Relative distribution of HPV genotypes in histological cervical samples and associated grade lesion in a women population over the last 16 years in Burgundy, France

Human papillomavirus is a predominant sexually transmitted viral pathogen. Our objective was to analyze the relative distribution of genotypes over time and to determine the genotypes associated with adverse clinical lesions. The study was based on data from adult women with cytological abnormalities from whom histological samples were obtained from 2005 to 2021. HPV genotyping was performed using PCR and INNO-LiPA assay (Fujirebio). Among the 1,017 HPV-positive biopsies, 732 (72%) were infected with a single HPV genotype and 285 (28%) were infected with several HPV genotypes. Most of the infections involved the high-risk genotypes 16, 31, and 52. Throughout the study period, HPV 16 was the most encountered genotype (541, 53.2%), while HPV 18 was rather under-represented (46, 4.5%), especially in invasive cervical carcinoma. HVP52 (165, 16.2%) was detected mainly from 2008 to 2014, and its distribution reached 19.7% in 2011. Such epidemiological data underlines the possibility of an emergence of a high-risk genotype. The most detected low-risk HPV in combination with high-risk HPV was HPV 54 in 6.5% of samples. Monoinfection by HPV 16 led statistically more often to severe lesions than multi-infection involving HPV 16 (p < 0.001), while for HPV 52, 31 or 33, multi-infections were significantly associated with severe lesions (p < 0.001 for each of these three genotypes). HPV 16 was involved in 55.2% of high-grade lesions and in situ carcinoma and 76.3% of invasive carcinomas. In severe lesions, HPV 16 participation was predominant, whereas diverse genotypes were seen in low-grade lesions. Importantly, we observed that high-risk genotypes, for example HPV 52, can emerge for a few years then decrease even without vaccine pressure.

Does mammogram attendance influence participation in cervical and colorectal cancer screening? A prospective study among 1856 French women

BACKGROUND

We aimed to determine participation rates and factors associated with participation in colorectal (fecal occul blood test) and cervical cancer (Pap-smear) screening among a population of women participating in breast cancer screening.

METHODS

From August to October 2015, a self-administered questionnaire was sent by post to 2 900 women aged 50-65, living in Côte-d'Or, France, and who were up to date with mammogram screening. Polytomic logistic regression was used to identify correlates of participation in both cervical and colorectal cancer screenings. Participation in all 3 screenings was chosen as the reference.

RESULTS

Study participation rate was 66.3% (n = 1856). Besides being compliant with mammogram, respectively 78.3% and 56.6% of respondents were up to date for cervical and colorectal cancer screenings, while 46.2% were compliant with the 3 screenings. Consultation with a gynecologist in the past year was associated with higher chance of undergoing the 3 screenings or female cancer screenings (p<10-4), when consultation with a GP was associated with higher chance of undergoing the 3 screenings or organized cancer screenings (p<0.05). Unemployment, obesity, age>59 and yearly flu vaccine were associated with a lower involvement in cervical cancer screening. Women from high socio-economic classes were more likely to attend only female cancer screenings (p = 0.009). Finally, a low level of physical activity and tobacco use were associated with higher risk of no additional screening participation (p<10-3 and p = 0.027).

CONCLUSIONS

Among women participating in breast screening, colorectal and cervical cancer screening rates could be improved. Including communication about these 2 cancer screenings in the mammogram invitation could be worth to explore.

[Interstitial, angular and cornual pregnancies: Diagnosis, treatment and subsequent fertility]

OBJECTIVE

Interstitial, angular and corneal pregnancies are not very frequent and often mistaken, each with its own definition and prognosis. The objective of this work is to relate 10 years experience of ectopic pregnancies at the UH in Dijon, based on the latest data from the literature in term of diagnosis, management and subsequent fertility.

METHOD

This is a retrospective study carried out at the UH of Dijon from 01/01/2005 to 01/01/2015. From the medical records of each patient who presented a corneal, interstitial or angular pregnancy, we identified the risk factors for ectopic pregnancy (EG), the diagnostic and therapeutic means used, and the subsequent obstetrical events.

RESULTS

In 10 years, 532 EG were managed including 10 interstitials, one angular and nine cornual. The main risk factors were previous EG (50%), salpingectomy (55%), curettage (45%) and smoking (40%). The localization of the EG was done in 75% by the endo-vaginal sonography, in 25% in peroperative. Thirty-five percent were treated with methotrexate, 20% had surgery and 40% had both. Seventy-five percent of patients had at least one ulterior pregnancy. In the case of caesarean section, no dehiscence of the corneal scar was identified.

CONCLUSION

This study shows the presence of medical antecedents which are risk factors of the tubular EG. A methotrexate protocol should be proposed first. Even after corneal surgery, vaginal delivery may remain possible.

[Assessment of restrictive episiotomy use and impact on perineal tears in the Burgundy's Perinatal Network]

OBJECTIVES

To analyse episiotomy and perineal tears rates in Burgundy after French National College of Obstetricians and Gynecologists (CNGOF) guidelines in 2005.

MATERIALS AND METHOD

Multicenter retrospective study, between 2003-2005 (period 1) et 2012-2014 (period 2), conducted on singletons vaginal deliveries, in cephalic presentation from 37 weeks. We compared the episiotomy rate (ER), and perineal lesions in normal deliveries (ND) and instrumental deliveries (ID) between the two periods.

RESULTS

A total of 74,268 women were included. The overall ER significantly decreased from 35.8 to 16.7% (P<0.01), without increasing third degree perineal tears (0.73% vs. 0.66%) or fourth degree (0.14% vs 0.14%). First degree perineal tears rose (42.1% vs 17.6%, P<0.001), second degree decreased (13.5% vs 20.5%, P<0.001). ER decreased whatever the level of motherhood, healthcare ward, vaginal delivery type, or the instrument used.

CONCLUSION

Our study found a strong impact in Burgundy of the French guidelines for the practice of restrictive episiotomy for both ND and for ID without increasing sphincter tears and in decreasing spontaneous morbidity.

[Before surgery predictability of malignant ovarian tumors based on ADNEX model and its use in clinical practice]

OBJECTIVE

The principal aim of this study was the predictability of malignant ovarian tumors and to determine a cut-off value for this score to indicate the risk of malignancy that would be easy to use in clinical practice.

METHODS

We retrospectively calculated the ADNEX score for all patients who underwent surgery for ovarian tumours in two Burgundy hospitals (Dijon University Hospital and Chalon-sur-Saône Hospital). We used the nine criteria of the ADNEX model. The inclusion criteria were the presence of all of the ADNEX criteria and a histology result. We analysed the sensitivity, specificity, PPV and PNV of four cut-offs (3%, 5%, 10% and 15%) for the entire pool then by age groups; from 14 to 42 (group 1) and 43 and more (group 2) RESULTS: Two hundred and eighty-four patients managed for an ovarian tumour were included between the 1st January 2013 and the 31st December 2015. Our AUC was of 0.94 (95% CI [0.903-0.977]) for discrimination between benign and malignant ovarian tumors. For a cut-off of 10%, sensitivity was 90%, specificity was 81.1%, PPV was 34.6% and PNV 98.5%. Results were lower for young women than for the second group. For a cut-off of 10%, group 1 had a sensitivity of 77.7% and specificity of 89.6%, PPV of 46.6% and PNV 97.5%. For the group 2, sensitivity was 95.2%, specificity was 76.6%, PPV was 33.8% and PNV was 99.2%. The most reasonable cut-off for the whole pool was 10%. For group 1 a cut-off of 5% was retained due to the less satisfying detection of "borderline" tumours more frequent in younger patients. For group 2 the cut-off of 10% gave the best results.

CONCLUSION

In our study, a lower cut-off for younger women seemed better suited to discriminate borderline tumours. In practice, the ADNEX score associated with the peroperative laparoscopic examination seems to be the best way to use the ADNEX model. Our study showed that the ADNEX model allows a good predictability of malignant ovarian tumours. The predictability becomes less satisfying for the youngest patients. A cut-off malignity value allowing surgical treatment of patients in a specialised facility was reached for two age groups: a cut-off of 5% for women under 42 years old and a cut-off of 10% for women over 43 years old.

[Quality of life after deep pelvic endometriosis surgery: Evaluation of a French version of the EHP-30]

OBJECTIVE

To evaluate the changes in the quality of life of patients after deep pelvic endometriosis surgery, with a French version of EHP-30 questionnaire, and the capacity of the EHP-30 to carry out this measurement.

MATERIAL AND METHODS

Study prospective monocentric, conducted in the obstetrics and gynecology department of the CHU Dijon during the period of October 2012 from October 2013. A EHP-30 questionnaire was given to patients before surgery. The same questionnaire was sent to their homes, away from surgery (3-6 months) to inform about their postoperative quality of life. The difference in preoperative and postoperative scores was tested using the test Wilcoxon signed ranks. A difference was considered significant if the p-value was less than or equal to 0.05. Sensitivity to change was calculated by the method of effect size (ES). The size of the effect is defined as the difference in mean preoperative and postoperative scores divided by the standard deviation of preoperative scores. A size effet of 0.20 indicates less change scores, of 0.50 a moderate change and of 0.80 a material change.

RESULTS

We included 22 patients in total in the prospective analysis. The majority of patients had gynecological symptoms of dysmenorrhea with 69.7%, 75.7% and 75.7% dyspareunia chronic pelvic pain. Nineteen patients (57.6%) had gastro-intestinal symptoms. Urinary symptoms were less frequent. The results of the EHP-30 showed a significant improvement for the items "pain" (P=0.01), "control and powerlessness" (P=0.02), "emotional well-being" (P<0,01) "social relations" (P<0.01), "sexual intercourse" (P=0.03) and "relationship with the medical world" (P=0.05). We observed a non-significant improvement for the items "self-image" (P=0.44), "work" (P=0.48) and "relationships with children" (P=0.50). The size of the effect (ES) was low to high for all dimensions of the questionnaire, ranging from 0.1 to 0.6 for the entire group. A significant sensitivity to change was found for the items "pain" (ES=0.60), "control and powerlessness" (ES=0.62), "social relations" (ES=0.57). A moderate sensitivity to change was found for the items "emotional well-being" (ES=0.29), "relationship with the medical world" (ES=0.26). A low sensitivity to change was found for the items "relationships with children" (ES=0.06), "self-image" (ES=0.16), "work" (ES=0.18), "sexual intercourse" (ES=0.20). A size that is important to moderate effect corresponded to a statistically significant improvement of the score EHP-30.

CONCLUSION

This study showed that the EHP-30 is a sensitive tool to change the health status and an appropriate instrument for the assessment of treatment effects in patients with deep pelvic endometriosis.

HPV vaccination coverage in French girls attending middle and high schools: a declarative cross sectional study in the department of Côte d'Or

OBJECTIVES

To assess human papillomavirus prophylactic vaccine coverage among a representative population of French girls, aged 14 years and above, attending middle and high schools, and to determine factors associated with the initiation and completion of the vaccination protocol.

STUDY DESIGN

This cross-sectional study, designed with cluster sampling, was conducted from October 2010 to May 2011, in 29 schools in the department of Côte d'Or, France. The schools were randomized according to their status (public or private) and location (rural or urban). Two classes per level were then included. All analyses were stratified on age.

RESULTS

948 questionnaires were collected (87.9% participation). Mean age was 15.2 years (SD=1.3), ranging between 14 and 19. Only 31.7% of 14-year-old girls and 61.4% of girls aged 15 and above initiated vaccination (one dose), and 7.8% of 14-year-old girls and 48.5% of girls aged 15 and above completed it (three doses). An urban school location and a physician's recommendation were independently associated with vaccination initiation in girls aged 14. In girls aged 15 and above, the parents' socioeconomic status, the family composition and a recommendation by a physician were independently associated with vaccination initiation. Once vaccination had been initiated, girls who attended private school, who belonged to families with higher outcomes, who lived with a single parent or who smoked were less likely to complete the vaccination protocol.

CONCLUSION

HPV prophylactic vaccine coverage in girls attending school in Côte d'Or appears to be low. Physicians play a major role in vaccine acceptance.

[Prospective evaluation of an intravaginal electrical stimulation in the treatment of women with pure genuine stress urinary incontinence]

OBJECTIVES

To study the objective and subjective effectiveness of transvaginal electrical stimulation for treatment of female pure genuine stress incontinence.

PATIENTS AND METHODS

This was a multicenter prospective trial including 207 patients with genuine stress incontinence who used the stimulator for 10 weeks. Similar pre-treatment and post-treatment assessments included both validated symptom severity index and health-related quality of life.

RESULTS

Objective evaluation showed a significant improvement in 65.7% of subjects with stress incontinence. All domains of quality of life improved significantly after treatment (P=0.0001) and rate of satisfactory was 84.7%. There were no statistical differences between the two stimulators.

DISCUSSION AND CONCLUSION

Pelvic floor electrical stimulation seems to be effective in treating female genuine stress incontinence and could be considered first-line therapy.

[Pheochromocytoma: rare lethal challenging diagnosis that may be encountered by gynecologists and obstetricians]

Pheochromocytomas are rare but potentially lethal tumors responsible for malignant hypertension. They may be encountered by gynecologists and obstetricians. The diagnosis is difficult because it can be mistaken for diseases more frequent like preeclampsia or other pelvic tumors. We report two cases highlighting clinical clues such as labile hypertension, headache, sweating, palpitations and failure to respond to conventional treatment should prompt physicians to screen patients for pheochromocytoma by measuring the 24-hour urinary catecholamines. The surgery must be performed after using an appropriate preoperative treatment, in order not to trigger lethal outcome. During pregnancy, C-section is recommended.

Regression of high-grade cervical intraepithelial neoplasia with TG4001 targeted immunotherapy

OBJECTIVE

We sought to evaluate the safety and efficacy of TG4001 in patients with human papillomavirus (HPV) 16-related cervical intraepithelial neoplasia (CIN) 2/3 at 6 and 12 months.

STUDY DESIGN

In all, 21 patients with HPV 16-related CIN 2/3 received 3 weekly subcutaneous injections of TG4001. Regression of the CIN 2/3 lesion and the clearance of HPV 16 infection were monitored by cytology, colposcopy, and HPV DNA/messenger RNA (mRNA) detection. A clinical response was defined by no CIN 2/3 found on conization, or no conization performed because not suspected at cytology or colposcopy.

RESULTS

Ten patients (48%) were evaluated as clinical responders at month 6. Nine patients experienced an improvement of their HPV 16 infection, by mRNA ± DNA eradication. HPV 16 mRNA clearance was associated with CIN 2/3 cytologic and colposcopic regression in 7 of 10 patients. At month 12, 7 of 8 patients without conization reported neither suspicion of CIN 2/3 relapse nor HPV 16 infection. The remaining patient was lost to follow-up.

CONCLUSION

These promising data warrant further development of TG4001 in CIN 2/3 treatment.

Regression of high-grade cervical intraepithelial neoplasia with TG4001 targeted immunotherapy

OBJECTIVE

We sought to evaluate the safety and efficacy of TG4001 in patients with human papillomavirus (HPV) 16-related cervical intraepithelial neoplasia (CIN) 2/3 at 6 and 12 months.

STUDY DESIGN

In all, 21 patients with HPV 16-related CIN 2/3 received 3 weekly subcutaneous injections of TG4001. Regression of the CIN 2/3 lesion and the clearance of HPV 16 infection were monitored by cytology, colposcopy, and HPV DNA/messenger RNA (mRNA) detection. A clinical response was defined by no CIN 2/3 found on conization, or no conization performed because not suspected at cytology or colposcopy.

RESULTS

Ten patients (48%) were evaluated as clinical responders at month 6. Nine patients experienced an improvement of their HPV 16 infection, by mRNA ± DNA eradication. HPV 16 mRNA clearance was associated with CIN 2/3 cytologic and colposcopic regression in 7 of 10 patients. At month 12, 7 of 8 patients without conization reported neither suspicion of CIN 2/3 relapse nor HPV 16 infection. The remaining patient was lost to follow-up.

CONCLUSION

These promising data warrant further development of TG4001 in CIN 2/3 treatment.

Preoperative embolization or ligature of the uterine arteries in preparation for conservative uterine fibroma surgery

OBJECTIVE

To compare the efficacy, feasibility and morbidity of two preparation techniques for conservative uterine myoma surgery: temporary embolization and temporary surgical ligature of the uterine arteries.

DESIGN

Retrospective study.

SETTING

Gynecological Surgery and Interventional Radiology departments, Centre Hospitalier Universitaire of Dijon, France.

POPULATION

A total of 100 women undergoing myomectomy between 2000 and 2008.

METHODS

Three groups were constituted: (1) no preparation (43 patients), (2) uterine artery embolization (UAE) (30 patients) and (3) temporary surgical ligature of the uterine arteries (SLUA) (27 patients). The choice of technique depended on the number, size and topography of the fibromas.

MAIN OUTCOMES MEASURES

Quantification of peroperative blood loss, delta hemoglobin, complications, subsequent fertility.

RESULTS

Blood loss and delta hemoglobin were both lower in group 2 (p = 0.026 and p = 0.0002) and in group 3 (p = 0.048 and p = 0.001), respectively, than in group 1. The two preparation techniques were efficient. SLUA increased the duration of the operation (p < 0.0001). Hospitalization was longer following UAE (p = 0.0001). The rate of complications was 16.3, 23.3 and 3.7%, and of synechiae 9.3, 13.3 and 0% for groups 1, 2 and 3, respectively. The number of pregnancies was 8, 5 and 6 after a mean postoperative period of 5.6, 4.3 and 3.9 years, respectively.

CONCLUSION

Both UAE and SLUA for myomectomy are feasible, reproducible and effective techniques for reducing peroperative blood loss. Use of these techniques must be generalized in patients with a high risk of hemorrhage, but may be compatible with subsequent fertility.

[Spontaneous acute intussusception in a pregnant woman]

Acute intussusception in adults is rare and particularly so in pregnant women (between 1 / 5000 and 1 / 68,000 deliveries). It is a life-threatening condition for both the mother and the fetus. In adults, such intussusceptions are mainly secondary to an intestinal disease and frequently a tumour. We describe here a case of spontaneous intussusception during pregnancy and surgical management of the condition. We also analyse the causes specific to pregnancy.

Hamman's syndrome associated with pharyngeal rupture occurring during childbirth

Hamman's syndrome is the classical association of subcutaneous emphysema and pneumomediastinum, with or without pneumothorax. Its onset during the expulsive phase of childbirth is exceptional. We report here the first case associated with pharyngeal rupture at the level of the piriform sinus and describe the warning signs and the management by endoscopy.

[Cervical screening: toward a new paradigm?]

OBJECTIVES

Analysis of the trials which compare the virologic testing (HPV testing) and the cytology in the cervical screening.

MATERIAL AND METHODS

The MedLine database was consulted using the Keywords: "cervical screening", "pap smear", "liquid based cytology", "HPV testing", "adults", "adolescents", "cervical intraepithelial neoplasia (CIN)", "uterine cervix cancer". Articles were selected according their concern about the debate of the uterine cervix cancer screening in France.

RESULTS

The HPV testing seems interesting allowing a decreasing delay in the diagnosis of CIN (more diagnosis of CIN2+ in the first round and less during the second one). But, when the two rounds are added, the number of CIN2+ are identical in the two arms (cytology and HPV testing) in all the trials (except the Italian NTCC trial). A negative HPV testing protects the women much longer than cytology can do: a delay of five years between two rounds seems ideal. The HPV testing alone increases the detection rate of cervical lesions, which could regress spontaneously and may induce an overtreatment, especially in the youngest population: a triage is necessary and the cytology appears to be the best way to select the candidates for colposcopy in case of positive HPV testing and cytology. The HPV infection presents some particularities in adolescent females: for this reason, the HPV testing should not be used in this special population. In vaccinated women, a consensus for the screening is necessary.

CONCLUSION

The health care providers in France have to understand the characteristics of the HPV testing: its advantages compared to the cytologic screening are only evident in case of an organization of the screening in France and even in Europe.

Interest of uterine artery embolization with gelatin sponge particles prior to myomectomy for large and/or multiple fibroids

PURPOSE

To evaluate the efficacy of pre-myomectomy uterine artery embolization with gelatin sponge particles to reduce operative blood loss and facilitate removal of fibroids.

MATERIALS AND METHODS

This retrospective study included 33 women (mean age, 36 years; range, 24-45 years), of whom at least 18 wished to preserve fertility. They presented with at least one large myoma (mean diameter, 90 mm; range, 50-150 mm) and had undergone preoperative uterine artery embolization with resorbable gelatin sponge by unilateral femoral approach between December 2001 and November 2008. Clinical, radiological and surgical data were available for all patients. Mean haemoglobin levels before and after surgery were compared with Student's t-test.

RESULTS

No complication or technical failure of embolization occurred. The myomectomies were performed during laparotomy (25 cases) or laparoscopy (8 cases). Dissection of fibroids was easier (mean, 3 per patient; range, 1-11), with a mean operating time of 108±50 min (range, 30-260 min). Bloodless surgery was the rule with a mean estimated peroperative blood loss of 147±249 mL (range, 0-800 mL). Mean pre-(12.9±1.3g/dL) and post-therapeutic (11.4±1.2g/dL) haemoglobin levels were not statistically different (p>0.05). There was no need for blood transfusion. None of the patients required hysterectomy. The mean duration of hospital stay was 7.5±1.3 days (range, 3-12 days).

CONCLUSION

Preoperative uterine artery embolization is effective in reducing intraoperative blood loss and improves the chances of performing conservative surgery. It should be considered a useful adjunct to myomectomy in women at high hemorrhagic risk or who refuse blood transfusion.

Evaluation of pelvic posterior exenteration in the management of advanced-stage ovarian cancer

PURPOSE

The main aim of this study was to show the interest of pelvic posterior exenteration to obtain complete resection of the tumor in case of invasion of the rectum by contiguity in advanced-stage ovarian cancer. The secondary aim was to determine the morbidity of this surgery.

METHODS

It is a multicentric, retrospective study of a series of 41 patients, who underwent posterior pelvectomy for advanced-stage ovarian cancer, over a period of 18 years, from July 1989 to July 2007.

RESULTS

The surgery resulted in macroscopically complete resection in 19 patients (46.34%), a residual tumor <2 cm in 19 patients (46.34%) and >2 cm in 3 patients (7.32%). In 34 patients (34/41), digestive continuity with satisfactory anal sphincter function was restored immediately or in the short term. The mean delay to the start of complementary treatment was 36 days. Median overall survival was 33 months.

CONCLUSION

The main aim of surgery for ovarian peritoneal carcinomatosis is to obtain a complete resection. In the case of direct invasion of the rectum by contiguity, when there is no cleavage plane between the uterus and the rectum, pelvic posterior exenteration is an effective method to achieve this objective. Morbidity is relatively high, but acceptable given the poor prognosis of this disease, the improved survival after surgery, and improvements in post-operative quality of life and functions.

[Uterine artery embolization with resorbable material prior to myomectomy]

PURPOSE

Fibroids are a frequent cause of gynecology referral. Myomectomy is a conservative treatment alternative. The main risk from this procedure is hemorrhage. The main objective of this study was to demonstrate the efficacy of preoperative uterine artery embolization with resorbable agents to reduce blood losses and facilitate myomectomy. Secondary objectives were to evaluate morbidity and subsequent fertility.

PATIENTS AND METHODS

Retrospective study of 21 patients with preoperative uterine artery embolization prior to myomectomy at the University Medical Center of Dijon over a 3 year period.

RESULTS

Myomectomy after uterine artery embolization with resorbable agents was associated with only minimal blood loss. Mean preoperative and postoperative hemoglobin levels were comparable (p<0.0001). Uterine suturing was technically simpler. The number of resected fibroids (p=0.2824) and the presence of preoperative anemia (p=0.474) had no statistically significant impact on the duration of hospital stay. Uterine synechiae occurred in three patients after the procedure, and were easily treated. Two patients had normal subsequent pregnancies.

CONCLUSION

Preoperative uterine artery embolization with resorbable agents was effective in reducing surgical blood losses. This technique reduces the number of hysterectomies and hemorrhagic complications (hematoma, infection, weaker scar tissue). It should be considered in patients wishing uterine preservation when the hemorrhagic risk is high. Its use in patients seeking subsequent pregnancy should be further assessed with larger series.

Vascular complication after insertion of a subcutaneous contraceptive implant

Implanon is a reliable method of contraception widely used in France and around the world. Cases of difficulties encountered in inserting or removing the implant have been described. We report the first case of an insertion accident that led to occlusion of the right brachial artery and required exploratory vascular surgery.

Prise en charge d’une néoplasie intra-épithéliale du col de l’utérus en cours de grossesse

Approximately 30% of women diagnosed with cervical cancer are in their childbearing years. Prenatal care provides an excellent opportunity for cervical cancer screening. The incidence of abnormal Pap smear has been reported in 5-8% of pregnant women. But we must know that Pap smears have cytologic modifications because of pregnancy. All abnormal smears have to be referred to colposcopic examination. The squamocolumnar junction is visualized in almost 100% of cases. The sensitivity of colposcopy is nearly 87% with complete concordance in 72.6%. Colposcopically directed biopsies have a good correlation with the final diagnosis with very minimal risks for both mother and fetus. The high rate of complications (hemorrhage, abortion, premature labor) and residual lesions in half of cases do not encourage conization during pregnancy. The final treatment is carried out after delivery. The only absolute indication for conization in pregnancy is to rule out microinvasive disease or make the diagnosis of invasive carcinoma when such a diagnosis will alter the timing of delivery but also when there is a no satisfactory colposcopy and a high-grade Pap smear. In these cases conization is performed for diagnostic and not therapeutic purpose. We must be aware of the high rate of loss of follow-up (6-33%).

[Voluntary interruption of pregnancy: comparative study between 1982 and 1996 in the main center of Côte d'Or. Study of women having repeat voluntary interruption of pregnancy]

Since the egal use of induced abortion (1975), all the studies have shown a relative stability of the abortion rate related to delivery. Otherwise since 1985 we have noted an increase of repeat abortions.

OBJECTIVE

We compared in same center two populations of aborters with a fifteen year's interval. Then we analysed the psyco-social conditions of patients who had more than one abortion (R).

METHODS

It was a comparative study between 1982 and 1996 in the main center of Côte d'Or (France). A representative sample of patients coming for abortion was retrospectively compared, (348 for 1982 and 343 for 1996).

RESULTS

There were more not married patients (p = 0.0003), more nulliparous women (p = 0.0017) and more nulligestities' one (p = 0.03) in 1996 than 1982. The interval between the previous pregnancy and in 1996 (p = 0.03). Repeat abortions (R) represented 15.8% in 1982 and 21.6% in 1996. Women who have had two or more abortions had increased significantly between 1982 (1.4%) and 1996 (5.2%) (p = 0.013). The R patients had more living children than patients who accessed for the first time at abortion (noR) in the two periods (p = 0.0003) and there were more women less thirty years old in the R group in 1996 than in 1992 (p < 0.05). The R mean age for the first abortion and for the first pregnancy were lower than the noR group in 1996: respectively 23.7 years versus 27.4% years (p = 0.00009) and 20.8 years versus 23.7 years (p = 0.0001). There were no significant difference between R and noR groups with regards of contraceptive failing, the reasons of abortion and the socio-professional categories.

CONCLUSIONS

There were no difference in the number of abortion between 1982 and 1996. However we noted an increase of repeat abortion. This group was characterised by great socio-economic problems, unstable couples and ambivalence with wish of pregnancy and no wish of children. It seemed exist a real psycho-social precariousness. Actually, this population was perfectly aware of contraceptive methods.

Pre-clinical study of the epinephrine-cisplatin association for the treatment of intraperitoneal carcinomatosis

We have previously shown that intraperitoneal (i.p.) epinephrine enhances tumour penetration and anti-cancer activity of i.p.-administered cisplatin in rats with peritoneal carcinomatosis. Here, we show a direct correlation between the i.p. epinephrine concentration and cisplatin accumulation in rat peritoneal tumour nodules up to a concentration of 5 mg/l. This concentration leads to a maximal 3.7-fold increase of tumour platinum content and a maximal vasoconstriction of the peritoneal and tumour superficial microcirculation when registered by a laser doppler probe. Further, epinephrine half-life was 20.8+/-3.6 min in the peritoneal cavity of two laparotomized pigs. In these animals, epinephrine plasma concentration, heart rate and systolic blood pressure were dependent on the intraperitoneal dose of epinephrine, and life-threatening signs were not observed in either animal. In conclusion, a 5 mg/l concentration of epinephrine could be safely maintained in peritoneal fluid by regular replacement. This concentration is sufficient to maintain a constant vasoconstriction of the peritoneal and tumoral microvascular bed, and enhance the slow diffusion of cisplatin into peritoneal tumour nodules in the course of per-operative intraperitoneal chemotherapy.

Transabdominal amnioinfusion to avoid fetal demise and intestinal damage in fetuses with gastroschisis and severe oligohydramnios

BACKGROUND/PURPOSE

Despite dramatic improvement in survival rate for neonates with gastroschisis, significant postoperative morbidity and a low mortality rate still occur. Furthermore, even in recent publications, some fetal death has been reported. Does this mean that antenatal diagnosis of gastroschisis is a missed opportunity? In fact, decreased amniotic fluid (AF) volume is observed in some fetuses with gastroschisis. However, oligohydramnios is associated with an increased risk of fetal suffering. When severe oligohydramnios is observed, intrapartum amnioinfusion, to restore AF volume, may help avoid fetal complications.

METHODS

Two fetuses with gastroschisis and severe oligohydramnios were treated antenatally with amnioinfusion of saline solution. In one case, fetal heart beat decelerations were observed at 27 weeks' gestation among with the oligohydroamnios and serial transabdominal amnioinfusions were performed. In the second case, severe oligohydramnios was observed at 31, weeks and an amnioinfusion was performed. The 2 babies were delivered at 31 and 34 weeks, respectively.

RESULTS

In both cases, exteriorized bowel was nearly normal at birth, and primary closure could be performed. Outcome was favorable, and they were discharged home on day 43 and day 54, respectively.

CONCLUSIONS

Because fetuses with gastroschisis and oligohydramnios are part of a particular high-risk group, serial ultrasound examination and computerized fetal heart beat monitoring are necessary during the third trimester. In selected cases of gastroschisis associated with severe oligohydramnios, serial amnioinfusion may be required.

Severe fetal cytomegalic inclusion disease after documented maternal reactivation of cytomegalovirus infection during pregnancy

Recurrent cytomegalovirus infection during pregnancy is considered less dangerous for the fetus than primary infection. We present a case of severe fetal cytomegalic inclusion disease after maternal reactivation of cytomegalovirus during the first trimester of pregnancy. The possibility of such fetal injury is an argument for prenatal diagnosis in seropositive pregnant women when ultrasonographic findings suggest cytomegalovirus infection.

[What are the current limits for prematurity?]

HIGH PREVALENCE: Over the last 15 years, there has been a 2-fold rise in the prevalence of early prematurity (birth before 33 weeks gestation) and very early prematurity (birth between 22 and 28 weeks gestation). More than 7000 infants weighing between 500 g and 1500 g are born alive each year. Survival rates above 50% at 25 weeks, 86% at 29 weeks and 96% at 32 weeks are reported. These infants have the same right to adapted care as any other person. Nevertheless, maternal risks and the fact that these early and very early premature infants account for less than 1% of all births and yet include 50% of all neonatal deaths and 50% of all sequelae. A multidisciplinary approach is crucial for women with a high risk of delivery before 27 weeks gestation.

ASSESSING PROGNOSIS

These infants comprise a very heterogeneous group of patients. Their survival and prognosis depends on many different factors. Antenatal factors include gestational age, estimated fetal weight, presence or not of malformations or fetal hypotrophy, and premature rupture of the membranes. During the perinatal period, antenatal corticosteroid therapy, pre-birth referral to a maternity ward with a pediatric intensive care unit, and care and degree of baro-trauma at delivery are essential. The neonatal assessment may lead to discontinuing treatment in case of extensive neurological damage.

OPTIMAL CARE

With optimal care, achieved with an organized perinatal network using well-defined criteria for maternal referral, it should be possible to save 650 more children each year and reduce the number of severe handicaps by 390 among infants born before 33 weeks gestation.

PREVENTION

Considerable progress has been made in perinatology, but simple and effective preventive measures must not be overlooked: reduction in the number of multiple pregnancies, detection of socio-demographic risk factors, treatment of asymptomatic bacteriuria, early diagnosis of threatening premature birth.

Chorioamnionitis with intact membranes caused by Capnocytophaga sputigena

We report a case of chorioamnionitis with intact membranes caused by Capnocytophaga sputigena. The pregnant woman was hospitalised in preterm labor without fever, neither tenderness, just regular contractions. In spite of the tocolitic treatment the patient gave birth to a girl at 29 weeks' gestation, weighing 1220 g and transferred to intensive care. The newborn had clinical and biological signs of infections and was initially treated by Ampicillin, cephalosporin and metronidazol. Capnocytophaga sputigena was found on membranes, cord, amniotic fluid and placenta. It was also identified in maternal endocervix culture. Histologic findings showed a focal chorioamnionitis. This was the fourteenth reported case of infection due to Capnocytophaga species occurring in pregnancy. All the cases are reviewed.

Preoperative radiotherapy and surgery for endometrial carcinoma: prognostic significance of the sterilization of the specimen

INTRODUCTION

We report a retrospective study on the analysis of the operative specimen after preoperative radiotherapy for FIGO (1971) stage I or II endometrial carcinoma.

METHODS AND MATERIALS

From 1976 to 1996, 221 patients were treated with external radiotherapy (XRT) and/or low-dose-rate brachytherapy (BT) followed by surgery (S). Patients with cervical involvement (89 patients) or with high-grade tumors (49 patients) received XRT and BT. Patients stage FIGO Ia (89 patients) or with low-grade tumors (57 patients) received BT alone. Surgery was performed 5 to 6 weeks after irradiation.

RESULTS

The mean follow-up is 78 months (12-216). The 5-year survival was 90% for FIGO Ia, 80% for FIGO Ib, and 84% for FIGO II (p = 0.51). According to the differentiation, 5-year survival was 87% for grade 1, 84% for grade 2, 84% for grade 3 (p = 0.10). Grade 3 complications were registered in 2% (no grade 4). The tumors were sterilized in 37 patients (17%), sterilized but with dystrophic glands in 34 patients (16%), only modified and altered in 21 patients (9.5%), with viable cells in 56 patients (26%). After preoperative radiotherapy, 37/148 specimens were sterilized (25%), 14/74 after brachytherapy and surgery (19%), 23/74 after external radiotherapy-brachytherapy and surgery (31%). According to the response of the specimen, 5-year survival was 87% when the tumor was sterilized, 96% when altered glands were present, 85% when modified, and 76% if residual tumor with viable cells was identified (p = 0.043).

CONCLUSION

Preoperative radiotherapy followed by surgery is a safe and effective treatment of FIGO stage I or II endometrial carcinomas. BT with two uterine tubes seems to be of interest in the contribution of the treatment of the uterus to sterilize the specimen. The analysis of this new prognostic factor remains important to select a population with worst prognosis.

Preoperative radiotherapy in stage I/II endometrial adenocarcinoma

From 1972 to 1993, 170 patients received preoperative radiotherapy followed, 5-6 weeks later, by total extrafascial hysterectomy with bilateral salpingo-oophorectomy without lymphadenectomy. Eighty-three patients with good prognostic factors (low grade tumour and no cervical involvement) received low dose rate utero vaginal brachytherapy alone before surgery (Group 1). Eighty-seven patients with poor prognostic factors (high grade tumors and/or cervical involvement) received external radiotherapy to 40 Gy and low dose rate brachytherapy before surgery (Group 2). A single vaginal failure was observed (0.6%). The overall pelvic failure rate was 2.3% (four patients) including two cases with pelvic recurrence and metastases. Three of the four pelvic failures occurred in Group 1. Using the 1971 FIGO clinical staging, 5-year disease-free survival was 82% in Stage Ia, 79% in Stage Ib, and 81% in Stage II (P = 0.36). Five-year disease-free survival was 86% in Grade 1, 76% in Grade 2, and 83% in Grade 3 (P = 0.20). Five-year overall survival was 83% in Stage Ia, 79% in Stage Ib, and 83% in Stage II (P = 0.78). Five-year overall survival was 88% in Grade 1, 77% in Grade 2,83% in Grade 3 (P = 0.27). Complications were recorded with the French-Italian syllabus. Grade 2 complications occurred in 12 cases (7%), Grade 3 in five cases (3%). The lack of correlation between classical risk factors (stage, grade) and disease outcome suggests that preoperative radiotherapy strategies should be preferred when such factors can be identified before surgery.

[Chlamydia trachomatis infection: risk factors]

Genital Chlamydia Trachomatis (CT) infections are the most common cause of tubal infertility. Its prevalence is variable between the authors, but seems to be more frequent in the young population.

OBJECTIVE

Evaluate the CT genital infection rate in a population consulting either in a sexually transmitted disease center (STD) or in a family planning unit (FPU). --Judge the interest of a routine screening, and by which technic. --Estimate the information level of population about STD and their prevention.

METHODS

270 men and 331 women were detected by uretral or endocervix sample with an immunofluorescence method (Syva Microtrack). CT serology were also realised.

RESULTS

18.5% of man samples, 20% of woman samples in the STD center and 17.9% of woman samples in the FPU were positive for CT. There is a strong correlation between CT positivity and cervical discharge or cervicitis (RR = 4.64, p < 0.01). Serology was positive in 45.5%, 32.5% and 21.2% respectively for STD center's men, STD center's women and PFU's women. The correlation between samples and serology was 62%. Positive samples were more frequent in the 15-30 years old population and positive serology in the over 30 years old population (RR = 3.57, p < 0.01). There is a correlation between CT positive samples and nulliparity, multiple sexual partner and history of genital infection.

CONCLUSION

The high prevalence of CT genital infection observed in our centers justify a routine screening especially in the young population.

[Intrepretation of elevated transaminase levels in a pregnancy after a liver transplantation]

A young woman became pregnant 36 months after a liver transplant following an episode of fulminant hepatitis A. At 38 weeks gestation, she delivered by cesarean section following an isolated and moderate elevation of her transaminase enzymes, indicating rejection of the graft. This was later confirmed by liver biopsy. Following augmentation of steroid therapy her postnatal progress was good. The infant progressed quite well. This case raises the question of the management of pregnant women following liver transplantation, with elevated transaminase levels.

Detection and identification of human papillomavirus DNA in genital tract by digoxigenin labelling using the polymerase chain reaction method

We propose here a simple and rapid method of Human Papillomavirus (HPV) detection applied to genital samples. The method consists of a polymerase chain reaction (PCR) of samples using a consensus primer ser (Snijders et al., 1990) with labelling by Dig-dUTP (Digoxigenin deoxyuridine triphosphate) during amplification. Type identification was carried out by hybridization of the labelling PCR product with a panel of different plasmidic HPVs dotted beforehand on nylon membranes. Forty-five genital samples were tested with this method (30 samples with evident signs of HPV infection, and 15 cervical scrapes which had a normal colposcopic examination and no cytologic signs of HPV infection). We found good sensitivity and specificity levels. The labelling method during PCR did not modify the sensitivity of PCR. Forty-five genital samples were analyzed by this technique and compared with the results of dot-blot and two PCR methods using different primers. They showed a good correlation except in four samples (high grade cervical lesions) which seemed to show a partial deletion or rearrangement. Our method, used for the first time in HPV detection, needed just one PCR and one dot-blot, thus saving an important amount of time and also decreasing examination costs.