Epidemiological, clinical, virological features of hepatitis B newly diagnosed in 2011 in Marseille University hospitals, southeastern France.

Hepatitis B virus (HBV) infection is a public health problem. In France, 0.68% of adults are chronically infected. We aimed to describe the epidemiological, virological and clinical characteristics of HBV infections newly diagnosed in 2011 in University hospitals of Marseille, the second largest French city. HBV serology was performed for 18,130 sera from 15,744 patients. A total of 167 patients were newly-diagnosed with HBV based upon the detection of hepatitis B surface antigen and anti-hepatitis B core antibodies. Clinico-epidemiological features were analyzed for 78 patients. Patients included a majority of men (59%), women being significantly younger with a mean age of 36 ± 17 versus 43.5 ± 16.2 years (P = 0.009). Country of birth was available for 52 patients and 35% of them originated from sub-Saharan Africa. Levels of the liver biological parameters were significantly lower in women compared to men, in whom mean alanine aminotransferase and gammaglutamyl transferase levels were 24 ± 39 versus 37 ± 36 IU/l (P = 0.0001) and 20 ± 20 versus 51 ± 53 IU/l (P = 0.0001), respectively. Co-infections with hepatitis C and human immunodeficiency viruses were found in 5% and 6% of the patients, respectively. HBV DNA was detectable in 90% of the HBeAg-negative patients. In addition, there was a positive correlation between the HBsAg titer and the HBV DNA level (P = 0.001). Genotype D was the most common HBV genotype and was found in 53% of the patients tested, followed by genotype E (21%). HBV remains a major concern with a slightly greater number of new diagnoses than in 2004. HBV genetic diversity was substantial in the present cohort.

Assessing the HLA diversity of cord blood units collected from a birth clinic caring for pregnant women in an ethnically diverse metropolitan area.

BACKGROUND: New strategies are emerging in cord blood banking where focusing on birth clinics caring for a high number of mothers belonging to ethnic minorities could offer new possibilities for allotransplantation both for patients of European origin and for patients from ethnic minorities or mixed ancestries. STUDY DESIGN AND METHODS: Marseilles Cord Blood Bank works with one university birth clinic caring for a culturally and sociologically diverse population. Stringent French legal restrictions apply to recording the geographic origin of parents. To circumvent this limitation and evaluate the contribution of newly banked cord blood units (CBUs) to increasing HLA diversity, we applied an algorithm that allows for the determination of parents' putative haplotypes and thus grossly deduce information on their ancestry. Generic resolution HLA-A, HLA-B, and allelic resolution HLA-DRB1 genotyping for 328 CBUs and 2691 unrelated donors (UDs) between January 2009 and May 2012 were performed. Enrichment from international CBU registry with nonreferenced generic HLA-A, HLA-B, and allelic HLA-DRB1 phenotypes was compared between CBUs identified with one or two non-European haplotypes and CBUs identified with two European haplotypes. RESULTS: Marseilles CBUs display an increased proportion of HLA antigens frequently expressed in African populations compared to UDs. Whereas 93% of 199 CBUs identified with one or two non-European haplotypes enrich international CBU registry, this result is reduced to 42% for the 129 CBUs identified with two European haplotypes. CONCLUSION: This study supports a new method to assess HLA diversity. However, such an increased of HLA diversity raises questions about frequencies of CBUs released and clinical relevance from their uses.

Does the experience of the provider affect pregnancy rates after embryo transfer?

OBJECTIVE: To study the influence of provider experience in a university hospital where resident physicians need to learn how to perform embryo transfer (ET). STUDY DESIGN: A cohort prospective study was conducted in a tertiary care university medical center between March 2008 and August 2009. A total of 443 women undergoing fresh ET after in vitro fertilization were studied. ET with Frydman catheter or tight difficult transfer (TDT), conducted by three groups of providers of varying experience were studied: attending physicians with > 20 years of experience, assistant physicians with 2-5 years of experience and resident physicians with < 6 months of experience. The main outcomes were clinical pregnancy and implantation rates. RESULTS: The provider's experience had an impact on the pregnancy rate: 29.9% for attending physicians, 28.2% for assistant physicians and 19.1% for resident physicians (p < 0.05). Resident physicians used TDT catheter more often than attending physicians: 42% vs. 21.3% (p < 0.05). CONCLUSION: Resident physicians must be better monitored to avoid the lower pregnancy rates. ET should be further standardized. In this study, the ET protocol was modified in our assisted reproductive technology unit.

Congenital lung malformation: evaluation of prenatal and postnatal radiological findings.

BACKGROUND AND OBJECTIVE: This study evaluated the accuracy of prenatal MRI and postnatal CT imaging in the identification of congenital cystic adenomatoid malformation and bronchopulmonary sequestration by comparison with histological analysis. METHODS: Over a 3-year period, 15 patients with lung malformations diagnosed prenatally by ultrasound were referred for prenatal MRI, and all were investigated postnatally by chest CT. All asymptomatic newborns with unresolved lesions underwent elective surgery by thoracoscopy. All surgical specimens were analysed histologically. RESULTS: Among the 15 patients with an abnormality diagnosed by ultrasound, prenatal MRI findings differed from the final histological diagnosis with respect to extent (n = 3), type of lesion (n = 1) and aberrant vessel identification (n = 4). Postnatal chest CT failed to visualize the aberrant vessel in one patient. Complete regression of the lesion was noted in two patients with bronchopulmonary sequestration, and in one patient with congenital cystic adenomatoid malformation and was confirmed by CT. Elective thoracoscopic lobectomy of the affected lobe was performed for 12 patients. Two conversions to thoracotomy were required. All operated patients had an uneventful hospital course. CONCLUSIONS: Prenatal MRI is less accurate than postnatal CT scan, which remains the most reliable diagnostic modality to specify the location and extent and kind of lesions.

Comparison of ropivacaine and lidocaine for paracervical block during surgical abortion.

BACKGROUND: The study was conducted to compare the effectiveness of ropivacaine and lidocaine as paracervical analgesia for elective abortion by vacuum aspiration. STUDY DESIGN: This single-center double-blinded randomized study tested two different agents for paracervical analgesia in elective abortions: lidocaine (n=57) or ropivacaine (n=57). We assessed intra- and postoperative pain according to both a visual analogical scale rated from 0 to 10 and postoperative analgesic requirements. RESULTS: Mean intraoperative pain was significantly lower in the ropivacaine group (5.23+/-2.72 vs. 4.18+/-2.77, p=.048.). There was no significant difference in mean assessed pain at the end of the intervention or at 2 or 4 h afterward. The rate of subjects requiring additional postoperative analgesia did not differ significantly between the lidocaine and ropivacaine groups [8/59 (13.5%) vs. 6/59 (10.1%), p=.33]. DISCUSSION: Intraoperative pain appears to be less with ropivacaine than with lidocaine. Nonetheless, the clinical difference was slight, as was therefore the benefit of using ropivacaine for paracervical block in elective abortions.

Development and validation of a nomogram to predict the risk of cesarean delivery in macrosomia.

OBJECTIVE: To develop and validate a nomogram that predicts individual probability of cesarean delivery in cases of macrosomia (>4,000 g). METHODS: The nomogram was built based on the data from 246 patients who delivered macrosomic infants at Conception Hospital (Marseille, France), and was validated on an external population of 206 patients. Logistic regression was used to construct a model to predict the probability of cesarean section. The calculations were based on actual birth weight. MAIN OUTCOME MEASURES: The accuracy of the model was evaluated by area under the receiver operator curve. RESULTS: In the multivariate analysis performed on the training set, maternal age (p=0.002), parity (p=0.003), and maternal height <1.65 m (p=0.01) were found to be significantly associated with the occurrence of cesarean delivery and included in the nomogram. The final variables included in the nomogram were: age (p=0.01), maternal height (p=0.02), parity (p<0.001), and previous cesarean section (p=0.009). Area under the ROCs was 0.80 and 0.78 in the training set before and after bootstrapping, respectively, and 0.88 in the validation set. The calibration of the nomogram was good. CONCLUSION: We have developed a nomogram based on actual birth weight that accurately predicts the risk of cesarean delivery in cases of macrosomia. This tool might be useful for decision-making.

Management of placenta accreta: morbidity and outcome.

OBJECTIVE: The aim of the study was to evaluate our results in the management of placenta accreta. STUDY DESIGN: In a retrospective study we reviewed cases of placenta accreta diagnosed in two university teaching hospitals between 1993 and 2003. For a subgroup of patients a conservative approach was attempted. In this procedure placenta was left in place until spontaneous resorption. RESULTS: Fifty cases (0.12%) of placenta accreta were observed in 41, 119 deliveries during the study period. Of the 50 cases, 24 patients (48%) were managed by the standard approach and 26 patients (52%) underwent conservative treatment. Additional surgical or medical treatment was performed in 35 of the 50 patients (70%). There was no maternal death. Overall hysterectomy rate was 40%, 10 patients were transferred to intensive care unit (20%), 7 had fever (14%), 5 had endometritis (10%) and 19 patients had blood transfusion (38%). Conservative treatment did not lead to hysterectomy in 21 cases (80.7%) and failed in 5 (19.3%). During the follow-up period, 3 women had successful pregnancy. CONCLUSION: Analysis of management of placenta accreta shows that for a subgroup of selected patients a conservative approach could preserve subsequent fertility without evident increase in morbidity.

Termination of pregnancy in patients with previous cesarean section.

OBJECTIVE: To evaluate the safety and efficacy of termination of pregnancy using mifepristone and misosprostol at more than 15 weeks' gestation in patients with uterine scar due to previous cesarean section. MATERIALS AND METHODS: This retrospective study was conducted in a tertiary maternity ward between January 2000 and October 2004. A total of 252 women at more than 15 weeks' gestation underwent termination of pregnancy including 50 women with uterine scar due to previous cesarean section (Group 1) and 202 control patients (Group 2) without known uterine scar. Abortion was induced with mifepristone and a prostaglandin analogue. Women between 15 and 34 weeks' gestation received misoprostol intravaginally every 3 h at doses of 200 microg (Group 1) or 400 microg (Group 2). Women at more than 34 weeks' gestation received Prostin E2 vaginal gel. Main end points were hemorrhage, fever, retained placenta, occurrence of complications including uterine rupture and dehiscence, and final outcome. RESULTS: A total of 13 (26%) patients in Group 1 and 79 (39.1%) in Group 2 were at more than 24 weeks' gestation. The abortion failure rate was 2% (1/50) in Group 1 and 0.5% (1/202) in Group 2 (p = .28). The median induction-to-delivery interval was 8.5 h (range, 3.0-114.2 h) for Group 1 and 9.0 h (range, 1.3-124.3 h) in Group 2 (p = .26). One case of uterine rupture and one case of dehiscence were observed, both in women in Group 1. The incidence of hemorrhage was not significantly different between Group 1 and Group 2 (2% vs. 0.9%, respectively, p = .56). The incidence of retained placenta was higher in the Group 1 (70% vs. 52.5%, respectively, p = .025). CONCLUSION: In this retrospective series of women who underwent abortion at 15-35 weeks' gestation using mifepristone and a prostaglandin analogue for labor induction abortion, history of cesarean section was not associated with higher morbidity except risk of uterine rupture. However, dose and interval of misoprostol should be determined. A larger study is needed before drawing definitive conclusions about the safety of these regimens.

Maternal morbidity associated with obstetrical maneuvers in shoulder dystocia.

OBJECTIVES: To determine whether shoulder dystocia and obstetrical maneuvers used for its relief have detrimental effects on perineum or immediate postpartum outcome. DESIGN: Case-control study. SETTING: Tertiary maternity ward in Marseille, France. POPULATION: A total 140 cases with shoulder dystocia and 280 controls without shoulder dystocia were enrolled by reviewing charts for the period between January 1999 and December 2004. METHODS: Demographic data including obstetrical history, age, height, weight before pregnancy and at the time of delivery, and respective body mass index (BMI) and obstetrical data including analgesic technique, duration of first and second stage of labor were compared in function of outcome and of the type and number of maneuvers used to relieve shoulder dystocia. RESULTS: Resolving shoulder dystocia required one obstetrical maneuver in 41 cases (29.3%) and two obstetrical maneuvers in 48 cases (34.3%). Third-degree tears occurred in one patient in the case group versus five in the control group. No correlation was found between the number of obstetrical maneuvers needed to relieve shoulder dystocia and risk for third-degree tear (OR: 0.8; 95% CI: 0.1-7.6). Mean hemoglobin values were 96.1 g/l in the case group and 96.0 g/l in the control group (p=0.95). There was no difference between the two groups regarding duration of postpartum hospitalization. The incidence of urinary incontinence was similar in the group that underwent obstetrical maneuvers: 4.7% (6/127) and in the control group: 3.7% (13/352). Only two patients reported de novo anal symptoms, both in the control group. CONCLUSION: Shoulder dystocia and obstetrical techniques used for its relief did not result in adverse maternal outcome.

Maternal factors influencing the decision to breastfeed newborns conceived with IVF.

OBJECTIVES: The breastfeeding initiation rate is extremely disparate worldwide and remains low in France, with a breastfeeding initiation rate of 60.2%. Some studies have reported increased early parenting difficulties in women who conceived with in vitro fertilization (IVF). Our study had two main objectives: (1) to determine by a retrospective chart review the demographic and medical factors associated with breastfeeding versus formula feeding in women who had undergone IVF and (2) to assess by survey study the reasons for the infant feeding decision (breastfeeding versus formula feeding) for women who conceived by IVF. SUBJECTS AND METHODS: By telephone interviews, we conducted a longitudinal nonexperimental cohort study of French women who had a live birth after IVF. Fertility data and obstetric outcomes were collected from individual medical records. RESULTS: Among women who had a live birth after IVF (n=73), 63% (n=46) initiated breastfeeding for a mean duration of 6.2±6.2 months. In our IVF population, the breastfeeding initiation rate was similar to that in the general French population. The following three factors were found to have a significant negative influence on breastfeeding initiation: duration of infertility greater than 2 years, cesarean delivery, and history of formula feeding when the women themselves were newborns. CONCLUSIONS: Long duration of infertility and history of cesarean delivery after IVF negatively influenced the breastfeeding initiation rate. For this subgroup of patients, postpartum care should be enhanced to support the early mother-baby relationship and promote breastfeeding.

Ethical dilemmas in extreme prematurity: recent answers; more questions.

Advances in perinatal care allow survival of more extremely premature infants, but the implementation and continuation of intensive care may itself constitute an ethical dilemma, given the limited chances of intact survival among the patients most at risk. This paper discusses several key issues raised by the options that are under general consideration with reference to births of infants at the threshold of viability, in particular: the implications of making a distinction between extreme prematurity and other general medical situations that may involve decisions on ending support; the concrete nature of the restrictions on therapy in such patients interactions and the need for feedback between parents, medical staff and society.

Spontaneous rupture of a first-trimester gravid uterus in a woman exposed to diethylstilbestrol in utero. A case report.

BACKGROUND: Poor reproductive outcome was well documented in several studies of women exposed to diethylstilbestrol in utero. Spontaneous rupture of an unscarred uterus is rare and very uncommon in the first trimester of pregnancy. CASE: Spontaneous rupture of the uterus was diagnosed in a 28-year-old nullipara who developed acute abdominal pain at 12 weeks' gestation. She was known to have been exposed to diethylstilbestrol in utero. Laparotomy revealed the rupture in the anterior fundal area of the uterus. Both tubes were normal. CONCLUSION: Several spontaneous ruptures have been described, but this is the first case of first-trimester spontaneous rupture of an unscarred uterus in a diethylstilbestrol-exposed woman.

Respiratory distress syndrome after elective caesarean section in near term infants: a 5-year cohort study.

OBJECTIVE: to assess the incidence of respiratory distress syndrome (RDS) in late preterm (34(0/7)-36(6/7)) and just term (37(0/7)-37(6/7)) infants born via elective caesarean section (CS) in a tertiary care maternity facility. METHODS: retrospective cohort study between 2005 and 2009. Hundred and eighty-eight near term infants, divided in two groups: group A: 125 late preterm (34(0/7)-36(6/7)) and group B: 63 just term (37(0/7)-37(6/7)), from elective CS (except CS after pre-mature rupture of membranes and foetuses presenting congenital malformation) were included. RESULTS: In group A the overall incidence of RDS (RDS at or shortly after birth, requiring respiratory support or oxygen therapy) was 44% (n = 55) vs. 15.9% (n = 10) in group B (p < 0.01). The incidence of SRDS (requiring admission in the neonatal intensive care unit (NICU)) in group A was 13.6% (n = 17) and 3.2% (n = 2) group B (p < 0.01). The risk decreased significantly as gestational age (GA) increased: for RDS, 50.9% at 34 weeks of gestation (WG), 52.5% at 35 WG, 21.5% at 36 WG, and 15.9% at 37 WG; for admission, 30.2% at 34 WG, 25% at 35 WG, 9.4% at 36 WG, and 6.3% at 37 WG. Among late preterm infants with RDS, 30.9% (n = 17) developed severe RDS (SRDS). CONCLUSIONS: Late preterm infants born via elective CS are at high risk for RDS and NICU admission. The risk is influenced by each additional week spent in utero. As the incidence of CS is increasing within this population, new preventative strategies must be sought.

Impact of reduced-intensity conditioning allogeneic stem cell transplantation on women's fertility.

INTRODUCTION: Available data on women fertility for younger patients treated using RIC Allo-SCT are still limited. We evaluated ovarian function and fertility among female patients younger than 35 years who received RIC Allo-SCT for hematological malignancy or aplastic anemia (AA). PATIENTS AND METHODS: Information on therapies before RIC Allo-SCT were collected. Data on ovarian function and fertility evaluation after RIC Allo-SCT included clinical and biological criteria. Twenty-two patients were evaluated. RESULTS: After RIC Allo-SCT, amenorrhea affects 68.1% of patients. Ovarian function was impaired for 86.3% of cases. All 3 AA patients have regular cycles and became pregnant after RIC Allo-SCT. Only 6 (27.2%) patients declared to have been correctly informed before RIC Allo-SCT on potential deleterious effects on fertility of anticancer treatment and only 36.8% of patients with ovarian failure had a hormonal supplementation. CONCLUSION: Results showed a high rate of ovarian failure, evaluated by clinical and biological criteria. The difference between AA and malignant diseases might suggest that a potential deleterious role was played by previous anticancer treatments rather than by RIC Allo-SCT.

Evolution of congenital malformations of the umbilical-portal-hepatic venous system.

OBJECTIVE: The objective of this study is to describe the evolution of 8 cases of congenital malformations of the umbilical-portal-hepatic venous system diagnosed before the first month of life. MATERIALS AND METHODS: All cases of congenital malformation of the portal and hepatic venous system diagnosed prenatally or during the first month of life in our institution were systematically reviewed since November 2000. Clinical features, imaging, and anatomical findings were reviewed, focusing primarily on clinical and radiologic evolution. RESULTS: Eight cases of congenital malformation of the umbilical-portal-hepatic venous system were studied. Fifty percent of these malformations were diagnosed prenatally. We report 4 portosystemic shunts. Three involuted spontaneously, and the fourth one required surgical treatment. We report a variation of the usual anatomy of portal and hepatic veins that remained asymptomatic, an aneurysmal dilatation of a vitelline vein causing portal vein thrombosis that needed prompt surgical treatment with good result, a complex portal and hepatic venous malformation treated operatively, and a persistent right umbilical vein that remained asymptomatic. CONCLUSION: Prenatal diagnosis of malformations of the umbilical-portal-hepatic venous network is uncommon. Little is known about the postnatal prognosis. Clinical, biologic, and radiologic follow-up by ultrasonography is essential to distinguish pathologic situations from normal anatomical variants.