us to make a inventory of fixtures concerning this evolution of the surgical practices whether on a technical, oncological, plastic or psychological plan. This technique is not validated in France and adjuvent therapies as the radiotherapy of the nipple are not validated yet. It seems that the NSM is a safe practice from the carcinologic point of view, while having a positive psychological impact in terms of disease and treatment acceptance. The technique seems possible after an information and selection of the patients and with a respect for technical rules (frozen section, peroperative evaluation of the nipple vitality).

Obstetrical and neonatal outcomes in obese women

OBJECTIVE

To compare the incidence of antenatal and intrapartum complications and neonatal outcomes among pre-pregnant obese women.

METHODS

At the Sud-Reunion Hospital's maternity, Reunion Islands, France, over a 54-month period, each obese pregnant woman (BMI > or = 30 kg/m2) delivering a singleton after 22-weeks gestation was compared to the next age and parity-matched woman of normal pre-pregnancy weight (BMI 18.5-25 kg/m2), who delivered after the index case. The Students t test, Mann and Whitney test, Chi-square test and logistic regression model were used for statistical analysis.

RESULTS

The study enrolled 2081 obese women and 2081 controls. The incidences of pre-eclampsia, chronic and pregnancy-induced hypertension, chronic and gestational diabetes mellitus were increased in the obese women group. Prenatal care in obese women required a high rate of hospitalizations as well as a high rate of insulin treatment. Obese women were more likely to be delivered by Caesarean section. The rate of in utero fetal death, neonatal and perinatal death was significantly higher in the obese women group. The high BMI in relation with both pre-eclampsia and in utero fetal death remained unchanged after adjustment of other risk factors.

CONCLUSION

Obese women were more likely to present several obstetric complications and to be delivered by Caesarean section. Obstetricians who decide on a first Caesarean section in an obese woman should be aware of the cumulated obesity and uterine scar risks that could threaten any subsequent Caesarean section.

[Obstetrical and neonatal outcomes of gestational diabetes mellitus at Reunion Island (France)]

OBJECTIVE

To assess maternal and fetal outcomes in patients with gestational diabetes mellitus.

PATIENTS AND METHODS

A retrospective study was conducted at the Sud-Reunion Hospital's maternity (French overseas department located in the Indian Ocean), during the period from January 1, 2001, through December 31, 2004. During this period, 1172 pregnant women presenting gestational diabetes mellitus were compared with 1172 non-diabetic controls matched on the basis of age, parity. Student t test, Pearson chi-square test and logistic regression model were used for statistical analysis.

RESULTS

Gestational diabetes mellitus complicates about 7.5% of pregnancies in Reunion Island. Its occurrence was associated with a significantly increased prevalence of pre-pregnancy obesity (27 versus 9.4%) and chronic hypertension (5.3 versus 3.3%). The prevalence of preeclampsia and obstetrical vascular disorders were not different between the two groups, respectively 2.2 versus 2.7% (P=0.43) and 6.2 versus 4.4% (P=0.06). The rate of caesarean sections and inductions of labour was increased in the study group. The term of delivery was inferior in the study group, consecutive to increased rate of labour induction at 38 week-gestation. Macrosomia and large for gestational age (LGA) newborns rate were significantly higher in the study group, respectively 8.9 versus 4.2% and 22.5 versus 10.1% (P<0.001) but the rate of admission into neonatal unit was not significantly different.

DISCUSSION AND CONCLUSION

Active management of gestational diabetes mellitus is associated with low maternal and perinatal morbidity. While age and parity are controlled by the study design, the prevalence of preeclampsia and gestational hypertension are not increased in women presenting gestational diabetes mellitus.

[Full term abdominal pregnancy]

Abdominal pregnancy is a rare localization of ectopic pregnancy, more frequently observed in underdeveloped countries. We report a case of abdominal pregnancy carried to full term delivery, discovered at a time of a cesarean for low site of placenta attachment. Discovery of an abdominal pregnancy at the time of C-section seems exceptional with clinical and ulrasonographic surveillance of pregnancy. The objective of our article is to emphasize the importance of localizing the appendix at the first quarter echography and the utility of the endovaginal ulrasound.

[Twin pregnancies in southern Reunion Island: a three-year cross-sectional study of risk factors and complications]

OBJECTIVES

To describe characteristics of multiples pregnancies in southern Reunion Island.

MATERIAL AND METHODS

A three-year [corrected] cross-sectional observational study aimed at describing risk factors, events and [corrcected] complications and associated with twin pregnancies from 22 weeks gestation onward, within a tertiary care hospital centre, the Groupe Hospitalier Sud-Réunion.

RESULTS

The study included 241 multiple pregnancies out of 15 837 pregnant women. The regional incidence of multiple pregnancies was 1.5%. Indicators of eligible twin pregnancies (n=234) were mother age up or equal to 35 years (63% of women, OR 8.4; CI95% 6.3-11.1), infertility treatments (15%): ovarian stimulations (OR: 50.2; CI95% 24.7-102) and in vitro-fertilisations (OR: 44.3; CI95% 22.6-86.3). A low maternal corpulence before pregnancy (BMI<20) and celibacy were negatively associated with twin pregnancies. Prenatal cares for twin pregnancies were globally adequate. The need for hospitalisation was 50% (30% of whom for preterm delivery threats). Twin pregnancies increased risks for pre eclampsia (OR: 3.0; CI95% 1.6-5.7) and gestational diabetes (OR: 1.9; CI95% 1.2-2.8). Caesareans and instrumental delivery rates were 50% and 12% (vs 16% and 7%), respectively. Twin infants were preterm for 62% and very preterm for 18%. Last, they were more likely to die than singletons (perinatal mortality: 78 per thousand for monochorionic twins, 57 per thousand for bichorionic twins vs 17 per thousand, p<0.0001, respectively).

CONCLUSION

In Reunion Island, the incidence of multiple pregnancies is similar to that seen in Europe, but seems less due to assisted reproduction techniques. In return, they are associated with higher morbidity and mortality rates.

[Chikungunya infection in pregnancy: Evidence for intrauterine infection in pregnant women and vertical transmission in the parturient. Survey of the Reunion Island outbreak]

PURPOSE

Since February 2005, an outbreak of Chikungunya virus (CHIKV) infections occurred in Reunion Island. It is transmitted by the Aedes albopictus mosquito. Neonatal cases observations suggest possible fetal transmission during pregnancy. MATERIAL [corrected] AND METHODS. Observations made in 160 pregnant mothers infected by CHIKV between June 1, 2005 and February 28, 2006, in the south of Reunion island were recorded.

RESULTS

Three of nine miscarriages before 22 weeks of gestation could be attributed to the virus. 3,829 births took place during this time. Among the 151 infected women, 118 were viremia negative at delivery, and none of the newborns showed any damage. Among the 33 with positive viremia at delivery, 16 newborns (48.5%) presented neonatal Chikungunya.

DISCUSSION

Though fetal contamination risks appear to be rare before 22 weeks of gestation, they are potentially dangerous. After 22 weeks gestation, newborns infection occurs if the mother is viremia positive at delivery. Transplacental transmission is suspected, but the pathogenic mechanism remains unknown.

Étude des 178 morts fœtales in utero dans le sud de l’île de la Réunion en 2001-2004

INTRODUCTION

The perinatal mortality rate is 18.5 in the southern part of the Reunion Island (Indian Ocean), of which 2/3 are due to antepartum fetal deaths (APFD).

METHODS

During a 4-year period (2001-2004) all APFD from 22 weeks gestation were recorded and analyzed with placental histology, bacteriological samples and autopsies in 27% of cases. The Australasian and New-Zealand classification PSANZ-PDC (2000) was used. Risk factors of fetal death with monofetal pregnancies are determined in comparison with live births.

RESULTS

Out of 21.495 total births, 178 APFD were recorded. The main obstetrical risk factors were primiparity (OR 1.6, p = 0.002), maternal age over 34 years (OR 1.6, p = 0.01), hypertensive disorders of pregnancy (OR 3.0, p < .001) and multiple births (OR 2.5, p < 0.001). The great majority of APFD (76%) involved preterm fetuses, of which 61% of very preterm (<33 weeks), and 25% of fetuses were growth retarded (OR 3.9, p < 0.001). Only 8% of cases were considered unexplained. The main etiologies were infectious causes in 26% of cases, vascular fetal growth restriction (18%), specific perinatal conditions (14%) of which one-third were due to cord anomalies, preeclampsia (10%), maternal conditions (8%), congenital anomalies (8%) and ante-partum hemorrhage (7%). We discuss the interests and the limitations of using the Australian and New-Zealand classification PSANZ 2000. Intra-uterine growth retardation is one of the principal risk factors of fetal death.

CONCLUSION

Besides well-known obstetrical risk factors such as diabetes, hypertension, multiple pregnancies, all screening of intra-uterine growth retardation in the second trimester of pregnancy should include a special survey in order to minimize the incidence of APFDs.

Linear association between maternal pre-pregnancy body mass index and risk of caesarean section in term deliveries

OBJECTIVE

Maternal obesity is a well-known risk factor for caesarean delivery. The aim of this study is to determine whether all the spectrum of pre-pregnancy maternal corpulence (body mass index [BMI]) is associated with the risk of caesarean delivery.

DESIGN

Observational study over 4.5 years (2001-05).

SETTING

Groupe Hospitalier Sud-Réunion's maternity (island of La Réunion, French overseas department, Indian Ocean).

POPULATION

All consecutive singleton live births having delivered at the maternity.

METHODS

Data have been analysed according to different risk factors. Maternal corpulence has been defined as the maternal pre-pregnancy weight. BMIs have been studied by multiples of 5 kg/m2 from 10-14.9 kg/m2 to 40-44.9 kg/m2.

MAIN OUTCOME MEASURE

Rate of caesarean section.

RESULTS

There were 17 462 singleton live births during the period, of which 16 952 (97.1% of the total) pre-pregnancy BMIs have been determined. There is a linear association (chi 2 for linear trend, P < 0.001) between maternal corpulence and risk of caesarean deliveries, the leanest mothers having the best rate of vaginal delivery. This linear association exists in a model controlling for diagnosis of gestational diabetes, term deliveries (> or =37 weeks), very short maternal height (<1.50 m), primiparity and maternal age > or = 35 years (adjusted chi 2, P < 0.001).

CONCLUSION

There is a significant linear association between pre-pregnancy maternal corpulence and risk of caesarean deliveries in pregnancies at term. The authors discuss several interpretations including the adaptability of fetal birthweights to maternal corpulence and the concept of soft-tissue dystocia.

Étude des facteurs de risques obstétricaux dans le suivi de 365 grossesses primipares adolescentes à l’île de la Réunion

OBJECTIVES

Analysis of obstetrical risk factors in teenage primiparous pregnancies in Reunion Island (4% of total births).

MATERIALS AND METHODS

Retrospective study, between 2001 and 2002, comparing primiparous adolescents (13-17 years, n = 365), with primiparous controls (18-29 years, n = 2050). The analysis included demographical factors, maternal medical histories, prenatal follow-up, obstetrical risk factors, delivery modes and neonatal characteristics.

RESULTS

Adolescents attended on average 8 prenatal consultations, however 4% had poor prenatal care (less than 3 visits, OR 4.2, P < 0.001 vs controls). They presented less gestational diabetes, but there were no differences concerning pre-existing hypertension, hypertensive disorders of pregnancy, medical reasons of hospitalisation between the two groups. Mode of delivery was more favorable in adolescents (half rate of caesarean sections, shorter duration of membrane ruptures). Nevertheless, adolescents presented a higher risk of severe prematurity (<32 Weeks gestation, incidence 3.6% vs 1.6%, OR 2.3, p = 0.008).

CONCLUSION

With optimal prenatal care (more than 90% of our cohort), primiparous adolescents present globally a favorable course of their pregnancies and have better deliveries than their young (18-29 years) counterparts. However, there is a significant risk of severe prematurity requiring special care for these pregnancies.

Endométriose avec ascite et épanchement pleural : à propos d'un cas

Massive ascites associated with pelvic endometriosis is an uncommon combination. Pleural effusion may rarely occur. Fourteen cases are reported in the literature. We report the case of a black nulligravida woman followed for a primary infertility. Endometriosis was suspected in presence of increasing dysmenorrhea, cystic adnexal masse, umbilical nodes and ascites. The diagnosis was confirmed at exploratory laparoscopy. The patient had been followed for assisted procreation for six years and had undergone a conservative laparoscopic surgery never described. After several ascites recurrences, the pathology was resolved by Gonadotropin-releasing hormone agonist therapy. But a right pleural effusion with ascites occurred following a bad therapeutic observance. This complication reveals an early pregnancy never reported for this exceptional pathology. A conservative management allowed this unique case of well outcoming pregnancy. The possible pathogenesis of ascites and pleural effusion are explored and recommendations for diagnosis and treatment options are discussed.

[Pregnancy beyond age 40 in 382 women: a retrospective study in Reunion Island]

OBJECTIVE

To examine obstetrical and neonatal outcomes among women age 40 years and older.

MATERIAL AND METHODS

There was a retrospective study including 382 pregnant women at least 40 years of age and 7786 controls aged 20-34, stratified according to parity. Associations between maternal age and pregnancy outcomes were assessed using Pearson's chi(2) test, Fischer exact test, Student test or Mann and Whitney test, as appropriate.

RESULTS

Maternal age 40 and over was associated with an increased risk for gestational diabetes (multiparas: OR 3.2, 95%CI 2.2-4.8; grandmultiparas: 2.8, 1.6-5.0), chronic diabetes (multiparas: 3.5, 1.04-10.6), chronic hypertension (multiparas: 3.1, 1.5-6.1; grandmultiparas: 12.1, 3.3-53.2), pregnancy-induced hypertension (nulliparas: 4.6, 1.01-17.3; multiparas: 2.6, 1.3-5.4) and preclampsia (multiparas: 2.9, 1.1-7.2). The risk for cesarean section was 2-fold higher in older multiparas and grandmultiparas. The same was true for the rate of operative vaginal delivery. The rate of fetal chromosomal abnormalities was 7-fold higher in older gravidas. Rates of fetal death were significantly increased in the cohort of older pregnant women (nulliparas: 11.2, 2.9-44.0; multiparas: 3.9, 1.4-10.9).

CONCLUSION

Pregnancy at age 40 and over is associated with high rates of obstetrical complications, cesarean sections and operative vaginal deliveries, emphasizing the importance of rigorous antenatal care.

[Factors associated with fecal incontinence after childbirth. Prospective study in 525 women]

OBJECTIVE

To determine the prevalence of fecal incontinence after childbirth and to identify the risk factors.

METHODS

This was a prospective observational study with a consecutive inclusion of 525 women who delivered over a three months period. Women were questioned about their fecal continence four days and six weeks after delivery.

RESULTS

The incidence of fecal incontinence four days and six weeks after childbirth was respectively 8.8% and 3.3%. The risk factors for fecal incontinence at 4 days after childbirth were instrumental delivery by forceps (adjusted odds ratio 8.64, 95% confidence interval 3.55-21.0, p < 0.001) and unassisted delivery at home (adjusted OR 8.06, 95% CI 1.30-50.0, p = 0.025). Independent risk factors for the presence of fecal incontinence 6 weeks later were: instrumental forceps delivery (adjusted OR 10.8, 95% CI 2.82-41.3, p = 0.001), unassisted delivery at home (adjusted OR 50.0, 95% CI 3.09-802, p = 0.006), bi-parietal diameter of the newborn > 93 mm (adjusted OR 4.56, 95% CI 1.46-14.1, p = 0.009) and maternal age >30 years (adjusted OR 4.60, 95% CI 1.11-19.1, p = 0.036).

CONCLUSION

Fecal incontinence is common after childbirth and its prevalence is predominantly associated with instrumental delivery, unassisted delivery at home, bi-parietal diameter of the newborn and maternal age.

[Post mortem brain MRI: an alternative for pathology examination in Bourneville tuberous sclerosis of the fetus?]

Antenatal discovery of cardiac rhabdomyomes evokes the diagnosis of Bourneville's disease. Antenatal brain exploration with ultrasonography and magnetic resonance imaging (MRI) can highlight cerebral localizations. In the event of termination of pregnancy, confirmation of the cerebral lesions can be achieved with post mortem MRI as well as pathology examination. MRI can be usefully employed in the event pathology examination is not feasible.

[Severe cytomegalic inclusions disease in the fetus of a woman immunized before pregnancy]

After detection of a fetal microcephaly at 24 weeks gestation, we performed an amniocentesis at 29 weeks with chromosomal and polymerase chain reaction (PCR) search for viral contamination. Cytomegalovirus (CMV) infection was confirmed by PCR although the mother had previously been tested as immunized for CMV prior to conception. Abortion was induced; the fetus presented clinical CMV injuries confirmed by positive tissue culture (liver, brain and lungs). Recent publications have reported similar observations with variable viral strains. These findings point out the importance attentive search for ultrasonographic signs suggestive of fetal CMV infection.

[Gas embolism and hyperbaric oxygen treatment during pregnancy: a case report and a review of the literature]

We report the first case of a pregnant woman presenting with a paradoxical air embolism due to accidental removal of a central venous catheter. Secondary right hemiplegia associated with a confused state justified emergency hyperbaric oxygen therapy, which was followed by complete neurological recovery. The aim of this case report is to assess risk situations of gas embolism during pregnancy and puerperium, as well as indications and fetal effects of hyperbaric oxygen therapy.

[Prevalence of hepatitis A, B, C virus markers in Réunion (south hospital and Saint Pierre prison)]

We studied the prevalence of Hepatitis A, B, C in different groups in the population of the South of Reunion Island. The aims of this study were the following: to estimate the prevalence of Hepatitis C virus (HCV) (anti-HCV antibodies) and Hepatitis B virus (HBV) (anti-HBc, HBs Ag and anti-HBs) in a population of 1455 women, who delivered in the Centre hospitalier Sud Reunion (CHSR), to estimate the prevalence of these two viruses in a population selected for risk factors (100 prisoners), to estimate the prevalence of Hepatitis A in a group of 400 persons (aged 0 to 19) hospitalised in CHSR since 1st January 1998 (100 for each 5-year age bracket), to research risks factors in these populations and immunity. The overall prevalence of anti-HCV was 0.14% in pregnant women and risk factor associated was found in 28.9% of this population (2.9% history of transfusion, 0.21% drug users). In the group of prisoners seroprevalence was 2%, far below that of prisoners in France. Anti-HCV seroprevalence is weak in Reunion Island and very inferior to seroprevalence in the French population as in other Indian Ocean islands. This is due to the low risk of parenteral transmission. Anti-HBc was found in 90 serum samples from women (overall prevalence 6.35%) and of these 90 positive samples, 9 were positive for HBs Ag (overall prevalence 0.63%), 68 were positive for anti-HBs (4.81%) and 22 (1.54%) were anti-HBc isolated (without HBs Ag and anti-HBs). The overall prevalence of anti-HBs was 62.8%. In the population of 100 prisoners, 2 were HBs Ag positive, 10 anti-HBc positive (2 anti-HBc isolated, 2 associated with HBs Ag, 6 with anti-HBs). The prevalence of anti-HBs was 22%. The major risk factor observed in this population of prisoners was tattooing and/or piercing (46%). These results show that: Reunion island is an area of low endemicity for HBV virus. The measure of protective inoculation is well followed. i.v. drug abuse and previous transfusion are weak routes of transmission. In the group aged 0 to 19, overall prevalence of anti-HAV was 11.9% with the highest rate found among 15 to 19 year-olds (25%). Seroprevalence falls with socio-economic progress. At the present time, the endemic is intermediate in Reunion Island. Given immunity levels within the young population, there is a risk of outbreak. This risk is due to the conditions in Reunion Island, but also to people who travel to other Indian Ocean countries where endemicity is high. It is thus very important that a vaccination strategy be determined.

[Prevalence of hepatitis C virus infection in pregnant woman on the island of Réunion]

AIMS

The aim of this prospective study was to assess the prevalence of anti-hepatitis C virus antibodies in a population of pregnant women in Réunion.

METHODS

Over a 6-month period, all blood samples of pregnant women who delivered at a hospital in the south of Réunion were tested with a third generation enzyme-linked immunoassay. In addition, risk factors for hepatitis C transmission were systematically looked for.

RESULTS

Among the 1,455 women tested during this period, only 2 sera were found to be positive, resulting in a prevalence of 0.14%. One of these women had a history of intravenous drug use, whereas the other had no identified risk factor. This low prevalence was found to be associated with a low frequency of risk factors of C virus infection in this population: a history of transfusion and intravenous drug use was found in 2.9% and 0.21% of cases, respectively.

CONCLUSIONS

The prevalence of hepatitis C virus infection is particularly low in Réunion. This low prevalence is explained by the rarity of risk factors for hepatitis C transmission in this region which is close to the African continent and has a similar high prevalence of hepatitis B virus infection.

[Myomectomy using laparoscopy. 23 cases]

The authors report their experience with laparoscopy for myomectomy and analyze their results (mean size of myomas: 7.5 cm, route of extraction: vaginal 56%). This is a recent, promising technique which requires further evaluation.

Hysteroscopic diagnosis of ectopic pregnancy

Although vaginal ultrasonography combined with plasma beta-hCG determination can provide a reliable diagnosis and location of ectopic pregnancy, the results can be difficult to interpret in the early stages when hCG levels are low. Hysteroscopy can be used in such cases to differentiate between ectopic pregnancy and non-viable uterine pregnancy when viable uterine pregnancy has been ruled out. General anaesthesia and laparoscopy are avoided. We performed 60 hysteroscopic procedures between January 1989 and December 1990 in patients with suspected ectopic pregnancies. The pregnancy had been located by means of vaginal ultrasonography in every case in which the hCG was above 1500 IU/ml and in 36% of cases in which the beta-hCG was below this level. Hysteroscopy was hindered by metrorrhagia in three cases and was inconclusive in one, necessitating laparoscopy. Diagnosis was possible in all the remaining cases, as follows: ectopic pregnancy in 41 cases, with an empty uterus and occasional bleeding from an ostium; non-viable uterine pregnancy in 18 cases, with the presence of material within the cavity. Hysteroscopy therefore confirmed the diagnosis in 55% of the cases and was itself diagnostic in a further 43% of cases. Its sensitivity for the diagnosis of ectopic pregnancy was 100% and its specificity 95%. We propose a diagnostic decision tree.