[Tetragametic chimerism: Case report]. / Chimérisme tétragamétique : à propos d'un cas.

We report the third case of spontaneous monochorionic dizygous pregnancy, discovered on foetal sex discordance. Blood group testing on the female twin revealed a hematopoietic chimera. The mechanism of monochorionic dizygous formation could be the fusion of two independent zygotes at a late morula stage. A single placental mass with vascular anastomosis then develops. Stem cells exchanged during early foetal life can thus lead to chimeras, in similar conditions to stem cell transfusion in adults. Immaturity of the foetal immune system allows cell graft in the other twin's marrow. Assisted reproductive procedures are believed to promote such pregnancies.

Brachytelephalangic chondrodysplasia punctata: prenatal diagnosis and postnatal outcome.

We report the prenatal management of a brachytelephalangic chondrodysplasia punctata (CDPX1) case and how postnatal findings confirmed the diagnosis. The mother was initially referred after ultrasound revealed an abnormal fetal mid-face and punctuation of upper femoral epiphyses. Chondrodysplasia punctata (CP) with Binder anomaly was suspected. 3D-HCT revealed brachytelephalangy suggesting CDPX1. At birth, mid-face hypoplasia was marked. Postnatal imaging and genetic analysis confirmed the initial diagnosis. Binder anomaly is probably always associated with CP. The newly revised CP classification facilitates the diagnosis. The main etiologies are metabolic and chromosomal abnormalities, and arylsulfatase E enzyme dysfunction. Thus, screening for arylsulfatase E mutation is mandatory for an accurate diagnosis and can lead to better delineation among CP etiologies associated with a Binder phenotype.

[Importance of human papillomavirus (HPV) screening in the follow-up after CIN2-3 treatment]. / Intérêt de la recherche du papillomavirus humain (HPV) dans le suivi post-conisation des CIN2-3. A propos de 386 cas.

INTRODUCTION: Cervical intraepithelial neoplasia (CIN) 2 and CIN3 lesions clearly represent precancerous states even if some of them would heal spontaneously. Management is based on surgical excision of part of the uterine cervix because such lesions can potentially progress into carcinomas. In most cases, this treatment leads to the cure of intraepithelial lesions. However, even after such an efficient treatment, theses patients are still at a higher risk of developing an invasive cervical cancer. That is why guidelines recommend a specific follow-up in order to screen for residual disease (incomplete excision) or for recurrences (after a complete excision). The actual problem in the follow-up strategy lies in the screening tools in use - cervical smears and colposcopy - whose sensitivities are low and hence, not quite sufficient when applied to a high risk population. These intraepithelial lesions are due to high risk human papillomaviruses (HPV) and there cannot be any lesion progression without HPV. Consequently, a viral testing would help in identifying a high risk subpopulation of women after cone loop cervical excision. MATERIAL AND METHODS: We studied, retrospectively, the contribution of HPV testing (Hybrid Capture 2((R))) in the follow-up after CIN2-3 treatment in 386 cone loop cervical excisions performed at a single centre during 80 months. RESULTS: Between three to six months follow-up after surgery, HPV remained present in 22.5% cases. The sensitivity of HPV testing in the screening for residual lesions or for recurrences was 100%, that of cervical smears cytology was 72%, whereas that of the pathological analysis of margins reached only 67%. The negative predictive value of a negative HPV detection associated with a normal cytology was 100%. DISCUSSION: Owing to its clinical relevance, HPV testing optimises postoperative follow-up and leads to the rapid and efficient selection of a subgroup, representing less than one upon three patients who are really at risk of an invasive lesion and to wholly reassure the others. Indeed, a negative HPV testing, associated with a normal cervical cytology, obtained after surgery correspond to a negative predictive value of almost 100% and this allows us to increase the time-interval between two screenings and to rapidly place the patient in a routine follow-up.

[Are there any factors predicting failure or complications rates of trans-obturator surgery for stress urinary incontinence?]. / Existe-t-il des facteurs prédictifs d'échec ou de complications dans la chirurgie de l'incontinence urinaire d'effort par voie transobturatrice?

OBJECTIVE: Since 2001 and the publication by Delorme of the trans-obturator route in the stress urinary incontinence (SUI), this technique has known an increasing development in France. The aim of this study is to evaluate the impact of different predicting factors on results and complications of trans-obturator surgery. PATIENTS AND METHODS: It is a retrospective, multicentric study, including 4 centers, 14 surgeons and 196 patients operated between February 2003 and August 2005. We have realized a univariate (Chi2 test) and multivariate (logistic regression test) statistic analysis concerning 7 sub-groups defined according to the literature on the TVT. RESULTS: Age>55 years (P=0,044) and SUI grade>2 (P=0,028) are statistically associated with a decrease of surgical success, age>55 years is also associated with an increase of complications rate in univariate (P=0,033) and multivariate (P=0,048) analysis. DISCUSSION AND CONCLUSION: Age>55 years should be considered, according to us, as a risk factor of surgical failure and complications in the trans-obturator surgery for SUI, none of the others risk factors found in the literature on the TVT seems to have an influence, in this study, on the results of trans-obturator surgery for SUI.

[Prenatal diagnosis and management of a case of rapidly involuting congenital hemangioma. Review of literature]. / Diagnostic prénatal et prise en charge d'un cas d'hémangiome congénital du cuir chevelu.

Rapidly involuting congenital hemangioma (RICH) is a rare vascular lesion, identified in 1996, of elective localization in the dermal-hypodermic tissue. Its name comes from its particular natural course: it is fully developed at birth and then completely involutes, usually in the first year. We present a case of a RICH of the scalp discovered with a screening ultrasonography in the 31st week of gestation. We list the differential diagnoses. After birth, positive diagnosis lies preferably on pathology examination of a biopsy specimen in order to eliminate the hypothesis of a less favorable vascular lesion, teratoma or malignant tumor.

[Use of tobacco cessation tools for pregnant women or couples attending pre-birth counseling sessions]. / Modalités de mise en oeuvre des outils de sevrage tabagique auprès des femmes enceintes ou des couples au cours des séances de préparation à la naissance.

Several tools have been helped to patients cease smoking. Many are poorly known and thus used little. In the context of pregnancy, midwives conducting pre-birth counseling sessions can help pregnant women and their partners stop smoking. The terms used during the sessions offer many occasions.

High-risk papillomavirus infection is associated with altered antibody responses in genital tract: non-specific responses in HPV infection.

In order to gain more information about local humoral immune responses to HPV infection, we quantified IgG, IgM, secretory-IgA (S-IgA), and total-IgA by ELISA, and lysozyme and lactoferrin by TR-IFMA, in cervical and cervicovaginal secretions of 40 healthy women and 28 high-risk HPV infected patients (11 were HPV16+). IgG, total-IgA, and S-IgA concentrations in cervicovaginal secretions (p < 0.0001) and high IgG and total-IgA concentrations (p < 0.001 and p < 0.01, respectively) in endocervical secretions were significantly higher in HPV+ patients than in the healthy group. Since the S-IgA/total-IgA ratio was significantly lower in cervicovaginal (7.5%) and endocervical secretions (36.5%) in HPV+ women compared to the control group (p < 0.003 and p < 0.001, respectively), HPV could be responsible for an increase in local production of non-secretory IgA (monomeric and dimeric forms). IgG and total-IgA concentrations in cervicovaginal and endocervical secretions fell in the same general percentage range in both HPV16+ and HPV+ groups (80% and 15%, respectively). However, the S-IgA/total-IgA ratio was much lower in HPV16+ than in HPV+ women, in both cervicovaginal secretions (3.4%) (p < 0.003) and in endocervical secretions (23.3%) (p < 0.001). Innate immunity proteins and local S-IgA response could not stop the spread of HPV infection in spite of high lysozyme and lactoferrin concentrations. HPV16+ disturbed the local humoral immune system, which could partly explain its low clearance.

Detection of cervical precancer and cancer in a hospital population; benefits of testing for human papillomavirus.

The aim was to determine the relevance of human papillomavirus (HPV) testing in identifying high-grade cervical intraepithelial neoplasia or worse (CIN2/3+) in a hospital population (n=3574) characterised by a high rate of cytological abnormalities and high-risk HPV infections. According to the results of the initial Papanicolaou and HPV test, women were directly referred for colposcopy/biopsy or recalled for a control visit. Sensitivity and specificity were corrected for verification bias. HPV-testing sensitivity was 94.3%, higher than that of cytological testing at any cut-off point (65.1%-86.8%), while specificity was greater for cytology than for HPV testing (99.3% or 91.8% versus 83.4%). The combination of both tests allowed 100% sensitivity and negative predictive value. We conclude that HPV testing is a relevant tool for the detection of cervical disease. The best way of combining cytology and HPV detection in screening programmes should be evaluated in large-scale studies.

[Ectopic pregnancy management: cervical and abdominal pregnancies]. / Prise en charge de la grossesse extra-utérine: les autres ectopies (cervicales et abdominales).

Cervical or abdominal pregnancies are rare forms of ectopic pregnancy and their management differs for different authors. Besides, the literature is mainly made of case-reports. The aim is to propose one or more management possibilities, keeping in mind that the level of proof obtained from the references used is insufficient to be affirmative. For cervical pregnancy, although hysterectomy is the reference treatment (especially in advanced pregnancy or hemorrhagic life-threatening forms), technical improvements in ultrasonography make feasible the diagnosis of non or weakly symptomatic forms, which could be treated conservatively in order to preserve fertility of these women. In this diagnostic situation the present treatment standard is methotrexate combined with intra-amniotic feticide in case of viable cervical pregnancy. Diagnosis of abdominal pregnancy is often made late. Treatment consists in laparotomy which enables better vascular control. Placental ablation remains as often as not dangerous and in most cases, it is better to abandon the attempt.

Improved TRAP-silver staining versus conventional radioactive TRAP assays: quantification of telomerase activity during immortalization and in pathological human endometrium.

OBJECTIVES: To develop a sensitive telomeric repeat amplification protocol (TRAP)-silver staining assay for telomerase activity quantification. DESIGN AND METHODS: TRAP assays were performed by using a TRAPeze telomerase kit with or without [alpha-32P]-dCTP. Amplification products were electrophoresed in polyacrylamide gels and detected by autoradiography or a modified silver staining protocol. Telomerase activity was quantified from radioactive counts or optical density of telomerase products from test extracts and controls. RESULTS: TRAP-silver staining assay was at least as sensitive as radioactive TRAP assay and quantified telomerase activity within linearity from 10 to 3,000 cell equivalents. Both methods quantified a weak telomerase activity in normal endometrial glandular epithelial cells (GEC) and a strong increase in immortalized GEC. In human pathologic endometria (n=24), telomerase activity was correlated with lesion seriousness and distinguished simple hyperplasias from nonhyperplasic or cancerous lesions. CONCLUSIONS: TRAP-silver staining assay is suitable for cell and tissue telomerase activity routine quantification.

[Epidemiology and natural history of genital infection by human papillomavirus]. / Epidémiologie et histoire naturelle de l'infection génitale à papillomavirus humain.

Human papillomavirus genital infection is a very common sexual transmitted disease, probably the most common of them. On one hand, this infection is more often than not transient and asymptomatic and induces an effective immunity which allows the infection cure; on the other hand it can be responsible for an intraepithelial lesion which can progress to an invasive cancer. In spite of the decrease of cervical cancer incidence thanks to Pap smear screening, it remains a real preoccupation for clinicians. If HPV is not sufficient for cervical carcinogenesis, it represents however a necessary factor. Near 100% of cervical cancers are indeed positive in HPV DNA. HPV infection is very frequent in young people aged less than 25 years and viral clearance average is 8 months. This clearance is the consequence of host immunity intervention which leads to spontaneous regression of infection and of the overwhelming majority of low grade squamous intraepithelial lesions (more than 80% within a period of two years). The major factor which permits the progression to high grade squamous intraepithelial lesions is the persistent feature of HPV infection. Cervical cancer is clearly the first viral-induced solid tumor discovered in human species. Furthermore it represents a woman death cause that can be avoided.

[Epidemiology of cervical papillomavirus infections. Recent knowledge]. / Epidémiologie des infections cervicales à papillomavirus. Acquisitions récentes.

GENERAL DATA: There is now considerable evidence that high risk human papillomaviruses (HPV), such as HPV 16, are closely associated with cancer of the cervix. HPVs that are primarily transmitted through sexual contact, are found in over 99% of the cases of invasive cervical cancer. Although most women can be infected during their sexual life, a small minority is at risk for developing cancer. The long latency period between primary infection and cancer emergence suggests that additional factors are involved in the process of tumor development: sexual behavior, immune status, genetic predispositions, nutritional status, tobacco use, socio-economical level. NATURAL HISTORY: HPVs infect epithelial cells of the transformation zone of the cervix. As with other sexually transmitted diseases, the incidence of HPV infection is highest among young women. However, this viral infection is more often than not transient, because most individuals develop an effective type-specific immune response. Approximately 1% of the population has genital warts and 4% of women have cervical precancerous lesions: low grade squamous intraepithelial lesion (LGSIL) or high grade SIL. These last lesions preferentially observed in women aged 35-40 yrs are at high risk of progression towards an invasive cancer. ONCOGENIC POTENTIAL OF HPV: Pre-malignant and malignant cells arise as a result of HPV DNA integration in the host cellular genome, and overexpression of the viral E6 and E7 oncogenes. Cells acquire a proliferative advantage by escaping growth control exerted by p53 and p 105Rb. Both cellular proteins are indeed inactivated respectively by E6 and E7 proteins. Aneuploidy and karyotypic abnormalities are also key events in the tumor progression. A PREVENTABLE DISEASE: Cervical cancer is more than ever a preventable disease. While waiting for clinically applicable vaccination programs, strategies to prevent cervical cancer include 1) improved screening covering the widest possible population and using HPV testing, 2) close management and follow-up of women with precancerous lesions.

[An appreciation of maternal smoking with high-performance liquid chromatographic determination of maternal and neonatal urinary cotinine]. / Appréciation du tabagisme maternel et néonatal par un dosage de la cotinine urinaire par chromatographie liquide haute performance.

OBJECTIVE: To study the correlation of urinary cotinine levels in mothers and newborns with the number of cigarettes smoked at the end of pregnancy. Population and methods. We recorded the smoking habits of 123 mothers attending a university maternity clinic and measured urinary cotitine levels in mothers and their newborns. All mothers were Europeans and gave birth to a normal full-term (37 weeks gestation) infant. Cotinine levels were measured with high-performance liquid chromatography from urine samples taken during the 6-hour period prior to or after delivery for the mothers and 24-h after birth for the newborns. RESULTS: The average cotinine level for non-smoking mothers, for those who smoked one to nine cigarettes a day and heavy smokers (ten or more cigarettes per day) were 0.21, 2.17 and 4.28 mol/l respectively (p<0.001). The average levels in their newborns were 0.04, 0.39 and 1.36 mol/l respectively (p<0.001). Thirteen percent of the mothers who claimed they did not smoke had cotinine levels higher than the significance cut-off (0.3 mol/l). There was a significant correlation 1) between the number of cigarettes the mothers stated they smoked at the end of pregnancy and their urinary cotinine concentrations (cotinine level=0.213 + 0.349 cigarettes, r=0.78, p<0.001); 2) between the number of cigarettes smoked and newborn's urinary cotinine concentration (cotinine level=0.002 + 0.104 cigarettes/day, r=0.81, p<0.001); and 3) between the mother's and the newborn's urinary cotinine concentrations (newborn cotinine=0.027 + 0.219 maternal cotinine, r=0.77, p<0.001). CONCLUSION: The number of cigarettes smoked at the end of pregnancy accounts for roughly 50% of the variance in the mother's urinary cotinine level and that in her newborn at birth. The urinary cotinine concentration in newborns is 3 to 5 times lower than that of their mothers. A woman smoking 3 cigarettes per day has a urinary cotinine concentration of 1 mol/l. The urinary cotinine level in newborns is 1 mol/l for mothers smoking 10 cigarettes per day.

Genital human papillomavirus infection among women recruited for routine cervical cancer screening or for colposcopy determined by Hybrid Capture II and polymerase chain reaction.

The purpose of this study was to evaluate the clinical use of the Hybrid Capture (HC)-II system for the detection of human papillomavirus (HPV) DNA to identify women at risk of progression to high grade squamous intraepithelial lesions (HGSIL) and carcinomas by differentiating low risk (LR) HPV types (6, 11, 42, 43, 44) and high/intermediate risk (HR) HPV types (16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68). Five hundred and ninety-six women were enrolled in the study. Among them, 466 attended the hospital for routine cytologic screening and 130 were referred for colposcopy because of an abnormal Pap smear. The presence of HPV DNA was tested in cervical samples collected with the Digene Cervical Sampler in Digene Specimen Transport Medium (Digene Corporation, Silver Spring, MD, U.S.A.) using the HC-II assay. Results were compared with those obtained by polymerase chain reaction (PCR) using the MY09-MY11 primers followed by several hybridizations with specific probes. The overall HPV positivity was 32.9% by HC-II and 37.8% by PCR. Among cytologically normal smears, 19.5% were positive by HC-II (14.3% HR) and 25.1% by PCR. Of the atypical squamous cells of undetermined significance samples, 52.9% were positive by HC-II (41.1% HR) and 55.9% by PCR. Of the low grade SIL, 64.5% were positive by HC-II (59.4% HR) and 68.7% by PCR. The HPV positivity rate was found identical by both techniques in high grade smears (81.6%) and squamous cervical carcinomas (100%). By using PCR as the reference method, the sensitivity of HC-II was higher among women with abnormal cytology than with normal cytology (87.3% vs. 70%). Specificity was 80.8% and 97.5%, respectively. In summary, these results indicate that the HC-II method and MY-PCR identified nearly equivalent prevalences of HPV in cervical smear specimens.

[A rare cause of postpartum hemorrhage: a genital thrombus]. / Une cause rare d'hémorragie du post-partum: le thrombus génital.

Puerperal hematoma is a grave but fortunately rare hemorrhagic post-partum complication (occurring in less than 1:1000 deliveries). The hematoma arises due to detachment of para-vaginal conjunctive tissue. In this type of tissue, no natural hemostasis take place and the hematoma may spread into the retroperitoneal cavity. The different risk factors include primiparity, instrumental extraction of the foetus, pre-eclampsia, twin pregnancy and the presence of vulvo-vaginal varicose veins. External bleeding may not always be evident and other clinical symptoms may be delayed. Despite this, rapid course may still occur with drastic consequences. When a case is referred, an examination of the vulvo-vaginal region is mandatory, resuscitation and surgery performed immediately. If this fails angiographic embolization should be carried out. The prognostic outcome of this rare case of post-partum hemorrhagia is highly dependent on early diagnosis and rapid treatment involving close cooperation between obstetricians and anesthetists, and also of rapid embolization to prevent possible intractable hematomas.

The purification of CD34 cells from human cord blood: comparison of separation techniques and cytokine requirements for optimal growth of clonogenic progenitors.

This study was performed to assess the methods which gave maximal recovery of purified CD34/45+ cells from a cord blood specimen and optimal growth of progenitors cultured from the purified cells. Cord blood samples were separated using Percoll gradients (either one (1.080) or two successive (1.080 and 1.068) gradient(s)) and commercially available devices for CD34+ cell isolation (affinity columns as manufactured by CellPro Inc. or immunomagnetic separation procedure as devised by Baxter Inc.). "CellPro' or "Baxter' techniques gave similar results in terms of nucleated, CD34/45+ and progenitor cell concentration; however, the yield of CD34/45+ cells in the CD34+ enriched fraction was significantly higher when using the "CellPro' technique. We also found significantly higher numbers of CD34/45+ cells in the CD34+ enriched final fraction when using only one, 1.080, Percoll density gradient in the first separation step. Using one density separation step followed by the "CellPro' technique, we obtained an average of 3 x 10(6) purified CD34/45+ cells from samples containing 8.5 x 10(8) nucleated cells. Granulomonocytic progenitors (CFU-GM) and mixed progenitors (CFU-GEMM) cells from light-density and purified CD34/45+ cell fractions were evaluated. We found that 20-30% of the light-density cells and the purified CD34/45+ cells, yielded a granulomonocytic colony in serum free medium in the presence of interleukins 3 and 6, erythropoietin, granulomonocytic and granulocytic colony-stimulating factors and stem cell factor. The addition of tumour-necrosis factor alpha to the cocktail significantly improved the growth of CFU-GEMM allowing 10% of the purified CD34/45+ cells to yield a mixed colony, which confirms the role of this cytokine on CD34+ cells from cord blood. This study provides an improved method for recovery of CD34/45+ purified cells and their colony formation. These methods may serve as a basis for studies on CD34/45+ cell amplification and gene transfer.

[Ultrasonic diagnosis and laparoscopic treatment of an ovarian pregnancy. A case report and review of the literature]. / Diagnostic échographique et traitement laparoscopique d'une grossesse ovarienne. A propos d'un cas et revue de la littérature.

Ovarian pregnancy is an uncommon type of ectopic pregnancy. Incidence has been estimated at 1 per 7 000 pregnancies and 1 to 6% of ectopic pregnancies. Pathogenesis is different from tubal pregnancy. Generally it occurs as a single event in an otherwise healthy woman. Early diagnosis of ectopic pregnancy is essential and is now possible with the advent of endovaginal sonography associated with serum beta-hCG assay. There are various forms of ectopic pregnancies. Macroscopically, 4 forms can be distinguished: hematoma, clar ovum, embryonnized ovum, and placenta with fetus. Histology alone can confirm the diagnosis and distinguish between the 4 forms: intrafollicular, justafollicular, justacortical and interstitial pregnancy. For many authors, laparotomy is required in all cases, but in any case, the ovary can generally be preserved as implantation is usually superficial. We describe here a case of ovarian pregnancy after stimulated ovulation. Early diagnosis with correct localization was achieved with endovaginal sonography. Conservative treatment with laparoscopy was successful.