Is intrapartum intravenous zidovudine for prevention of mother-to-child HIV-1 transmission still useful in the combination antiretroviral therapy era?

BACKGROUND: Intrapartum intravenous zidovudine (ZDV) prophylaxis is a long-standing component of prevention of mother-to-child transmission (MTCT) of human immunodeficiency virus (HIV) in high-resource countries. In some recent guidelines, intravenous ZDV is no longer systematically recommended for mothers receiving combination antiretroviral therapy (cART) with low viral load. We evaluated the impact of intravenous ZDV according to viral load and obstetrical conditions. METHODS: All HIV-1-infected women delivering between 1 January 1997 and 31 December 2010 in the French Perinatal Cohort (ANRS-EPF) were analyzed if they received ART during pregnancy and did not breastfeed. We identified maternal and obstetrical characteristics related to lack of intravenous ZDV and compared its association with MTCT rate and other infant parameters, according to various risk factors. RESULTS: Intravenous ZDV was used in 95.2% of the 11 538 deliveries. Older age, multiparity, and preterm and vaginal delivery were associated with lack of intravenous ZDV (n = 554). In women who delivered with viral load ≥1000 copies/mL, the overall MTCT rate was higher without than with intravenous ZDV (7.5% vs 2.9%; P = .01); however, there was no such difference when the neonate received postnatal intensification therapy. Among them, 77% of women who had viral load <400 copies/mL, there was no difference in MTCT rate (0% without intravenous ZDV vs 0.6% with intravenous ZDV; P = .17). Intravenous ZDV was not associated with increased short-term hematological toxicity or lactate level. CONCLUSIONS: Intravenous ZDV remains an effective tool to reduce transmission in cases of virological failure, even in cART-treated women. However, for the vast majority of women with low viral loads at delivery, in the absence of obstetrical risk factors, systematic intravenous ZDV appears to be unnecessary.

Evaluation of a follow-up customized strategy for women treated with methotrexate for an ectopic pregnancy: An observational study.

OBJECTIVE: To evaluate a follow-up customized strategy used in women treated with methotrexate for tubal ectopic pregnancy. STUDY DESIGN: This observational monocentric study took place from November 2009 to December 2015 in the emergency unit at La Conception University Hospital in Marseille, France. 440 women were treated by methotrexate for tubal ectopic pregnancy. Women were assigned in a classic follow up protocol with a weekly hCG evaluation (conventional protocol) if the drop in hCG between D1 and D4 was inferior to 20% or in an alternative follow up (streamlined protocol) with a hCG evaluation at one month. The main outcome measures were the success rate, the proportion of women requiring several methotrexate injections, and the mean number of consultations per women and duration of the follow-up. RESULTS: During this period, the success rate was 348/440 (79.1%). The rate of women requiring 1, 2, or 3 injections and of women lost to follow-up were comparable between the two protocols. The mean number of consultations per woman was 3.6 ± 1.33 vs. 5.95 ± 2.25 days (p < 0.0001), and the follow-up was 27.5 ± 12 vs. 28.1 ± 15.4 (p = 0.6) respectively in the conventional protocol group and the streamlined. CONCLUSION: Our customized strategy allows for a decrease in the number of consultations per woman without changing the success rate or the need for methotrexate injection. hCG count drop between D1 and D4 allows for the selection of a low-risk group that can benefit from appropriate aftercare.

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

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

Complications of vaginal myomectomy by posterior colpotomy.

OBJECTIVE: To evaluate the morbidity of vaginal myomectomy by posterior colpotomy. STUDY DESIGN: From January 1, 1994, through December 31, 2003, 108 patients in our department underwent a vaginal myomectomy procedure by posterior colpotomy. This study assessed the intra-operative (conversion to laparotomy, organ injury, hemorrhage) and post-operative (hematoma, abscess) complications as well as the risk factors for conversion to laparotomy. RESULTS: There were 27 intra- or post-operative complications (25%), 17 (15.7%) of which concerned conversion to laparotomy necessary for successful myomectomy. One case involved rectal injury (0.9%), three hemorrhages (2.8%), one hematoma (0.9%) and five abscesses (4.7%). The mean weight of fibromas was significantly higher in the group of patients undergoing laparotomy (19 cases) than in the vaginal-myomectomy-only group (89 cases) (270+/-197 g versus 181+/-143 g, p=0.02). Similarly, the fibroma size measured by ultrasound was higher in the laparotomy group than in the vaginal-myomectomy-only group, but this difference was not significant (82.6+/-27.1 mm versus 73.7+/-21.8 mm, p=0.13). CONCLUSIONS: The principal risk of vaginal myomectomy is that it will require conversion to laparotomy. The risk of pelvic abscess also appears greater in myomectomy than in other procedures. However, apart from the risk of conversion to laparotomy, vaginal morbidity is lower with this procedure. Vaginal myomectomy is a useful alternative to laparotomy for specific indications.

Effect of laparoscopy by single-port endoscopic access in benign adnexal surgery: study protocol for a randomized controlled trial.

BACKGROUND: Laparoscopic surgery has become the preferred surgical approach due to a reduction in postoperative pain, better recovery, shorter hospitalization, and improved esthetic outcomes. Laparoscopic surgery with single-port laparoscopy (SPL) is a laparoscopic surgery technique that is based on making a single parietal incision using a single trocar specifically designed to allow introduction of several instruments. The level of evidence regarding the advantages of SPL in terms of postoperative pain has remained low despite several randomized studies. Adult patients exhibiting a surgical indication for an a priori benign ovarian pathology or for prophylactic purposes that can be performed by laparoscopy will be randomized to receive conventional laparoscopy (CL) or SPL. The aim of our study is to evaluate whether SPL offers advantages over CL in benign adnexal surgery. METHODS: The patients will be evaluated preoperatively to confirm their eligibility. The perioperative data up to 24 h after the intervention, as well as the postoperative data at day 7 and at one month from the intervention will be collected. The primary outcome for the study will be the postoperative pain at 24 h ± 2 h after the intervention. The pain will be assessed by a numeric rating scale of 0-10. Other outcomes will also be assessed, such as pain at other times, the consumption of analgesics, the operative time, perioperative bleeding, the number of additional trocars in the two groups, the incidence of laparoconversion, the esthetic criteria of the scar at one month, the incidence of complications, and the quality of life at one month. DISCUSSION: If our hypothesis is confirmed, this study will provide evidence that the use of SPL can decrease postoperative pain in adnexal surgery. The standard surgical treatment of this condition would thus be modified. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02739724 . Registered on 12 April 2016.

Twin pregnancy as a risk factor for mother-to-child transmission of HIV-1: trends over 20 years.

OBJECTIVE: We investigated whether twin pregnancies were at increased risk of mother-to-child HIV-1 transmission (MTCT), in comparison with singletons. METHODS: Among HIV-1 infected women enrolled in the French Perinatal HIV Cohort (n = 9262), we studied the association between twin deliveries and MTCT rate according to three time periods (pre-1994, 1994-1996, 1997-2004) and the effect of birth order. The mother was considered to have transmitted if at least one of the twins was infected. Univariate and multivariate analyses of risk factors for MTCT were performed for deliveries in the periods up to 1996. RESULTS: Overall, 2.1% (192/9262) of all the deliveries were twins. The rate of prematurity was greater in twins than in singletons (54% and 13%, respectively). Up to 1996 the rate of MTCT of HIV-1 was 28.3% (15/53) in twin pregnancies, versus 13.5% (414/3077) in singletons [odds ratio (OR), 2.5; 95% confidence interval (CI), 1.4-4.7; P = 0.002; adjusted OR, 2.3: 95% CI, 1.1-2.3; P = 0.03). In the period from 1997 to 2003, MTCT was low and did not differ between twins (1.0%) and singletons (1.8%; P = 1.0). Overall, the transmission rate for the first-born child was threefold that for the second-born child (14/164, 8.5% versus 4/164, 2.4%; P = 0.008). CONCLUSION: Twin pregnancies were at increased risk of transmission, but in the era of HAART this risk was reduced for twins, as well as singletons. Management of multiple pregnancies should take into account the risks of premature rupture of the membranes and preterm delivery.

In situ methotrexate injection for treatment of recurrent endometriotic cysts.

OBJECTIVE: Ovarian endometrioma recurrence is frequent. Conventional treatment of ovarian endometrioma is by surgical cystectomy. We proposed an alternative medical treatment for recurrent ovarian endometrioma: cyst aspiration followed by in situ methotrexate injection. STUDY DESIGN: From January 2002 to May 2003, 14 patients with recurrent homolateral ovarian endometrioma underwent transvaginal ultrasound guided cyst puncture and aspiration followed by methotrexate injection, whilst under general anasthesia. Recurrence rate during follow up was evaluated. RESULTS: No complication was reported. After a mean follow up of 20+/-5 month (min: 13, max: 29), four recurrences were diagnosed (28.6%). Two asymptomatic recurrences were not treated and two painful recurrences underwent a second cyst drainage with methotrexate injection. CONCLUSIONS: In situ methotrexate injection is a simple, effective and an interesting alternative to surgical treatment in women with recurrent homolateral ovarian endometrioma.

Management of placenta accreta: morbidity and outcome.

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

Value of laparoscopic assistance for vaginal hysterectomy with prophylactic bilateral oophorectomy.

OBJECTIVE: This study was undertaken to compare morbidity for women undergoing laparoscopy-assisted vaginal hysterectomy with bilateral oophorectomy (LAVHO) and vaginal hysterectomy with bilateral oophorectomy without laparoscopic assistance (VHO). STUDY DESIGN: Between April 1, 2002, and February 1, 2004, a prospective randomized study at Marseille University Hospital (La Conception) included 48 patients who underwent a hysterectomy with prophylactic bilateral oophorectomy for benign uterine conditions. These patients were allocated to 2 groups (LAVHO vs VHO). The study variables were duration of surgery and of hospitalization and surgical and postoperative complications. RESULTS: There was no significant difference in the duration of surgery between the LAVHO and VHO groups (100.2 +/- 27.9 vs 83.9 +/- 34.6, P = .08). The rate of complications was significantly higher in the LAVHO group (13/24 [54.1%] vs 6/24 [25%], P = .039). CONCLUSION: The overall complication rate was higher with LAVHO than VHO. It thus appears that laparoscopic assistance is not useful in performing vaginal hysterectomies with prophylactic bilateral oophorectomies in patients without other related disorders (endometriosis, adhesions, adnexal anomalies).

Immediate complications of tension-free vaginal tape (TVT): results of a French survey.

BACKGROUND: The aim was to evaluate morbidity following operation using tension-free vaginal tape (TVT). METHODS: Between June 2002 and June 2003, a questionnaire was sent to French gynecologists and urologists. Participants reported the number of TVT procedures performed before January 2002, number of minor or major pre- and post-operative complications. RESULTS: The questionnaire was returned by 92 participants (21 urologists and 71 gynecologists) who reported 12,280 TVT procedures (median: 100, minimum: 5, maximum: 2100). Overall, 901 preoperative bladder injuries were reported (7.34%). For 809 patients (6.59%), complete post-operative urinary retention requiring catheterization was noted. There were 26 cases of vaginal defect healing (0.21%). Retropubic or vulvovaginal hematoma was reported for 39 patients (0.32%). Ten major organ injuries were reported (0.08%): one obturator nerve injury, three bowel perforations, four vessel injuries and two ureteral injuries. CONCLUSION: The risk of major complications following the use of tension-free vaginal tape is low. However, these potential complications require experienced surgeons for the practice of tension-free vaginal tape.

Risk of coexisting endometrial carcinoma in case of atypical endometrial hyperplasia diagnosed on total hysteroscopic resection.

OBJECTIVE: To evaluate the rate of coexisting endometrial carcinoma or atypical endometrial hyperplasia (AEH) residue in patients who had a total hysteroscopic resection with diagnosis of AEH and without suspicious lesions detected during hysteroscopy. STUDY DESIGN: This retrospective bicentric study included patients diagnosed with AEH on hysteroscopic resection products, and who subsequently underwent secondary hysterectomy. Cases of hysteroscopic appearance suggesting an endometrial carcinoma were excluded. Histopathological results of hysterectomy specimen determined the persistence or absence of AEH and the possible presence of coexisting endometrial carcinoma. RESULTS: Thirty-two patients were selected. Histopathological analysis of hysterectomy specimens diagnosed an absence of AEH in 24/32 (75%) subjects, an AEH residue in 6/32 (18.8%) subjects and a coexisting endometrial carcinoma in 2/32 (6.2%) subjects. CONCLUSION: The risk of missing an endometrial carcinoma in patients diagnosed with AEH based on total hysterocopic resection is low when there is no suspicious hysteroscopic aspect, but this risk cannot be entirely excluded. Total hysteroscopic resection may be a possible alternative to hysterectomy in patients with AEH who refuse hysterectomy or are a high surgical risk. These patients require a close and long term follow-up due to the risks of residual lesion.

Outcome and Follow-up of Patients with Endometrial Carcinoma Diagnosed on Operative Hysteroscopic Resection Specimens.

AIM: To study outcomes of patients diagnosed with endometrial carcinoma (EC) after histological analysis of endometrial resections retrieved during operative hysteroscopy performed for a presumed benign lesion. PATIENTS AND METHODS: A retrospective study was conducted using medical records of patients who underwent operative hysteroscopy for a presumed benign lesion with a final diagnosis of EC between January 1994 and April 2014 in two tertiary academic centers. RESULTS: A total of 29 patients were selected. International federation of gynecology and obstetrics (FIGO) classification was distributed as follows: 16 stages IA, 7 stages IB, 4 stages II and 2 stages III. Peritoneal cytology was positive in one case (stage IIIA). Median follow-up was 4.2 years (range=0.3-20.51). Two deaths were observed and were attributed to endometrial cancer. CONCLUSION: Operative hysteroscopy does not appear to influence stage of EC nor cause retrograde seeding of EC for 27/29 (93%) patients. For 2 patients, the impact of operative hysteroscopy remains uncertain.

Oxytocin during myomectomy: a randomized study.

OBJECTIVE: To evaluate the influence of oxytocin on peroperative blood loss during myomectomy. STUDY DESIGN: From October 1998 to May 2002, 94 patients requiring surgical myomectomy by laparotomy or by the vaginal approach were enrolled in a randomized double blind study. Patients were randomized to two groups. In the first group (47 patients) oxytocin was administered during myomectomy and in the second group (47 patients) a placebo was used. The main outcome measures were peroperative blood loss and rates of blood transfusion and autotransfusion. RESULTS: Peroperative blood loss was no different between the oxytocin group and the placebo group (508 +/- 558 ml versus 451 +/- 336 ml; P=0.55). Rates of autotransfusion and blood transfusion were also similar in both groups. CONCLUSION: Administration of oxytocin during myomectomy did not reduce peroperative blood loss in our study. The benefits of using oxytocin to prevent hemorrhage during myomectomy seem to be limited.

Risk of bladder injury during vaginal hysterectomy in women with a previous cesarean section.

OBJECTIVE: To determine the risk of bladder injury during vaginal hysterectomy in women with a previous cesarean section. STUDY DESIGN: Analysis of selected studies found through a MEDLINE search from 1980 to 2003. RESULTS: Four comparative studies (women with or without a previous cesarean section) were selected and analyzed. Risk of bladder injury was significantly increased in only 1 study. Analysis of cumulative data did not find a significant difference (8 of 430 [1.86%] vs. 11 of 1,227 [0.89%], p = 0.12). CONCLUSION: The risk of bladder injury during vaginal hysterectomy does not seem to be increased in women with a previous cesarean section.

Postoperative infection and surgical hysteroscopy.

OBJECTIVE: To evaluate the risk of infection after surgical hysteroscopy. DESIGN: Prospective observational study. SETTING: University hospital. PATIENT(S): One thousand nine hundred fifty-two patients requiring operative hysteroscopy during a 10-year period from January 1990 to January 2000. INTERVENTION(S): Two thousand one hundred sixteen operative hysteroscopies were performed: 782 fibroma resections, 422 polyp resections, 623 endometrectomies, 90 uterine septa sections, and 199 lyses of synechiae. MAIN OUTCOME MEASURE(S): Postoperative infectious complications. RESULT(S): Thirty (1.42%) infections occurred. There were 18 (0.85%) cases of endometritis and 12 urinary tract infections. No other severe infectious complications were reported. The risk for early-onset endometritis was higher after lysis of synechiae compared with endometrectomy, fibroma, or polyp resections. However, the risk for early-onset endometritis was similar for endometrectomy, septa, fibroma, or polyp resections. CONCLUSION(S): Infectious risk following surgical hysteroscopy is low. No major infectious complications occurred. Risk for early-onset endometritis was higher after lysis of synechiae compared with other procedures.

Risk of finding an endometrial cancer when atypical hyperplasia was incidentally diagnosed on hysteroscopic resection products.

OBJECTIVE: To evaluate the risk of discovering an endometrial cancer when atypical hyperplasia was diagnosed by histologic examination of hysteroscopic resection products. STUDY DESIGN: A retrospective monocentric study from January 1994 to January 2001. Seventeen patients with atypical hyperplasia were included. Initial endometrial status was provided by operative hysteroscopy resection products. For all patients, there was no hysteroscopical aspect evocative of adenocarcinoma. Histopathological analysis of the hysterectomy pieces precised the final diagnosis. RESULTS: Among the 17 hysterectomy pieces, one adenocarcinoma was diagnosed. Risk for discovering adenocarcinoma when atypical hyperplasia was diagnosed by operative hysteroscopy resection products was 5.9% (1/17). CONCLUSION: Risk of omitting adenocarcinoma when atypical hyperplasia is discovered by hysteroscopy resection pieces is low.

Vaginal myomectomy using posterior colpotomy: feasibility in normal practice.

BACKGROUND: Myomectomy is classically performed via laparotomy. Endoscopic surgery is limited for some indications. Vaginal myomectomy is a surgical procedure that has recently been evaluated. The aim of this study was to evaluate the feasibility, reproducibility and complication rate of vaginal myomectomy via posterior colpotomy. METHODS: A retrospective study was performed from November 1998 to February 2001 in three departments of gynaecology. RESULTS: Forty-five patients were involved, 17 (37.8%) of whom underwent laparoscopy before vaginal myomectomy for evaluation or treatment of a second pelvic disorder. Myomectomy was performed vaginally in 40 (89%) of the 45 patients. Peroperative laparotomy was required in five patients (11%), either because vaginal myomectomy proved impossible (four cases) or because of rectal injury (one case). One patient needed supplementary laparotomy on day 8 for the treatment of a pelvic abscess. CONCLUSION: Posterior vaginal myomectomy seems to be a feasible and reproducible surgical procedure. The success rate of vaginal myomectomy in this study was over 80%. Further randomised studies are needed to compare this procedure with laparotomy and laparoscopy.

Leiomyoma remaining after vaginal hysterectomy for symptomatic leiomyomas. A case report.

BACKGROUND: A remaining leiomyoma, an uncommon postoperative complication of vaginal hysterectomy for symptomatic leiomyomas, occurred. CASE: A second vaginal operation for a remaining leiomyoma was necessary 1 month after a vaginal hysterectomy for a myomatous uterus. CONCLUSION: Checking the pelvic cavity during hysterectomy may avoid this complication.

Acceptance of outpatient flexible hysteroscopy by premenopausal and postmenopausal women.

OBJECTIVE: To compare tolerance for and feasibility of outpatient flexible hysteroscopy in premenopausal and postmenopausal women. STUDY DESIGN: A comparative, prospective study including 475 premenopausal and 216 postmenopausal women who underwent outpatient hysteroscopy without analgesia. RESULTS: Mean pain score was higher in postmenopausal patients (1.55 +/- 0.56 vs. 1.27 +/- 0.38 [P < .0001]). Outpatient flexible hysteroscopy was feasible without analgesia in 471/475 premenopausal (99.2%) and 210/216 postmenopausal women (97.2%) (P = .07). CONCLUSION: Outpatient flexible hysteroscopy was feasible and well tolerated; local anesthesia should be reserved for postmenopausal women.