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.

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.

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.

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.

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.

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.

Salpingectomy for ectopic pregnancy by transumbilical single-site laparoscopy with the SILS system.

OBJECTIVE: To evaluate the feasibility in everyday practice and the advantages of salpingectomy for ectopic pregnancy by single-incision laparoscopic surgery with the SILS system. STUDY DESIGN: This single-center prospective observational study included 37 women requiring salpingectomy for ectopic pregnancy who underwent single-incision laparoscopic salpingectomy with the SILS system. Information about feasibility and intra- and post-operative data were collected. The data for these patients were compared with those of a control group of 40 women treated by standard laparoscopy. RESULTS: Thirty-six (97%) patients were treated successfully with the SILS system. After laparoscopic confirmation of the ectopic pregnancy, salpingectomy was performed with bipolar forceps and scissors. In one case, conversion to classic laparoscopy was performed because SILS was not feasible. Compared with the control group, operative time was longer (50 ± 35 vs 35 ± 30 min, p=0.001) but duration of hospitalization shorter with single-site laparoscopy (1.5 ± 1.5 vs 2.3 ± 1.5 days, p=0.02). CONCLUSIONS: Laparoscopic salpingectomy for ectopic pregnancy appears to be feasible in everyday practice by single-incision laparoscopic surgery with the SILS system and appears to reduce the duration of hospitalization. Larger series are necessary to confirm this conclusion.

A double-blind, randomized controlled trial of the use of a 50:50 mixture of nitrous oxide/oxygen in legal abortions.

BACKGROUND: The study was conducted to evaluate the effectiveness of oxygen/nitrous oxide (O(2)/N(2)O) in elective abortions by vacuum aspiration with paracervical block and intravenous paracetamol. DESIGN: This single-center double-blinded randomized study tested O(2)/N(2)O (n=36) and placebo (air, n=36) for additional analgesia in elective abortions with paracervical block and intravenous paracetamol. We assessed intra- and postoperative pain according to both a visual analogic scale rated from 0 to 10 and postoperative analgesic requirements. RESULTS: Mean (±SD) intraoperative, immediate postoperative and late postoperative pain did not differ significantly for patients with O(2)/N(2)O and with air [3.4±2.6 vs. 3.7±3.05 (p=.75), 1.89±2.4 vs. 1.56±2.03 (p=.78), 0.5±0.8 vs. 0.75±1.2 (p=.45)]. The number of patients with scores for low (0-4), moderate (4-7) and severe (7-10) intraoperative, immediate postoperative and late postoperative pain did not differ significantly between the groups. Total adverse effects were significantly higher in the O(2)/N(2)O group [35/180 (19.4%) vs. 18/180 (10%), p=.01]. CONCLUSION: O(2)/N(2)O did not reduce intraoperative or postoperative pain in elective abortions by vacuum aspiration with paracervical analgesia and intravenous paracetamol, and its adverse effect rate was substantial.

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.

Cornual resection for interstitial pregnancy by laparoendoscopic single-site surgery.

OBJECTIVE: To present two cases of interstitial pregnancy treated successfully by use of laparoendoscopic single-site surgery (LESS). DESIGN: Case series. SETTING: Department of obstetrics and gynecology at a tertiary health care facility. PATIENT(S): Two women with interstitial pregnancy requiring surgical treatment. INTERVENTION(S): Laparoscopy by use of LESS with the single-incision laparoscopic surgery (SILS) system. MAIN OUTCOME MEASURE(S): Feasibility of LESS with the SILS system. RESULT(S): Two patients were treated successfully by use of LESS with the SILS system. After laparoscopic confirmation of the interstitial pregnancy, a cornual resection was performed with bipolar forceps and scissors for the first patient and with an automatic stapler for the second. CONCLUSION(S): Laparoscopic treatment of interstitial pregnancy by use of LESS seems feasible. Larger series are necessary to confirm these findings.

Obstetric outcome of women with in vitro fertilization pregnancies hospitalized for ovarian hyperstimulation syndrome: a case-control study.

OBJECTIVE: To evaluate the obstetric outcome of women with IVF pregnancies hospitalized for ovarian hyperstimulation syndrome (OHSS). DESIGN: A case-control study. SETTING: Department of Obstetrics-Gynecology and Reproductive Medicine. PATIENT(S): All IVF patients hospitalized for OHSS with a positive pregnancy test matched to an IVF pregnancy control group who did not develop OHSS. INTERVENTION(S): Retrospective study of all clinical and laboratory data. MAIN OUTCOME MEASURE(S): OHSS morbidity, early pregnancy outcome, and obstetric complications. RESULT(S): The incidence of OHSS requiring hospitalization was 1.14% among 3,504 IVF cycles. Forty patients (31 singletons, 8 twins, and 1 triplet) hospitalized for severe OHSS with a mean duration of hospitalization of 10.2 ± 7.2 days were compared with a control group of 80 IVF pregnancies (48 singletons, 15 twins, and 2 triplets). Early OHSS occurred in 22.5% of patients, and late OHSS in the remaining 77.5% patients. In the OHSS group, 10% had thromboembolic complications. The miscarriage rate was similar for the OHSS group and the control IVF group (17.5% vs. 16%). Concerning ongoing clinical pregnancies, pregnancy-induced hypertension (PIH) and preterm labor were significantly higher in the OHSS group (respectively, 21.2% vs. 9.2% and 36% vs. 10.7%). In the subgroup of singletons, PIH was significantly higher for OHSS pregnancies than for controls. CONCLUSION(S): Pregnancies after IVF and OHSS are associated with a greater risk of adverse obstetric outcome.

Plasma creatine phosphokinase level may predict successful treatment after a single injection of methotrexate for ectopic pregnancy.

Our finding that creatine phosphokinase level was significantly higher in women successfully treated for ectopic pregnancy with only a single injection of methotrexate suggests that this indicator predicts this outcome.

Prenatal and postnatal diagnosis of 22q11.2 deletion syndrome.

Microdeletion of chromosome 22q11.2, the most common human deletion syndrome encompasses a wide spectrum of abnormalities. Many clinical or ultrasonographic findings may support deletion studies, either in utero or in the post-natal period. The objective of our study was to evaluate the circumstances of 22q11.2 deletion diagnosis in a single centre of genetics during a 12 years period. Testing for 22q11.2 deletion was performed in 883 cases. Congenital heart defect was the most common reason for referral. An antenatal 22q11.2 microdeletion was detected in 8 fetuses (4.7%) among 169 pregnancies, all presenting conotruncal anomalies. In one case prenatal diagnosis led to the identification of the deletion in the mildly affected father and had negative impact on the family. During the same period, postnatal 22q11.2 DS was diagnosed in 81 out of 714 patients aged from birth to 42 years (11.3%) (p = 0.02). A CHD was present in 37 (45.7%). This figure is significantly lower than the 75% commonly reported. These results suggest that deletion studies could be justifiable in fetuses with non-cardiac prenatal sonographic findings that have been reported in association with 22q11.2 DS. However, as most of these malformations are rather common and non specific, systematic 22q11.2 testing is not justifiable. In such cases, careful cardiac and thymus examination could provide additional clues for 22q11.2 testing. In addition parents should be given accurate information before antenatal or postnatal testing, including the wide variability of the clinical phenotype, the impossibility to establish a precise prognosis concerning psychomotor development and psychiatric risks.

High vaginal concentrations of Atopobium vaginae and Gardnerella vaginalis in women undergoing preterm labor.

OBJECTIVE: To estimate the relationship between vaginal quantification of the main microorganisms related with bacterial vaginosis and the risk of preterm delivery among women with preterm labor. METHODS: Molecular methods were used to prospectively quantify Lactobacillus species, Gardnerella vaginalis, Atopobium vaginae, and Mycoplasma hominis in vaginal fluid samples from women admitted for spontaneous preterm labor with intact membranes from July 2007 through July 2008. The primary outcome measure was the relationship between bacterial concentration at admission and preterm delivery, before 37 weeks of gestation. Sensitivity and specificity of molecular cutoff values and 95% confidence intervals (CIs) were calculated using the University of British Columbia Bayesian Calculator type 2. RESULTS: Of the 90 women included, 36 delivered before 37 weeks of gestation (40%). Preterm delivery was not associated with the presence of Lactobacillus species, G vaginalis, A vaginae, or M hominis. In contrast, molecular quantification detected high concentrations of A vaginae (10(6)/mL or more: 25.0% in the preterm group and 9.3% in the term group, P=.04) and G vaginalis (10(7)/mL or more: 16.7% and 3.7%, P=.03) more often in women with preterm deliveries compared with term deliveries. Moreover, high vaginal concentrations of these two microorganisms together were associated with a significantly (P=.03) shorter interval between preterm labor and delivery (46 days, 95% CI 30-61) than were lower concentrations (85 days, 95% CI 75-95). The hazard ratio for a short preterm labor-to-delivery interval was three times higher for high vaginal fluid concentrations of A vaginae and G vaginalis than for lower concentrations (hazard ratio 3.3, 95% CI 1.1-9.5, P=.03). CONCLUSION: The risk of preterm delivery is significantly associated with high vaginal concentrations of A vaginae and G vaginalis in women with preterm labor. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00484653. LEVEL OF EVIDENCE: III.

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.

Differences in the management of suspected cases of placenta accreta in France and Argentina.

OBJECTIVE: To compare the imaging procedures and surgical strategies used to treat placenta accreta at referral centers in France and Argentina. METHOD: A total of 52 women suspected of having placenta accreta underwent ultrasound and placental magnetic resonance imaging evaluations at these centers between May 2003 and October 2006. Findings and management were recorded. RESULTS: The use of the 2 imaging technologies was similar in France and Argentina and conservative surgical treatment was predominant in both groups. The placenta was left in situ in 64.7% of cases at the French center whereas resection of the placenta and invaded area were performed in 91.4% of cases in Argentina. CONCLUSION: The same diagnostic tools were used in the 2 groups, but there were differences in diagnostic accuracy and in the types of surgical procedures performed.

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.