Added Value of Mean Blood Pressure and Placental Growth Factor in the Early Detection of Pre-eclampsia among Gabonese Women.

OBJECTIVE: To evaluate the use of the Foetal Medicine Foundation (FMF) algorithm in routine practice for early pre-eclampsia (PE) screening in Libreville. MATERIALS AND METHODS: We conducted a cohort study on pregnant women within their 11-13 + 6 weeks of gestation (WG). We had measured mean blood pressure (MBP), placental growth factor (PlGF), soluble Fms-like tyrosine kinase 1, Uterine Artery Pulsatility Index (UtA-PI) and resistance index (UtA-RI). Statistical analyses were considered significant for P < 0.05. RESULTS: There were 30 participants. At the first quarter (T1), 36.7% of them were at high risk of PE according to the FMF algorithm and were consequently prescribed aspirin (100 mg/d). By the end of the observation period, we have found a 13% incidence of PE. MBP was higher in the higher risk PE group than in the lower risk group as early as the T1 (90 ± 6 vs. 81 ± 6 mmHg; P = 0.0007, threshold is >86 mmHg/area under the curve (AUC) = 0.86; P = 0.0012). It was the same for PlGF (58 ± 24 vs. 88 ± 38 pg/ml; P = 0.03; threshold is <71.98 pg/ml/AUC = 0.73; P = 0.03). At the second quarter (20-27 WG), biochemical markers did not change between the two groups. UtA-RI, UtA-PI and notch were unconclusive individually, but they are still very important for FMF algorithm application. CONCLUSION: Early detection of PE using the FMF algorithm is possible in routine practice in Gabon. MBP and PlGF levels at T1 seem to be very significant. However, the present study must continue to obtain the larger cohorts that would achieve more conclusive statistical analyses.

The contribution of research results to dramatic improvements in post-abortion care: Centre Hospitalier de Libreville, Gabon.

In 2009, we published an article in RHM showing a large delay in provision of emergency obstetric care to women who died from unsafe abortion complications at the Centre Hospitalier de Libreville. The paper raised awareness among hospital and government authorities of a serious delay in timely treatment, and they supported the recommendation of the hospital's Maternal Mortality Committee to greatly reduce the delay and also improve the care of women with abortion complications. Training in manual vacuum aspiration (MVA) for uterine evacuation was introduced, for use by midwives as well as obstetrician-gynaecologists, with local anaesthesia. The mean delay in providing care to women with abortion complications in the 2008 findings was compared to data from the five months from 1 November 2011 through 31 March 2012. In 2008, all incomplete abortions were treated by physicians with dilatation & evacuation (D&C) or electric vacuum aspiration (EVA) with general anaesthesia. In 2011-12, two-thirds of women were treated with manual vacuum aspiration with local anaesthesia instead, one half of them by midwives. The mean delay between presentation and treatment was 18.0 hours in 2008 and 1.8 hours in 2011-12. The mean delay did not differ between women treated with MVA or D&C/EVA, nor if treated by midwives or physicians.

[Induction of labor by oral administration of 50 µg of misoprostol: a prospective study in Libreville (Gabon)]. / Déclenchement du travail d'accouchement par le misoprostol à 50 µg par voie orale : étude prospective menée à Libreville (Gabon).

OBJECTIVES: to describe and to analyze the results of our experience in inducing labor with the misoprostol, 50 µg, administered orally. MATERIAL AND METHODS: this descriptive prospective study took place at the Josephine-Bongo Maternity Hospital, in Libreville, in Gabon, from 1st January 2007 to 31st December 2009. It included pregnancies with a gestational age greater or equal to 29  weeks of singletons in cephalic presentation. The induction consisted in the administration of one quarter of a misoprostol tablet (that is, a dose of 50 µg) at 6 in the morning, fasting, and repeated every 4 h up to a maximum of five doses. The principal study indicators were epidemiologic characteristics, dose received, duration of labor, and outcome. RESULTS: the study included 91 patients, with a mean age of 26  years. On average, women received 1.6 doses of 50 µg of misoprostol, for a mean dose of 78.5 µg. A single dose of 50 µg was sufficient to induce labor for 61 patients (67%), as well as for 69% of patients (34/49) with a parity less than or equal to 1. Delivery occurred within 24 h for 80 patients (88%). Vaginal deliveries accounted for 86% of the births (n = 78 patients). There were five failures (5.5%), no adverse effects, and no maternal complications. CONCLUSION: our series confirms the effectiveness and good tolerance of 50-µg misoprostol, administered orally. This route has a period of rapid action, is easy to use, and requires no invasive procedures.

Dynamic and features of SARS-CoV-2 infection in Gabon.

In a context where SARS-CoV-2 population-wide testing is implemented, clinical features and antibody response in those infected have never been documented in Africa. Yet, the information provided by analyzing data from population-wide testing is critical to understand the infection dynamics and devise control strategies. We described clinical features and assessed antibody response in people screened for SARS-CoV-2 infection. We analyzed data from a cohort of 3464 people that we molecularly screened for SARS-CoV-2 infection in our routine activity. We recorded people SARS-CoV-2 diagnosis, age, gender, blood types, white blood cells (WBC), symptoms, chronic disease status and time to SARS-CoV-2 RT-PCR conversion from positive to negative. We calculated the age-based distribution of SARS-CoV-2 infection, analyzed the proportion and the spectrum of COVID-19 severity. Furthermore, in a nested sub-study, we screened 83 COVID-19 patients and 319 contact-cases for anti-SARS-CoV-2 antibodies. Males and females accounted for respectively 51% and 49% of people screened. The studied population median and mean age were both 39 years. 592 out of 3464 people (17.2%) were diagnosed with SARS-CoV-2 infection with males and females representing, respectively, 53% and 47%. The median and mean ages of SARS-CoV-2 infected subjects were 37 and 38 years respectively. The lowest rate of infection (8%) was observed in the elderly (aged > 60). The rate of SARS-Cov-2 infection in both young (18-35 years old) and middle-aged adults (36-60 years old) was around 20%. The analysis of SARS-CoV-2 infection age distribution showed that middle-aged adults accounted for 54.7% of SARS-CoV-2 positive persons, followed respectively by young adults (33.7%), children (7.7%) and elderly (3.8%). 68% (N = 402) of SARS-CoV-2 infected persons were asymptomatic, 26.3% (N = 156) had influenza-like symptoms, 2.7% (N = 16) had influenza-like symptoms associated with anosmia and ageusia, 2% (N = 11) had dyspnea and 1% (N = 7) had respiratory failure, which resulted in death. Data also showed that 12% of SARS-CoV-2 infected subjects, had chronic diseases. Hypertension, diabetes, and asthma were the top concurrent chronic diseases representing respectively 58%, 25% and 12% of recorded chronic diseases. Half of SARS-CoV-2 RT-PCR positive patients were cured within 14 days following the initiation of the anti-COVID-19 treatment protocol. 78.3% of COVID-19 patients and 55% of SARS-CoV-2 RT-PCR confirmed negative contact-cases were positive for anti-SARS-CoV-2 antibodies. Patients with severe-to-critical illness have higher leukocytes, higher neutrophils and lower lymphocyte counts contrarily to asymptomatic patients and patients with mild-to-moderate illness. Neutrophilic leukopenia was more prevalent in asymptomatic patients and patients with mild-to-moderate disease for 4 weeks after diagnosis (27.1-42.1%). In Patients with severe-to-critical illness, neutrophilic leukocytosis or neutrophilia (35.6-50%) and lymphocytopenia (20-40%) were more frequent. More than 60% of participants were blood type O. It is also important to note that infection rate was slightly higher among A and B blood types compared with type O. In this African setting, young and middle-aged adults are most likely driving community transmission of COVID-19. The rate of critical disease is relatively low. The high rate of anti-SARS-CoV-2 antibodies observed in SARS-CoV-2 RT-PCR negative contact cases suggests that subclinical infection may have been overlooked in our setting.

Natural and vaccine-induced B cell-derived systemic and mucosal humoral immunity to human papillomavirus.

Introduction: Human papillomavirus (HPV) are the causative agent of mucosal neoplasia. Both cervical, anal and oropharyngeal cancers incidence is constantly increasing, making the HPV infection, a significant worldwide concern. Together, the CD8+ T cytotoxic cell-mediated response and the HPV-specific antibody response control most of the HPV infections before the development of cancers.Areas covered: We searched the MEDLINE and EMBASE databases and identified 228 eligible studies from 1987 to 2019 which examines both naturally acquired and vaccine induced humoral immunity against HPV infection in female and male subjects from worldwide origin. Herein, we synthesize current knowledge on the features of systemic and mucosal humoral immunity against HPV. We discuss the issues of the balance between the viral clearance or the escape to the host immune response, the differences between natural and vaccine-induced HPV-specific antibodies and their neutralizing capability. We also discuss the protection afforded after natural infection or following prophylactic vaccination.Expert opinion: Understanding the antibody response induced by HPV infection has led to the design of first-generation prophylactic vaccines. Now, prophylactic vaccination induces protective and long-lasting antibody response which would also strengthened the natural moderate humoral response in people previously exposed to the virus.

Serum and cervicovaginal IgG immune responses against α7 and α9 HPV in non-vaccinated women at risk for cervical cancer: Implication for catch-up prophylactic HPV vaccination.

BACKGROUND: Cervical cancer associated with high risk-human papillomavirus (HR-HPV) infection is becoming the one of the most common female cancer in many sub-Saharan African countries. First-generation immigrant African women living in Europe are at-risk for cervical cancer, in a context of social vulnerability, with frequent lack of cervical cancer screening and HPV vaccination. OBJECTIVE: Our objective was to address immunologically the issue of catch-up prophylactic HPV vaccination in first-generation African immigrant women living in France. METHODS: IgG immune responses and cross-reactivities to α7 (HPV-18, -45 and -68) and α9 (HPV-16, -31, -33, -35, -52 and -58) HPV types, including 7 HR-HPV targeted by the Gardasil-9® prophylactic vaccine, were evaluated in paired serum and cervicovaginal secretions (CVS) by HPV L1-virus-like particles-based ELISA. Genital HPV were detected by multiplex real time PCR (Seegene, Seoul, South Korea). RESULTS: Fifty-one immigrant women (mean age, 41.7 years; 72.5% HIV-infected) were prospectively included. More than two-third (68.6%) of them carried genital HPV (group I) while 31.4% were negative (group II). The majority (90.2%) exhibited serum IgG to at least one α7/α9 HR-HPV. Serum HPV-specific IgG were more frequently detected in group I than group II (100% versus 68.7%; P = 0.002). The distribution of serum and genital HPV-specific IgG was similar, but mean number of IgG reactivities to α7/α9 HR-HPV was higher in serum than CVS (5.6 IgG per woman in serum versus 3.2 in CVS; P<0.001). Rates of IgG cross-reactivities against HPV different from detected cervicovaginal HPV were higher in serum and CVS in group I than group II. Finally, the majority of groups I and II women (68.6% and 68.7%, respectively) exhibited serum or cervicovaginal IgG to Gardasil-9® HR-HPV, with higher mean rates in group I than group II (6.1 Gardasil-9® HR-HPV per woman versus 1.4; P<0.01). One-third (31.2%) of group II women did not show any serum and genital HPV-specific IgG. CONCLUSIONS: Around two-third of first-generation African immigrant women living in France showed frequent ongoing genital HPV infection and high rates of circulating and genital IgG to α7/α9 HPV, generally cross-reacting, avoiding the possibility of catch-up vaccination. Nevertheless, about one-third of women had no evidence of previous HPV infection, or showed only low levels of genital and circulating HR-HPV-specific IgG and could therefore be eligible for catch-up vaccination.

Unusual and unique distribution of anal high-risk human papillomavirus (HR-HPV) among men who have sex with men living in the Central African Republic.

BACKGROUND: High-risk (HR) human papillomavirus (HPV) infection remains a great concern in relation to African men who have sex with men (MSM), especially those infected with HIV. The prevalence of HR-HPV and associated risk factors was estimated in a cross-sectional observational study covering MSM living in Bangui, Central African Republic. METHODS: MSM receiving care at the Centre National de Référence des Infections Sexuellement Transmissibles et de la Thérapie Antirétrovirale, Bangui, were included. HIV serostatus and socio-demographic and behavioral characteristics were collected. HPV DNA was detected and genotyped on anal swabs using Anyplex™ II HPV28 test (Seegene, South Korea), and HSV DNA by in-house real-time PCR. Logistic regression analyses were used to determine risk factors associated with HPV outcomes. RESULTS: 42 MSM (mean age, 23.2 years; range, 14-39) including 69.1% HIV-1-positive and 30.9% HIV-negative were prospectively enrolled. The prevalence of anal HPV was 69.1%, including 82.7% of HR-HPV which were multiple in 52.0%. The most prevalent genotypes were HPV-35, HPV-58, HPV-59 and HPV-31. While, HPV-16 and HPV-18 were present in a minority of samples. Multiple HR-HPV infection was more frequent in HIV-positive MSM (41.4%) with 2.7 genotypes per anal samples than in HIV-negative (7.7%) with 1.5 genotypes per anal samples. HPV types included in the prophylactic Gardasil-9® vaccine were detected in 68.9% of specimens and HPV-58 was the most frequently detected. MSM infected by HPV-16 and HPV-18 were all infected by HIV-1. Few anal swabs (11.9%) contained HSV-2 DNA without relationship with HPV detection. Condomless receptive anal intercourse was the main risk factor to being infected with any type of HPV and condomless insertive anal intercourse was significantly less associated with HPV contamination than receptive anal intercourse (Odd ratio = 0.02). CONCLUSION: MSM in Bangui are at-risk of HIV and HR-HPV anal infections. The unusual distribution of HPV-35 as predominant HPV suggests possible geographic specificities in the molecular epidemiology of HR-HPV in sub-Saharan Africa. Scaling up prevention strategies against HPV infection and related cancers adapted for MSM in Africa should be prioritized. Innovative interventions should be conceived for the MSM population living in Bangui.

[Audit of the severe obstetrical morbidity (near miss) in Gabon]. / Audit de la morbidité obstétricale grave (near miss) au Gabon.

OBJECTIVE: To examine "near-miss" cases to identify the weak points of our department. MATERIAL AND METHODS: This prospective study took place at the Libreville Hospital Maternity Center for six months, from 1 June to 31 December 2006. It included all pregnant women with a severe obstetrical complication (uterine haemorrhage with signs of shock, eclampsia, severe infection) or whose condition required a major intervention to prevent death. The quality of these patients' management was studied from their arrival in the department to their discharge. RESULTS: The prevalence of near-misses was of 3.15%, that is, 137 cases among 4350 deliveries. Ruptured ectopic pregnancies, haemorrhage following clandestine elective abortions, and post-partum haemorrhages (third stage of delivery) were the three primary causes for near misses. Almost 40% of these women waited more than 45 minutes before seeing any qualified personnel. Once the patient was seen, clinical examinations were impossible for 22% because of the lack of the appropriate material. The average time to surgery was 5 hours and 15 minutes. The lack of sterilized surgical linens was one of the major causes of delay in surgical management. CONCLUSION: The number of patients seeking care in our department, relative to the staff resources, makes it difficult to optimise the quality of emergency obstetric care.

Cervical cancer in sub-Saharan Africa: a preventable noncommunicable disease.

INTRODUCTION: Infections caused by high-risk human papillomavirus (HPV) are responsible for 7.7% of cancers in developing countries, mainly cervical cancer. This disease is steadily increasing in sub-Saharan Africa, with more than 75,000 new cases and 50,000 deaths yearly, further increased by HIV infection. Areas covered: The current status of cervical cancer associated with HPV in sub-Saharan Africa has been systematically revised. The main issues discussed here are related to the public health burden of cervical cancer in sub-Saharan Africa and predictions for the coming decades, including molecular epidemiology and determinants of HPV infection in Africa, and promising prevention measures currently being evaluated in Africa. Expert commentary: By the year 2030, cervical cancer will kill more than 443,000 women yearly worldwide, most of them in sub-Saharan Africa. The increase in the incidence of cervical cancer in Africa could counteract the progress made by African women in reducing maternal mortality and longevity. Nevertheless, cervical cancer is a potentially preventable noncommunicable disease, and intervention strategies to eliminate cervical cancer as a public health concern should be urgently implemented.

[Nonpalpable breast lesions: correlation of the BI-RADS classification and histologic findings]. / Corrélation radio-histologique des lésions mammaires infracliniques à partir de la classification BI-RADS (étude gabonaise).

UNLABELLED: Diagnosis of nonpalpable breast lesions too often requires a breast biopsy or tumorectomy. OBJECTIVE: To validate the American College of Radiology (ACR) classification and lexicon using a standardized description to improve the uniformity of management of abnormal mammographic lesions and reduce the number of unnecessary tumorectomies. MATERIAL AND METHODS: This prospective study was conducted in Libreville Hospital Center over a 4-year period and compared the histologic results of 150 nonpalpable masses identified by mammography and their ACR classification to assess the correlation between the radiographic and histologic findings. RESULTS: There were 90 cases (60%) of ACR2 lesions, 28 cases (18%) of ACR3, 6 cases (4%) of ACR4 and 26 cases (17%) of ACR5 lesions. Histologic results showed that 3% of the ACR2 lesions were malignant, 11% of the ACR3, 67% of the ACR4 and 92% of the ACR5 lesions. CONCLUSION: The correlations showed that the ACR classification was highly reliable for ACR2 and ACR5 lesions and makes it possible to optimize their treatment. ACR3 and ACR4 lesions must be watched carefully.

[Risk factors for eclampsia in Libreville (Gabon): a case-control study]. / Facteurs de risque de l'éclampsie à Libreville (Gabon): étude cas-témoins.

OBJECTIVES: To determine the current prevalence of eclampsia in our department, identify its risk factors and assess the prognosis of mother and child. MATERIAL AND METHODS: This retrospective case-control study took place from January 1, 2004, through December 31, 2005, in the gynecology-obstetrics and intensive care departments of the Libreville Hospital Center. Every case of eclampsia was compared with three control patients. We collected social, demographic and clinical variables and compared them between the two groups. Univariate analysis was conducted with Epi Info 6.0. The odds ratio (OR) and 95% confidence intervals (95% CI) were calculated for each variable and compared with the Chi 2 test (significance defined as a p value less than 0.05). RESULTS: The prevalence of eclampsia was 0.5%. The principal risk factors were: mother aged younger than 19 years (OR=3.38; CI= 1.77-6.47), nulliparity (2.21; 1.22-4.02) and one or no prenatal consultations (19.23; 6.45-61.40). Severe high blood pressure (>160/110 mmHg) was found in 52% of cases. There were 14 maternal deaths (21%) in the case group and none among the controls. CONCLUSION: Improvement in the quality and quantity of prenatal care should help reduce the incidence of eclampsia.

[Current aspects of extra-uterine pregnancy in Libreville (Gabon): an account of 153 cases]. / Aspects actuels de la grossesse extra-utérine à Libreville (Gabon): à propos de 153 cas.

The impact of extra-uterine pregnancy is still increasing in the world. At the same time, its treatment is being improved in developed countries. The purpose of this study is to assess the current aspects of extra-uterine pregnancy in Libreville (Gabon) and to suggest actions which may improve its vital prognosis in the African context. The present study is only prospective and focuses on 153 extra-uterine cases of pregnancy recorded from February 1, 1997 to July 31, 2000. The average frequency was 2.32%. This frequency has been steadily increasing and went from 2% in 1997 to 2.32 % in 2000. The average age of the patients was 29. Extra-uterine pregnancy was diagnosed until the patients were 17. It concerned all parities. The average age was 8 weeks of pregnancy. Three para-clinical investigations allowed the confirmation of the diagnosis: ultrasound scan, coelioscopy, beta GCH plasma dosage. Laparotomy was the main therapeutic solution. No maternal death was recorded. The education of women capable of procreating on the necessity of early consultations, the supplying of hospitals with means which allow para-clinical investigations and the motivation of medical staff seem to be the main solutions to decrease the mortality rate due to extra-uterine pregnancy in Africa.

[Emergency obstetrical hysterectomy: about 58 cases at Libreville Hospital Centre]. / L'hystérectomie obstétricale d'urgence. A propos de 58 cas au Centre hospitalier de Libreville.

OBJECTIVE: To evaluate the incidence, indications and prognosis of this surgery in our daily practice in order to suggest preventive action. PATIENTS AND METHOD: This is a retrospective study over a period of 10 years, from January 1, 1992 to December 31, 2001. Using patient's documents, parameters have been analysed as followed: age, parity, antecedent of uterine surgery, indications, surgery technique, foeto-maternal prognosis. RESULTS: The frequency of this intervention is 0.07%. The average age of patients was 31 years and the average parity was 6. The indications were: 44 cases of haemorrage (76%) and 14 cases of post-abortum infection (24%). Sub-total hysterectomy was performed on all the patients. We have observed 14 cases of maternal death (24%) and 24 cases of foetal death (57%). CONCLUSION: The frequency of this surgery is weak in our daily practice, compared with other Black African countries. But foeto-maternal prognosis is severe. A better sensibilisation of the population on prenatal consultations benefits and the setting up of a real national strategy of obstetrical emergency care constitute a means to prevent this type of surgery.

[Neonatal prognosis for breech infants delivered vaginally at the Joséphine Bongo Maternity Hospital in Libreville, Gabon]. / Prognostic néonatal de l'accouchement par les voies naturelles du foetus en présentation du siège à la Maternité Joséphine Bongo de Libreville.

UNLABELLED: Vaginal delivery of infants in the breech position always presents a risk. OBJECTIVE: To assess the neonatal prognosis of vaginal breech deliveries in an urban maternity hospital in West Africa. EQUIPMENT AND METHOD: This four-year retrospective study, from January 1996 through December 1999, examined all singleton breech deliveries at a gestational age of 32 weeks or later. Each breech delivery was compared with the two singleton births in cephalic presentation that followed. Epi Info 6.04 software was used for data analysis. RESULTS: During the study period, the frequency of breech deliveries in our department was 2.7%, and 83 involved singleton births at or after 32 weeks. The average age of these mothers was 27.9 +/- 5.7 years old (versus 26.4 +/- 5.9) and ranged from 16 to 39 years (versus 16 to 43 years). Average parity was 3.4 +/- 2.2 (versus 3.2 +/- 2.4). Mean uterine height was lower for fetuses in the breech position (30.7 +/- 2.8 cm versus 31.8 +/- 2.6 cm; p=0.04). The frequency of premature deliveries was 33.5% and that of low weight babies (<2,500 g) 35.4%. Both were twice that for babies delivered in the cephalic presentation (17.5% and 17.7%). Neonatal morbidity was 8 times higher for the breech deliveries, with prematurity its main cause. The rate of instantaneous neonatal mortality was 10.8% (versus 2%), that is, 5 times greater. No clinical factors that might account for these deaths was recorded. CONCLUSION: Breech delivery is a risk for newborns. Development of measures and standards for obstetric practice in Gabon would help improve its prognosis.