A preliminary study for the treatment of cervical colposcopic lesions with the biological compound AV2.

OBJECTIVE: To evaluate the efficacy of Anti Viral 2 (AV2) in the regression of moderate and severe colposcopic lesions, when com- pared to placebo. MATERIALS AND METHODS: Women, aged over 18 years with a colposcopic diagnosis of moderate to severe dysplasia were randomized to receive either two applications of AV2 or placebo within four days. Both examining physician and patients were blinded to the treatment option. Follow-up colposcopy was performed on days 11, 2 1, and 60. RESULTS: A total of 50 patients were enrolled in this study. There was no statistically significant difference in screening entry criteria between the two groups. The results showed that the application of AV2 yielded a reduction of more than 50% for 21 out of 28 (75%) patients who received the active treatment versus a 0% for the comparable placebo group (p < 0.00 1). CONCLUSIONS: The authors conclude that AV2 can have a place in the treatment of colposcopically-detected cervical lesions. Due to the proven broad spectrum antiviral activity of AV2, a plausible explanation is that the lesions regress due to deactivation of the virus. Further trials with larger numbers and detailed cytology and histology are needed to confirm these results.

An exploration of attitudes towards breast cancer screening in orthodox Jewish women in Antwerp--Belgium.

OBJECTIVE: To explore determinants of participation in breast cancer screening in orthodox Jewish women living in Antwerp, Belgium, and to uncover their opinions and attitudes towards screening, and thereby to detect ways to optimize participation. STUDY DESIGN: Focus group discussions were performed during the last months of 2011 and the first half of 2012 to explore motivation to participate or not in breast cancer screening. Groups consisted of five to seven women. Inclusion criteria were: being female, considering oneself as orthodox Jewish, aged between 50 and 69 years. RESULTS: Three focus group discussions with in a total of 20 women had taken place. All participants in the focus group discussions had a screening mammography taken on a regular base. All participants agreed that the social cohesion between Jewish orthodox women and the importance that is given to healthcare within the Jewish tradition are important contributors to their participation in a breast cancer screening program. Pain, lack of information during the exam, lack of confidence in the quality of the exam, perceived problems when the examining doctor/technician is male, and fear of the results are mentioned as barriers. The participants, however, state that these were not important enough to result in non-participation. Barriers could be diminished by information sessions specifically aimed at orthodox Jewish women. CONCLUSION: This qualitative research demonstrates a generally positive attitude of orthodox Jewish women living in Antwerp, Belgium, towards mammographic breast cancer screening. Increased and repeated structured information sessions are likely to improve breast cancer awareness in this population.

Flemish obstetricians' personal preference regarding induction of labor and mode of delivery in term births.

INTRODUCTION: In a 2002 survey, 2% of Flemish gynecologists preferred elective cesarean section for themselves or their partner. This study aims to determine actual preference regarding induction of labor and mode of delivery in term cephalic or breech births for gy- necologists or their partners. MATERIALS AND METHODS: An anonymous postal questionnaire was sent to all gynecologists and trainees in Flanders. RESULTS: Response rate was 28.2 % (241/852). In case of an uncomplicated cephalic singleton pregnancy, 39 gynecologists (16.2%) preferred cesarean section. Most (n=134, 66.5%) chose induction at 41 weeks, 26 (13%) at 40 weeks, 37 (18%) at 42 weeks, 26 (13%) at 40 weeks, three (1.5%) preferred induction before 40 weeks and two (1%) would wait until after 42 weeks. Concerning term breech, 30% (n=72) opted for vaginal delivery and 70% (n = 169) for planned cesarean section. Ninety-nine (41%) gynecologists pre- ferred to attempt external version first. Only 115 (47.7 %) gynecologists felt professionally capable to assist vaginal breech delivery them- selves; about one-third (n=96; 38%) had performed less than ten vaginal breech deliveries in their career. CONCLUSIONS: Flemish gynecologists are still in favor of vaginal delivery for themselves in terms of cephalic position, but an increasing number favor planned cesarean section. Most Flemish gynecologists opt for cesarean section for themselves or their partners in case of term breech and state that they do not feel capable in assisting vaginal breech delivery for their patients.

Intussusception in pregnancy after gastric bypass: a case report.

Laparoscopic Roux-en-Y gastric bypass (RYGB) remains the gold standard procedure in obesity surgery and is mostly performed in young women of reproductive age. Since the worldwide prevalence of obesity is increasing and fertility improves after surgery, more complications in the pregnant population will emerge. The differential diagnosis of acute abdominal pain in patients with a history of gastric bypass is rather broad and includes mainly anastomotic ulcers, leaks, and small bowel obstructions. Early diagnosis and treatment of these complications is of utmost importance and should be performed on a multidisciplinary basis. Whether surgery should be performed by laparoscopy or laparotomy remains subject of discussion. We report a case of a 29-year-old pregnant woman at 33 + 5 weeks gestational age, presenting with an intussusception after RYGB. A successful surgical reduction was performed by laparotomy.

The use of intravenous magnesium in non-preeclamptic pregnant women: fetal/neonatal neuroprotection.

PURPOSE: To review the effect of intravenous magnesium in obstetrics on fetal/neonatal neuroprotection. METHODS: A systematic review of published studies. RESULTS: Five randomized trials and 4 meta-analyses have shown a significant 32% reduction of cerebral palsy when administering magnesium sulfate in case of preterm delivery. The pathophysiologic mechanism is not fully unraveled: modulation of the inflammatory process, both in the mother and the fetus, and downregulation of neuronal stimulation seem to be involved. After long-term high-dose intravenous administration of magnesium, maternal and neonatal adverse effects such as maternal and neonatal hypotonia and osteoporosis and specific fetal/neonatal cerebral lesions have been described. In case of administration for less than 48 h at 1 g/h and a loading dose of 4 g, these toxic amounts are not achieved. American, Canadian and Australian guidelines recommend the use of intravenous magnesium in any threatening delivery at less than 32 weeks. The "number needed to treat" to avoid 1 cerebral palsy is between 15 and 35. CONCLUSIONS: Intravenous magnesium significantly reduces the risk for cerebral palsy in preterm birth. Open questions remain the optimal dosing schedule, whether or not repeating when delivery has been successfully postponed and a new episode of preterm labor occurs. Some concern has been raised on a too optimistic value for random error which might have led to over-optimistic conclusions in classic meta-analysis. Randomized trials comparing different doses and individual patient data meta-analysis might resolve these issues.

Factors contributing to the low participation rate of Turkish women to a breast cancer screening program in Antwerp, Belgium.

OBJECTIVES: To explore possible factors explaining a low participation rate to breast cancer screening for Turkish women living in Antwerp, Belgium, and to develop ways to increase participation rate. MATERIAL AND METHODS: The authors used focus group discussions with Turkish women to explore their reasons to participate or not to participate in breast cancer screening. Groups consisted of four to six women. Inclusion criteria were: being female, having a Turkish origin, and age between 50 and 69 years. For each focus group, one Turkish women was invited and asked to invite five other women meeting the inclusion criteria. RESULTS: Three focus group discussions with in total 17 women have taken place. Six women had participated to all consecutive invitations for breast cancer screening. One woman had participated once, but not the next time she was invited. Ten women had never participated to screening mammography, although some of them had undergone diagnostic mammography. In all three focus groups, insufficient knowledge of the Dutch language, the unavailability of a professional interpreter, being careless about healthcare, and a negative influence of the husband, were the main reasons not to participate in breast cancer screening. Invitation letters are not read because they are in a language the woman does not understand. Less frequently mentioned obstacles were being on a holiday or being sick on the day of the scheduled mammography, fear of pain, considering an examination useless when not having any symptoms, being anxious for a positive result, and the physical distance to the screening center. Receiving an invitation in Turkish and knowing that a person speaking Turkish will be available at the screening center were proposed as possible measures to improve participation. CONCLUSION: The single most important reason why Turkish women living in Antwerp, Belgium, do not participate in breast cancer screening was a language problem; other reasons were a lack of knowledge concerning breast cancer screening and not worrying about breast cancer. The language barrier in this population of older women can possible be overcome by Turkish speaking personnel at the screening centers.

Pregnancy at late premenopausal age: outcome of pregnancies at 45 years and older in Flanders, Belgium.

To describe the obstetric outcome in women at ages ≥ 45. A retrospective cohort study on a large existing database covering all deliveries in the Flanders region, Belgium, was performed, comparing obstetric outcomes at age 25, 35, 40 and 45 or older, for the period 2005-2010. In the period studied, 421 women gave birth at maternal age ≥ 45 vs 3,405, 15,206, 22,586 at ages 40, 35 and 25, respectively. With advancing maternal age, a significant linear increase for low birth weight (< 2,500 g) and preterm delivery (< 37, < 35 weeks and < 29 weeks), maternal hypertension and diabetes, both primary and secondary caesarean section, was noted. Between ages 40 and ≥ 45, both fetal and early neonatal death demonstrated a significant rise from 4.9/1,000 and 1.8/1,000 to 26/1,000 and 9.5/1,000, respectively. With advancing maternal age, a gradual but not statistically significant decline in the proportion of male fetuses was noted, from 51.6% at 25, to 47.2% in the oldest group. Multivariate analysis confirmed advanced maternal age to be a significant factor in low birth weight, preterm delivery, hypertension, diabetes, caesarean section and perinatal mortality. In Flanders, mothers at age 45 and older have a significantly increased risk for low birth weight, preterm delivery, hypertension, diabetes, caesarean section and perinatal mortality.

Vitamin B12 and folic acid status of term pregnant women and newborns in the Antwerp region, Belgium.

OBJECTIVE: Descriptive study on maternal serum vitamin B12 and folic acid in term pregnancy and in umbilical cord blood that was performed in an inner city hospital with a mixed ethnic population in the region of Flanders in Belgium. MATERIALS AND METHODS: A prospective cohort study that took place from April 1 until May 31, 2011. Plasma folic acid and vitamin B12 were measured in maternal and umbilical cord blood from all term uncomplicated deliveries in a single regional hospital. Data on age, previous obstetric history, ethnicity, nutritional intake, and use of vitamin supplements were registered. RESULTS: Data were collected from 110 patients, mean maternal serum vitamin B12 was 243.9 pmol/l and mean folic acid level was 43.0 nmol/l. Using a cutoff of respectively 150 pmol/l for vitamin B12 and 7.1 nmol/l for folic acid, 13% of the women were classified as vitamin B12-deficient and 23% were deficient for folic acid. Vitamin B12 deficiency was only seen in autochthonous Belgian women. A correlation between the maternal and umbilical cord levels was noted (R = 0.7 for vitamin B12, R = 0.85 for folic acid), but none of the umbilical cord levels demonstrated deficiency. Number of previous pregnancies and intake of supplements had no influence. CONCLUSION: Pregnant women in Antwerp, Belgium, frequently show vitamin B12 and folic acid deficiency, although a correlation exists with lower umbilical cord levels, the present limited data did not demonstrate any case of deficiency in umbilical cord blood. The frequency is highest in the autochthonous population and is not influenced by intake of vitamin supplements.

Sexual function in women after vaginal surgery with synthetic mesh material.

OBJECTIVE: To prospectively assess the impact of surgery for stress urinary incontinence (SUI) and pelvic organ prolapse (POP) with vaginal synthetic mesh on female sexual function and satisfaction. MATERIALS AND METHODS: Forty-four women treated by vaginal surgery for SUI and POP between October 2009 and October 2011 were asked to fill in questionnaires at baseline and at six months after surgery to determine the impact on their sexual function and satisfaction. The questionnaires used for assessment were the 19-item Female Sexual Function Index (FSFI) and the Dutch Seksueel Functioneren Algemeen (General sexual function) or SFA-questionnaire. RESULTS: The questionnaire was completed by 27 patients (61.4%) at baseline; Nineteen reported being sexually active and eight were not. At six months follow-up, the questionnaire was returned by eight patients. In the studied population, an overall improvement of sexual function at six months follow-up was found. All six FSFI-domains: desire, arousal, lubrication, orgasm, satisfaction, and pain seemed to slightly improve. CONCLUSION: The authors found that there was an overall improvement of sexual function after vaginal surgery with synthetic mesh for POP and SUI.

Elective induction of labour increases caesarean section rate in low risk multiparous women.

The aim of this study was to compare the risk of secondary caesarean section in induced versus spontaneous labour in the second delivery of low risk women who had a vaginal delivery in their first pregnancy. The data were retrospective cohort from an existing regional database, comparing term (between 37 and 42 gestational weeks) second deliveries in cephalic position in women who had previously given vaginal birth. Diabetes, hypertension and multiple pregnancy were excluded as were those with a birth weight less than 2500 g or more than 4500 g. The difference was not significant when induction was performed after 41 weeks. The results showed a total number of 29693 deliveries were included, 21243 in spontaneous labour and 8450 after induction of labour. In the spontaneous group 312 (1.5%) underwent secondary caesarean section, as compared to 237 (2.8%) in the induced group, p < 0.001, OR 1.93 (95% confidence interval 1.63-2.29). It was concluded that elective induction of labour in low risk women who have previously given vaginal birth is associated with an almost doubled rate of secondary caesarean section if performed before 41 weeks.

Foetal monitoring during labour: practice versus theory in a region-wide analysis.

PURPOSE: To evaluate cardiotocography (CTG) alone versus CTG and ST-analysis (STAN) in daily obstetric practice in a complete region. METHODS: Prospective registration in the region of Flanders in combination with standard registration of perinatal outcome. RESULTS: Of 62,606 term deliveries registered, 57,141 (91.3%) were available for complete analysis. In 50,748 (88.8%) CTG alone and in 6,393 (11.6%) CTG+STAN was used. STAN was used significantly more in case of hypertension, diabetes and induction of labour and was associated both in univariate and multivariate analysis with significantly more secondary caesarean section for suspected foetal distress, instrumental vaginal delivery, low Apgar score and need for neonatal intensive care. There was no difference in perinatal death or asphyxia. CONCLUSION: ST-analysis versus CTG results in more caesarean sections, instrumental vaginal deliveries and neonatal intensive care. This can not be explained solely by its use in more complicated cases as in multivariate analysis including hypertension, diabetes and induction of labour ST analysis persists as a significant factor. We hypothesise that this could be explained by less well trained users not adhering to STAN-guidelines.

Pregnancy outcome of Moroccan and Turkish women in Belgium.

OBJECTIVE: To compare perinatal outcome in women from Turkish and Moroccan descent versus autochthonous women in Belgium. METHODS: Retrospective cohort study, data from an existing database, coupled with sociodemographic data from birth certificates. RESULTS: There were more teenage pregnancies in the Moroccan and Turkish group, Moroccan women delivered more frequently after age 40 but Turkish women less frequently. In Moroccan and Turkish women the level of education was lower, they had less hypertension, fewer pregnancies after artificial reproductive technology and preterm deliveries, more diabetes and more grand multiparity. Moroccan women demonstrated more HIV infection. Planned cesarean section was less frequent in the Moroccan and Turkish group, and there was no difference for secondary cesarean section. Belgian women had more induction of labor, instrumental vaginal delivery and epidural anesthesia. There were more babies with low birth weight in both the Moroccan and Turkish group. Moroccan woman had more babies with a birth weight above 4500 g. Total perinatal death rate was higher for Moroccan women while there was no difference between Belgian and Turkish babies. CONCLUSION: Moroccan women demonstrated higher rates of HIV infection and perinatal mortality, while in both Turkish and Moroccon women diabetes was higher and hypertension less frequent. Belgian women underwent more interventions during pregnancy.

Anaesthesiological considerations on tocolytic and uterotonic therapy in obstetrics.

AIM: Significant side effects of tocolytic and uterotonic substances may be of concern to the anaesthesiologist. Recently, new drugs have been introduced having less side effects for both the mother and the neonate. METHODS: A literature search was undertaken mainly focusing on meta-analyses, to review the possible side effects that might affect the course of anaesthesia and to suggest which precautions should be considered to prevent the occurrence of significant interactions with anaesthetic manipulations and drugs. RESULTS: Magnesium sulphate has a proven benefit in lowering systolic blood pressure and preventing the occurrence of eclampsia, but not as a tocolytic. beta-adrenergic agonists are being abandoned due to the availability of tocolytic agents causing less side effects. Calcium channel blockers (CCB) are frequently used but can cause major maternal cardiovascular complications. Nitroglycerin seems to be appreciated as an acute tocolytic rather than a routine substance during pre-term labour. Cyclo-oxygenase-2 inhibitors are still under investigation but their tocolytic benefit is questionable mainly due to foetal side effects. Atosiban is considered the first-choice tocolytic. With respect to oxytocic drugs, oxytocine, prostaglandines and methylergometrine may all cause serious side effects especially when combined. The cardiovascular side effects of prostaglandins and methylergometrine can be life-threatening. Both oxytocin and carbetocin have a rather low risk for maternal complications. CONCLUSION: Atosiban and CCB are at least as effective tocolytic agents as beta-mimetics but have significantly less side effects. Magnesium sulphate can cause neuromuscular blockade, especially when combined with CCB. Concerning oxytocic agents, short-acting oxyctocin and long-acting carbetocin have the least side effects as compared with prostaglandins and methylergometrine.

Regional anaesthesia for primary caesarean section in patients with preterm HELLP syndrome: a review of 102 cases.

OBJECTIVE: To determine the feasibility and the safety of combined spinal/epidural and spinal anaesthetic techniques for primary caesarean section in case of preterm HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome. METHODS: A retrospective study was carried out in a tertiary centre including all patients who underwent primary caesarean section for HELLP syndrome. The immediate preoperative and the lowest thrombocyte count, the method of anaesthesia and eventual complications were recorded. Patients were categorised as having antepartum or postpartum HELLP syndrome. RESULTS: A total number of 102 charts was reviewed. Mean gestational age was 30.6 weeks (SD 2.7, range 23-36 weeks). There were seven (6.9%) patients with postpartum HELLP and 95 with antepartum HELLP. In case of antepartum HELLP in 37 (36.3%) general anaesthesia was selected; in 53 (52.0%) combined spinal epidural anaesthesia and in 12 (11.8%) single dose spinal anaesthesia. Preoperative thrombocyte count was significantly higher (p < 0.01) in the combined spinal epidural group (113,000/mm3) while there was no difference between general (88,000/mm3) and spinal anaesthesia (95,000/mm3). There were no cases of epidural haematoma. Two patients received a combined spinal epidural although their immediate preoperative thrombocyte count was < 50,000/mm3. CONCLUSIONS: Our data demonstrate that combined spinal/epidural is feasible and safe in selected cases of HELLP syndrome.

Postpartum C-Reactive Protein: A limited value to detect infection or inflammation.

BACKGROUND: During pregnancy the maternal immune system adjusts to preserve the foetoplacental unit. These adjustments lead to an increase in CRP, continuing into the postpartum. The objective of this study was to determineantepartal, peripartal and postpartal factors associated with an elevated CRP on the second postpartum day. METHODS: A retrospective quantitative, monocentric file analysis in which antepartal, peripartal and postpartal factors were collected from a convenience sample was performed. On the second day postpartum CRP was taken according to local protocol. Uni- and multi-variate analysis was performed to determine factors that are related to postpartum level of CRP. The total sample size consisted of 1400 patients. RESULTS: Multiple regression analysis indicated 11 factors related to increased CRP on the second day postpartum: gestational age (p=0.002), maternal blood leukocyte count on day 2 postpartum (p<0.001), artificial rupture of the membranes (p<0.001), fever during labor (p<0.001), indwelling urinary catheter (p=0.008), epidural anesthesia (p<0.001), fetal scalp electrode (p<0.001), primary planned caesarean (p=0.019), secondary caesarean h (p<0.001), formula feeding (p=0.030) and fever during postpartum (p=0.001). CONCLUSION: This research indicates that many antepartal, peripartal and postpartal factors are related to high postpartum CRP. CRP can not be used as a screening test test in the postpartum to discriminate between normal and pathologic inflammatory/infectious changes.

Performance of OncoE6TM Cervical Test in detecting cervical precancer lesions in HIV-positive women attending an HIV clinic in Bujumbura, Burundi: a cross-sectional study.

OBJECTIVE: New rapid and low-cost molecular tests for cervical cancer screening, such as the OncoE6 Cervical Test, are emerging and could be alternatives for low-income and middle-income countries. To this end, we evaluated the clinical performance of the OncoE6 Cervical Test in detecting cervical intraepithelial neoplasia (CIN) among HIV-infected women in Bujumbura, Burundi. METHODS: From June to December 2017, a cross-sectional study was conducted in 680 HIV-positive women at the University Hospital. Women aged 25-65 years who declared having had vaginal intercourse were consecutively recruited, and cervical specimens for OncoE6, liquid-based cytology and human papillomavirus (HPV) genotyping were obtained and visual inspection with acetic acid performed. Thereafter, participants underwent a colposcopic examination. The sensitivity, specificity, and positive and negative predictive values of the different tests were calculated with reference to 'colposcopic-histological' diagnoses, and areas under the receiver operating curves of OncoE6 and cytology tests were compared. RESULTS: The prevalence of CIN was 4.9%, and OncoE6 positivity was 3.1%. OncoE6 sensitivity varied from poor to low with increasing disease severity (42.1%, 95% CI 19.9% to 64.3% at CIN2+ threshold; and 58.3%, 95% CI 30.4% to 86.2% at CIN3+ threshold). OncoE6 had the highest specificity compared with all other tests used together. The performance of the OncoE6 test was significantly lower compared with cytology at atypical squamous cell of undetermined significance (ASCUS+) cut-off (AUC=0.68 vs 0.85, p=0.03) and low-grade squamous intraepithelial lesion (LSIL+) cut-off (AUC=0.68 vs 0.83, p=0.04) for CIN2+ diagnoses. However, the performance of the OncoE6 test was similar to that of cytology at high-grade squamous intraepithelial lesion (HSIL+) cut-off (AUC=0.68 vs 0.76; p=0.30) for CIN2+ diagnoses and was also similar to that of cytology at all cut-offs (ASCUS+, LSIL+ and HSIL+) for CIN3+ diagnoses (p1=0.76, p2=0.95 and p3=0.50, respectively). CONCLUSION: The current OncoE6 test proved to be a point-of-care test. However, given its poor performance for CIN2+ diagnoses, we do not recommend it for primary screening. We recommend to enrich it with more oncogenic HPV types, which may improve the performance of the test akin to that of cytology.

Sentinel node biopsy for ipsilateral breast cancer recurrence: a review.

The aim of this study was to review published reports on the feasability, results, and reliability of sentinel node biopsy in cases of ipsilateral recurrent breast cancer. A Medline search on publications from January 1999 to December 2007 and cross-references in published articles were looked for. We identified 16 reports on sentinel node biopsy in recurrent breast cancer, including a total of 287 patients. In 210/287 (73.2%) a sentinel node was identified, 77/210 (37.7%) had had previous axillary lymph node dissection and 131 (62.3%) a previous sentinel node procedure. Aberrant lymphatic drainage, other than the ipsilateral axilla was noted in 68/210 (32.4%). Of these 16/68 (23.6%) were located in the contralateral axilla. Of the removed contralateral axillary sentinel nodes 8/17 (47.1%) were invaded by cancer. We conclude that sentinel node biopsy in cases of recurrent ipsilateral breast cancer is feasible. In about one out of three cases drainage to the contralateral axilla with invasion in almost half the cases takes place. The therapeutical consequences of these findings need further study.

An objective measurement to diagnose micrognathia on prenatal ultrasound.

PURPOSE: We introduce the frontal naso-mental angle as an objective measurement for the prenatal detection of fetal retrognathia. The aim of this study is to present normal values for the frontal naso-mental angle from 18 to 35 weeks gestational age. MATERIALS AND METHODS: In 81 patients between gestational ages 18 and 35 weeks the frontal naso-mental angle was measured on a profile view of the foetal face. The values were compared with four cases of proven Pierre Robin syndrome. RESULTS: The frontal naso-mental angle is not dependent on gestational age, the mean value is 146.74 degrees, standard deviation 2.7 degrees; 5th percentile 142 degrees, 95th percentile 151 degrees. All four cases of Pierre Robin syndrome demonstrated a significantly lower frontal naso-mental angle below the 5th percentile. CONCLUSION: The frontal naso-mental angle represents an objective way to diagnose retrognathia.