Use and representations of intrauterine device in Martinique, F.W.I.: A cross-sectional survey.

INTRODUCTION: Abortion rate is higher in Martinique than in metropolitan France. Difference in pattern of contraception may be involved, particularly regarding IUD use. IUD use is often hampered by misconceptions. The aim of the study was to evaluate IUD use in a non-selected population in Martinique and to explore knowledge and acceptance of the method. MATERIAL AND METHODS: Women were submitted a self-questionnaire about their contraceptive history, appropriate candidates for, effectiveness, side effects and perceived risks of IUD. Acceptance of the method among men and women and reasons for rejecting it were also surveyed. We included 112 men and 136 women. Descriptive statistics and comparison of answers between ever and never IUD-users were realized. RESULTS: Past or current IUD use was found in 26.5% [19.3-34.8] of women and the method was known by 90.4% of women and 85.1% of men. Pain at insertion (important for 22%), infectious risk (increased for 23.6%), and eligible candidates for the method (possible in nulliparous for only 56.9%) were the main misconceptions recorded. Knowledge was better among ever than never IUD-users. Theoretical acceptance of the method was high (87.5% among women of reproductive age, 82.5% among men). Rejection of the method was mainly motivated by doubts on efficacy and fear from pain, whereas religious barriers were seldom set forward. DISCUSSION: IUD use seems comparable in Martinique and France but misconceptions are still common. Information may help diffusion of IUD in a targeted population at higher risk of unintended pregnancy.

Knowledge, attitudes and practices of pregnant women in Martinique in the immediate aftermath of the Zika virus outbreak.

INTRODUCTION: The WHO and the HCSP recognize the Zika virus as a public health problem of international concern primarily because of the foetal risks. During the epidemic in Martinique, several modifications to the normal obstetrical follow-up were set up and information had to be delivered to pregnant women about these modifications, the attitudes to prevent infection and the signs motivating additional visits. The objective of our work was to evaluate the knowledge, attitudes and practices of pregnant women in Martinique about the risks associated with Zika infection during pregnancy in the immediate aftermath of the epidemic. MATERIALS AND METHODS: A descriptive cross-sectional survey was conducted from February to May 2017. It took place through an anonymous and standardized face-to-face questionnaire. The questions dealt with the pregnant women general knowledge about the virus, information disseminated by media on this subject, the potential risks, the protective measures taken and the monitoring throughout the pregnancy in case of infection. RESULTS: The total sample consisted of 297 pregnant women. Despite a weak adherence to individual and domestic protection recommendations, we found a good level of knowledge about Zika virus from pregnant women in Martinique. The fetal risk in case of maternal infection was known for 96.6% of those surveyed, individual protective measures were followed by 64.6% of women, 77.0% knew where to go in case of suspected infection, and 79.4% reported that the modifications in follow-up mainly concerned ultrasound monitoring. CONCLUSION: The awareness campaign on zika virus had a significant impact on population's knowledge and main practical information was correctly captured. The information did not spill excessive fear. Nevertheless, modification of individual behavior appeared harder to obtain.

High abortion rate in Martinique (F.W.I.) in spite of a large contraceptive availability. What are the determinants?

INTRODUCTION: Despite a similar health insurance coverage and access to contraception, Martinique F.W.I. has a higher rate of abortion than continental France (25.6 versus 15.3 per thousand respectively). The reasons are still largely unknown. A different contraceptive pattern, a lower use of emergency contraception in Martinique may be involved. We sought to explore the contraceptive pattern, to evaluate the use of emergency contraception and the reasons leading to an unwanted pregnancy among women seeking for an abortion. MATERIAL AND METHODS: An anonymous cross-sectional survey about the contraceptive use in the year and in the month before abortion, the use of emergency contraception and the reasons why, to patients' point of view, they became pregnant albeit not willing it was proposed to women seeking for an abortion in the dedicated unit of the university hospital of Martinique. RESULTS: Six hundred patients were included. A total of 83.7% of patients declared having a regular contraceptive use during the year preceding. Just before abortion, 61.1% of women had no contraception or a low reliable method (fertility awareness, withdrawal…). Lack of recognition of pregnancy risk was the main reason leading to abortion, accounting for 51.1% of cases, explaining a low use of emergency contraception (13.8%), whereas a difficult access to contraception was rarely quoted. Emergency contraception was used in 27.8% of relevant situations. CONCLUSION: Insufficient estimation of pregnancy risk is the main reason leading to unwanted pregnancy. Availability of emergency contraception does not reduce the risk.

[A case study regarding the use of antibiotic therapies for the treatment of preterm premature rupture of fetal membranes, and emergence of antibiotic resistant bacteria]. / Comparaison des protocoles d'antibiothérapie en cas de rupture prématurée des membranes avant terme entre deux maternités de niveau III en termes de sélection de bacilles Gram négatifs résistants.

OBJECTIVE: The objective of this retrospective study is to compare two types of antimicrobial management used to treat premature rupture of membranes in pregnancy. This study evaluates both duration and the type of antibiotic therapy used for treatment. PATIENTS AND METHODS: The antimicrobials used to treat premature rupture of membranes include a first generation cephalosporin in one group and amoxicillin in the other group. Cephalosporin was used over a 7-day period to treat 38 cases, whereas amoxicillin was used through delivery in 52 cases. Emergence of multidrug-resistant Gram negative bacteria (GNB) on maternal of neonatal sampling was the primary outcome. RESULTS: Emergence of antibiotic resistant GNB can be seen under both antibiotic regimens and appears to be linked to the duration of latency, and to duration of antibiotic treatment. Other outcomes (duration of latency period, gestational age at delivery, maternal and neonatal complications) were similar in both groups. CONCLUSION: Antibiotic treatment in PPROM favors a selection of GNB. This emergence is positively linked with the duration of latency between rupture of membranes and delivery and with the length of antibiotic administration. The extension of antibiotherapy does not alter other maternal or neonatal parameters.

[Risk factors associated with spontaneous preterm deliveries before 30 weeks in Martinique F.W.I.: a case-control study]. / Facteurs de risque de prématurité spontanée avant 30 SA en Martinique: étude cas témoins.

OBJECTIVES: Early premature delivery is more prevalent in overseas territories than in continental France. Many differences are observed between pregnant women in France and in Martinique which may explain the higher preterm birth rate in the latter territory. The study compares prevalence of possible risk factors in preterm and term deliveries in Martinique. PATIENTS AND METHODS: A retrospective study was conducted during two years (2010-2011). All deliveries before 30 weeks were included and several characteristics were compared with a group of term deliveries during the same period. All premature deliveries before 30 weeks were collected but only spontaneous ones were analysed. RESULTS: Fifty deliveries before 30 weeks were recorded, among which 38 were spontaneous. Only a significantly higher prevalence of previous preterm delivery (OR=4.1 [1.3-13]) and twin pregnancies (OR=26.6 [3.19-219.6]) was found in the study group. Gram negative bacterial species were also more prevalent in vaginal sampling of preterm deliveries (OR=23.3 [2.7-204.6]). CONCLUSION: Factors linked to prematurity before 30 weeks in Martinique are classical. Several features are different between pregnant women in France and in Martinique but do not appear as risk factors for prematurity in the latter territory.

Is African descent an independent risk factor of peripartum cardiomyopathy?

Risk factors for peripartum cardiomyopathy (PPCM) are controversial. PPCM seems to be more prevalent in women of African descent, the highest observed incidence is in Haiti (1 per 300 live births). Our retrospective study conducted in Martinique showed an incidence of 1 per 5500 live births. This incidence is significantly lower than in Haiti. Women from Martinique and Haiti do not differ for most classical risk factors: African descent, age, pregnancy-associated hypertension, multiple pregnancy and pre-eclampsia. However, the parity rate and the socioeconomic level are different. Thus, African descent could be confounded by high parity rate and socioeconomic status.

[Twin dystocia: about one case of compaction]. / Dystocie gémellaire: à propos d'un cas de compaction.

We report a case of twin dystocia during the evacuation of full-term fetus both in cephalic presentation. A low-outlet forceps for second-phase arrest was performed for the first twin but the head remained stuck to maternal perineum, mimicking a shoulder dystocia. Digital examination found a twin compaction, that is the presence of the second twin's fetal head at the level of the first twin's chest. The discrepancy between fetal weights and the use of forceps could favor this rare complication. Various maneuvers were described previously attempted to solve the problem. Forcing back the second head may help to achieve delivery of the first twin.

[Isolated antenatal pyelic dilatation: postnatal follow-up and care for vesico-ureteral reflux]. / Dilatations pyéliques isolées: diagnostic prénatal, suivi postnatal et prise en charge des reflux vésico-urétéraux.

OBJECTIVE: To assess the risk of aneuploidia in case of isolated antenatal pyelic dilatation and to detail urological care for these children. METHODS: Prenatal and postnatal follow-up was analyzed in 350 cases. RESULTS: The overall rate of chromosome anomalies was 1.3%. Trisomy 21 was found alone in one case (0.3%). The sex ratio was 26% girls and 74% boys. Vesico-ureteral reflux was similar in both sexes (13%). CONCLUSION: The question of proposing karyotyping in case of isolated pyelic dilatation remains unsolved because minimal subjective signs such as slightly excessive amniotic fluid can completely change the assessment of the risk of aneuploidia. The frequency of postnatal vesico-ureteral reflux associated with prenatal pyelic dilatation warrants complete prenatal ultrasound screening.

Biochemical investigation of foetal and neonatal thyroid function using the ACS-180SE analyser: clinical application.

Despite sonographic detection of foetal goitre, uncertainty persists in the initial diagnosis of thyrotoxicosis and hypothyroidism. The aim of this study was to establish foetal and neonatal iodothyronine and thyrotrophin reference values for the ACS-180SE analyser. From 22 to 36 weeks of gestation, median foetal serum free thyroxine (FT4) levels increased from 6.0 pmol/L to 143 pmol/L, while free tri-iodothyronine (FT3) levels increased from 0.7 pmol/L to 1.9 pmol/L and mean thyrotrophin (TSH) levels remained stable (10.2 +/- 3.8mU/L; n = 33). At birth, concentrations were independent of gender and gestational age. Among the 10 cases of sonographically detected foetal goitre, serum TSH and FT4 were measured in five, showing hypothyroidism (3/5) or hyperthyroidism (2/5). Cord blood TSH levels reflected the efficacy of prenatal therapy. Measurement of foetal FT4 and TSH can be used to confirm foetal thyroid dysfunction, whereas treatment efficacy can be assessed sonographically and confirmed by measurement of TSH assay at birth.

Failure of cervical fibronectin to predict premature delivery in a population of monofetal pregnancies with idiopathic preterm labor.

OBJECTIVE: The purpose of the study was to evaluate the correlation between the presence of cervical fibronectin in a high-risk population of women with symptoms of preterm labor and the occurrence of preterm delivery or the need for aggressive tocolysis. STUDY DESIGN: One hundred and thirty women presenting with symptoms of threatened preterm labor were included. Cervical sampling for detection of fibronectin was performed on admission and every day until discharge or delivery. Time to delivery, length of hospital stay, use of indomethacin, delivery before 37 weeks of GA, mean term of delivery and failure of tocolysis to prevent delivery were compared to fibronectin test results. Data were analyzed using Student's t-test for continuous variables and the chi(2) test or Fisher exact test for discrete variables. RESULTS: No correlation could be found between the results of fibronectin cervical sampling on admission and any of the outcome parameters studied. Test performances were low (sensitivity 28%, specificity 57%, positive predictive value 19%, negative predictive value 69%). Results were not modified when the findings of repeated tests were taken into account. CONCLUSION: Cervical fibronectin failed to discriminate a subgroup of symptomatic women delivering prematurely. The prognostic value of fibronectin testing was not better than clinical data in our series. This observation is in disagreement with previous studies on the diagnostic value of vaginal or cervical fibronectin in preterm labor.

Neonatal group B streptococcal infection. Results of 33 months of universal maternal screening and antibioprophylaxis.

OBJECTIVE: To assess the efficacy and pitfalls of a protocol of generalized screening for group B Streptococcus (GBS) and intra-partum treatment of all carriers in a clinical setting. DESIGN: A descriptive study and comparison with an historical group. SETTING: A tertiary perinatal center. POPULATION: All women attending prenatal care in our center and delivered after 37 weeks were eligible. Study period ranged from January 1994 to September 1996. Comparison group consisted in deliveries of years 1992 and 1993. METHODS: Vaginal cultures were performed at 36 weeks on non-selective medium followed by intra-partum treatment of all carrier mothers. Rate of carriage, incidence of neonatal GBS sepsis, influence of risk factors and the reasons for failures were analysed. Comparison was made with an historical group. Statistical analysis was performed using a Chi-square test. RESULTS: There were 5374 term deliveries during the study. 3906 were screened (72.7%) and 559 of them found positive for GBS (14.3%). We observed 46 early-onset GBS diseases (0.86% of term-births). 43.5% of infections occurred in babies born from mothers without risks factors at delivery. Negative GBS cultures at sampling accounted for 43.5% of protocol failures. Comparison of the incidence of early-onset GBS disease with the previous two years showed a significant drop (1.45-0.86%, P<0.05). CONCLUSIONS: Our protocol revealed feasible and effective in reducing the incidence of early-onset GBS disease. Improvements must be studied particularly as to the predictive value of screening cultures.

Improvement of mesenteric superior artery Doppler velocimetry by amnio-infusion in fetal gastroschisis.

This study aimed to analyse the influence of amnio-infusion on superior mesenteric Doppler velocimetry and to correlate Doppler data with outcome in fetuses presenting with gastroschisis. Umbilical and intra- and extra-abdominal superior mesenteric artery Doppler velocimetry was measured prospectively before and after amnio-infusion in fetuses with gastroschisis. Doppler index values and changes were correlated with the following outcome parameters: importance of fibrous coating, duration of hospitalization in the neonatal intensive care unit, total duration of hospitalization, duration of parenteral feeding, duration of ventilatory assistance, and the interval to initiation of oral feeding. A significant improvement of diastolic flow was observed in the extra-abdominal superior mesenteric artery with amnio-infusion. No similar change was seen in the intra-abdominal superior mesenteric or in the umbilical artery. Pre-amnioinfusion extra-abdominal mesenteric Doppler index was correlated with maximal diameter of exteriorized bowel and slightly with duration of hospitalization in the neonatal intensive care unit, but no other relation between Doppler index and outcome parameter could be ascertained. Amnio-infusion induces modifications in the vascularization of exteriorized bowel in gastroschisis. This could partly explain the beneficial effect of this procedure on fetal gut.

Management of fetal thyroid goitres: a report of 11 cases in a single perinatal unit.

Fetal thyroid goitres may reveal hormonal imbalance. This can jeopardize neurological development and fetal outcome even when early postnatal treatment is provided. We report a series of 11 goitres diagnosed antenatally in women with past or present thyroid disorders or discovered fortuitously on ultrasound scan. Fetuses presented with hyperthyroidism in three cases and hypothyroidism in eight. Hypothyroidism was iatrogenic in five cases, due to maternal anti-thyroid drugs. Hyperthyroidism was induced by transplacental transfer of thyroid stimulating antibodies (TSHrab). Accurate diagnosis of fetal thyroid status was obtained by fetal blood sampling but this invasive method was deemed necessary only in four cases as maternal clinical and biological data and ultrasound signs provided sufficient information to infer the type of thyroid disorder in the remaining patients. Fetal therapy relied on reduction of maternal antithyroid medication and, in selected cases, intra-amniotic injection of levothyroxin in hypothyroidism, and on administration of antithyroid drugs in hyperthyroidism. All newborns were healthy and none displayed consequences of severe thyroid imbalance. No caesarean section was performed for dystocia. Fetal thyroid goitres can be managed successfully with selected use of invasive diagnostic and therapeutic techniques.

[Indications for axillary node dissection in breast cancers]. / Indications du curage axillaire dans les cancers du sein.

Axillary lymph node dissection is in theory of both therapeutic and prognostic benefit for patients with breast cancer. For several authors, its therapeutic function, which consists in surgical dissection of potentially metastatic nodes, may be assured effectively by radiotherapy, but results of different comparative studies are contradictive. However, axillary dissection should be eliminated for small tumors (< 5 mm) because of the low yield of positive nodes (< 3%). Even if new histologic prognosticators are currently in evaluation, axillary node stagging is the single most important prognostic variable, and determines the indication for chemotherapy for premenopausal patients. Morbidity remains high, even if rarely severe, and new technologies are studied to try to locate the first node draining the tumor, in order to pick it out electively for histologic examination.

Induction of transient murine T cell anergy by a low molecular weight compound obtained from supernatants of human placental cultures is linked to defective phosphorylation of TCR CD3 chain.

PROBLEM: Allopregnancy induces specific transient tolerance to paternal grafts, and we know that a low molecular weight material ("filtrate") present in a human placental supernatant can do so in vitro (specific unresponsiveness) as well as in vivo, such as when preventing graft-versus-host reaction (GVH) produced by A cells injected into irradiated A x B F1s recipient. We also know by studies carried out using specific anti-V beta-specific stimulation as well as secondary and primary mixed lymphocyte reaction in major histocompatibility complex (MHC) only incompatible combinations that the material acts by inducing T cell anergy rather than clonal deletion. We explored the mechanism of such an anergy, which we know was not dependent on calcium fluxes, cyclic adenosine monophosphate (cAMP) levels, or PkC by studies of protein phosphorylation. Having observed in previous studies that expression of T cell reactivity (TcR) in anergic cells was enhanced, but that the numbers of cells expressing a given reactivity (TcR) V beta after specific stimulation in the presence of a filtrate was much higher than it should be, we monitored the receptor expression by fluorescence-activated cell sorter (FACS). METHOD OF STUDY: We used short-term stimulation of the T-cell-derived Jurkat E6-1 cells by anti-CD3 monoclonal antibody (mAb) or phorbol myristite acetate plus calcium ionophore in the presence or absence of human placental low molecular weight suppressor factors, followed by Western blotting. Transfer on nitrocellulose filters so as to allow the revelation of the phosphorylations was realized by means of a specific antiphosphotyrosin mAb. The final revelation was obtained by chemiluminescence. Similar experiments were performed on anti-V beta-stimulated BALB/c splenocytes, as well as cyproflaxin-treated cells, which are hyper-responsive in cell proliferation assays in the presence of the filtrate. In parallel, cells that were stimulated by a specific anti-V beta and were rendered specifically anergic were studied by a specific anti-V beta and were rendered specifically anergic were studied for other TcR expression using an FACS and both fluorescein isothiocyanate (FITC) and phycoerythrin (PE)-labelled, related and unrelated anti-V beta mAbs. RESULTS: The phosphorylation of the zeta chain homodimer quantitatively defective in filtrate-treated, anti-V beta 6-stimulated splenocytes as well as in Jurkatt cells. In parallel, cells from cyproflaxin-treated Jurkatt cells were showing enhanced phosphorylation of all bands. The labelling of filtrate-treated anti-V beta 6-stimulated cells by an unrelated anti-V beta (anti-V beta 8) showed double expression of V beta chains. The percentage of cells expressing this unrelated V beta (V beta 8) was normal. CONCLUSIONS: T cell anergy induced by a filtrate is linked to defective phosphorylation of the zeta-chain homodimer. The abnormal percentage of the cells expressing TcR after filtrate treatment might be due to adsorption by unstimulated cells of soluble TcR V beta-chain, possibly as a result of excess synthesis followed by membrane protease cleavage, allowing release in a soluble form of TcR V beta-chain nonspecifically captured by other cells.

Immune suppression and Th1/Th2 balance in pregnancy revisited: a (very) personal tribute to Tom Wegmann.

PROBLEM: The paradigm of local suppression necessary to understand the survival of the fetal allograft is often compared with the host-tumor relationship. METHODS: We investigated two components of local immune suppression: placenta-induced immunosuppression, which is mediated at least in part by a soluble factor of low molecular weight that can induce anergy in lymphocytes, and interleukin-10 (IL-10). RESULTS: We show that enhancement of IL-10 production in the decidua and placenta after alloimmunization requires the presence of Asialo GM1+ cells. Placenta-induced immunosuppression is linked with defects in phosphorylation of some components of the T cell receptor. CONCLUSION: NK cells could be in fact regulatory cells pushing maternal immune response toward a Th2 profile, beneficial for fetal survival, or toward a Th1 type of immune response, which acts in synergy. Modulation of TcR may represent a new mechanism for maternal-fetal tolerance.