Identification of women at high risk for severe perineal lacerations.

OBJECTIVES: To evaluate the frequency and to identify the risk factors of severe perineal lacerations and the subgroup of women exposed to the highest risk for these complications. STUDY DESIGN: We conducted a case-control study in a large cohort of women for which vaginal delivery management consisted in systematic perineal support and restrictive use of mediolateral episiotomy. The case group comprised women with severe perineal lacerations while the control group comprised women without severe perineal lacerations. Maternal, labor, delivery and neonatal characteristics were analyzed in logistic regression models and a classification and regression tree (CART) was constructed. RESULTS: Between 2000 and 2009, 19,442 women delivered vaginally in our centre, 88 of whom had severe perineal lacerations (0.5%). Instrumental delivery (aOR 4.17, 95% CI 2.51-6.90), nulliparity (aOR 2.58, 95% CI 1.55-4.29), persistent posterior orientation (aOR 2.24, 95% CI 1.02-4.94) and increased birth weight (aOR 1.28, 95% CI 1.03-1.60) were independent risk factors of severe perineal lacerations whereas mediolateral episiotomy had a protective effect (aOR 0.38, 95% CI 0.23-0.63). CART identified instrumental delivery of neonates smaller than 4500 g in persistent posterior orientation in nullipara without mediolateral episiotomy as the clinical situation associated with the highest risk of severe perineal lacerations (12.5%). Conversely, patients with the lowest risk (0.1%) were those delivering spontaneously, neonates larger than 3200 g after mediolateral episiotomy. CONCLUSIONS: Instrumental delivery, nulliparity, persistent posterior orientation and increased birth weight are independently associated with severe perineal lacerations. Restrictive use of mediolateral episiotomy protects against severe perineal lacerations especially in case of instrumental delivery.

Cervical ripening with low-dose prostaglandins in planned vaginal birth after cesarean.

OBJECTIVES: To compare uterine rupture, maternal and perinatal morbidity rates in women with one single previous cesarean after spontaneous onset of labor or low-dose prostaglandin-induced cervical ripening for unfavourable cervix. STUDY DESIGN: This was a retrospective cohort study of 4,137 women with one single previous cesarean over a 22-year period. Inpatient prostaglandin administration consisted in single daily local applications. RESULTS: Vaginal delivery was planned for 3,544 (85.7%) patients, 2,704 (76.3%) of whom delivered vaginally (vaginal birth after Cesarean (VBAC) rate = 65.4%). Among women receiving prostaglandins (n=515), 323 (62.7%) delivered vaginally. Uterine rupture (0.7% compared with 0.8%, OR 1.1, 95% CI 0.4-3.4, p=0.88), maternal (0.9% compared with 1.2%, OR 1.3, 95% CI 0.5-3.2, p=0.63) and perinatal (0.3% compared with 0.8%, OR 2.4, 95% CI 0.7-8.5, p=0.18) morbidity rates did not differ significantly between patients with spontaneous onset of labor and those receiving prostaglandins, nor did these rates differ according to the planned mode of delivery. CONCLUSION: In comparison with patients with spontaneous labor, inducing cervical ripening with low-dose prostaglandins in case of unfavourable cervix is not associated with appreciable increase in uterine rupture, maternal or perinatal morbidity.

Multiple synchronous (multifocal and multicentric) breast cancer: clinical implications.

Multifocality in breast cancer is a frequent phenomenon, whose prevalence may vary between 13 and 75%. The differences in estimation of the prevalence of multifocality across studies may be explained by the differing definitions used for multifocality and multicentricity; this inconsistency makes it difficult to analyze the literature on the subject. The incidence of multifocality is probably often underestimated. Currently, the diagnosis relies on imaging. The performance of mammography is relatively low, but the addition of breast ultrasonography can improve diagnostic sensitivity. Recently, breast magnetic resonance imaging (MRI) has been shown to be more accurate for detecting multifocality compared to conventional imaging. However, this modality is associated with high rates of false-positives that could result in inappropriate disease management. Thus, the use of MRI is not recommended as a first-line technique for diagnosing multifocality. The diagnosis of multifocality is important for breast cancer management, particularly with regards to the choice of surgery. A finding of multifocality may spur a decision to perform a wider excision that will avoid positive margins. Regarding the results of conservative surgery in the presence of multifocality, studies are contradictory, and no international consensus exists. Multifocality may also modify the management of the axillary basin; studies have shown that multifocality is associated to an over-risk of 20% of lymph node invasion. The sentinel node biopsy has been considered as an alternative to complete axillary lymph node dissection by the American Society of Clinical Oncology. The prognostic value of multifocality is still not well known, although some studies have suggested that it is associated with a worst prognosis. Further studies are needed to better assess the impact of multifocality on breast cancer prognosis.

Pregnancy outcomes in women with HIV type-1 receiving a lopinavir/ritonavir-containing regimen.

BACKGROUND: The pregnancy-related adverse effects of antiretroviral therapy (ART) have yielded discordant results, which could be explained in part by the heterogeneity of ART protocols. The objective of our study was to explore whether lopinavir/ritonavir (LPV/r) exposure during pregnancy is associated with adverse outcomes. METHODS: Data on 100 consecutive HIV type-1 (HIV-1)-infected women receiving LPV/r during pregnancy and who delivered after 15 weeks gestational age (GA) between January 2003 and June 2007 in a single centre were analysed. For each HIV-1-infected woman, two uninfected women matched by age, parity and geographical origin were selected among patients delivering during the same period. Preterm delivery (PTD), vasculoplacental complications, gestational glucose intolerance and post-partum complication rates were compared between cases and controls. Factors associated with PTD and post-partum complications were assessed in HIV-1-infected women by a logistic regression model. RESULTS: Rates of vasculoplacental complication and gestational glucose intolerance were not higher among HIV-1-infected women than in controls. PTD was higher in HIV-1-infected women (21%) than in controls (10%; P<0.01). In HIV-1-infected women, PTD was associated with HIV-1 RNA level > or =50 copies/ml at delivery (adjusted odds ratio 6.15, 95% confidence interval 1.83-20.63; P=0.003). No association was found between occurrence of PTD and LPV/r exposure before 14 weeks GA. CONCLUSIONS: In this population of HIV-1-infected pregnant women receiving LPV/r, the risk of PTD was higher than in HIV-1-uninfected controls. As PTD risk was not associated with early exposure to LPV/r, these data support current guidelines to initiate ART earlier in pregnancy.