Prevalence and surgical outcomes of stage 3 and 4 pelvic organs prolapse in Jimma university medical center, south west Ethiopia.

BACKGROUND: Pelvic organ prolapse (POP) affects about half of the women and affects their quality of life. The current study is, therefore, aimed at determining the prevalence and surgical outcomes of severe stage POP at Jimma University medical center from November 2016 to May 2018. METHOD: A Hospital-based cross-sectional study was conducted on all patients with stage 3 and 4 POP, who were admitted, and had surgery. Data were collected from the patient's chart, and logbooks, which were filled up from entry till her discharge. A Simplified POPQ(S-POPQ) was used to stage the prolapse at admission, at discharge, and three months follow-ups. RESULTS: Among 92 patients who were analyzed, POP accounts for 10.6% of all gynecologic admissions, and 43.8% of all gynecologic surgeries. The mean age of patients is 46 (± 12) years, and nearly 34% of the patients had stage 3 and 66% had stage 4 POP. Based on the type of prolapse, 93.5% of patients had stage 3 and more anterior vaginal wall prolapse (AVWP) and apical prolapse, while 57.6% had stage 3 or more posterior vaginal wall prolapse. Out of 72 patients who had anterior colporrhaphy, 58.7% had anterior colporrhaphy with colposuspension. Out of 83 patients who had apical suspension, 48.2%, 39.8%, and 12% had uterosacral, sacrospinous, and Richardson respectively. Ninety-seven patients had stage 0 or 1 POP at discharge while 90% of 20 patients who returned for follow-up at three months had stage 0 or 1 POP. Eight patients had surgery-related complications; bladder injury, urinary retention, Hemorrhage during SSLF, and rectal injury. CONCLUSION: The prevalence of pelvic organ prolapse is high and the majority of patients presented with advanced-stage pelvic organ prolapse, with a long duration of symptoms and associated problems. The surgical techniques used have resulted in a high immediate success rate of 97% and 90% at discharge and three months follow up respectively. Therefore, awareness creation activities are important to facilitate an early presentation for treatment to improve the quality of life and the current surgical technique; native tissue vaginal repair (NTVR), being practiced in the setup has had better success.

Quality of life after laparoscopic removal of Essure® sterilization devices.

OBJECTIVES: To assess changes in quality of life after laparoscopic removal of Essure® sterilization devices (Bayer AG, Leverkusen, Germany). STUDY DESIGN: In this prospective observational study in an academic research hospital, 80 women with new or worsening symptoms since placement of Essure® sterilization devices undergoing subsequent surgical removal were included. Laparoscopic removal of Essure® devices and salpingectomy with or without cornual excision were performed. Concomitant uterine procedures could be associated where indicated for gynaecological complaints. Comparison using the T student test for coupled series was done in this before-and-after study. RESULTS: Health related quality of life (HRQL) was the primary outcome measured by the Short Form 12 (SF-12) questionnaire and a global 10 cm visual analogue scale (VAS). Secondary outcomes included assessment of pain, using continuous (VAS) and ordinal scales (Modified McGill Pain Questionnaire), menstrual bleeding (pictorial blood loss assessment chart (PBAC) score) and surgical feasibility and safety. There was a significant improvement in quality of life in both mental and physical health aspects of the SF-12 (34.02 (+/-1.19) vs. 49.61 (+/-1.42, P < .0001) and 36.55 (+/-0.99) vs. 43.32 (+/-1.18, P < .0001 respectively) as well as global VAS assessment (+2.91 (SD +/-0.27)) at the end of the first post-operative month. These improvements were maintained at three and six months. Mean pain decreased at one month following surgery compared to baseline (VAS 3.6 (+/-0.36) to 1.4 (+/-0.25), P < .0001 and McGill pain score 18.70 (+/-1.88) to 4.73 (+/-0.90), P < .0001). Improvements of a similar magnitude were observed when analysis was restricted to the 47 women without concomitant uterine surgery. No significant changes in bleeding were seen following of Essure® device removal. Planned procedures were all successfully completed. CONCLUSION: Laparoscopic removal of Essure® devices in symptomatic women is technically successful and associated with short and medium-term improvement in quality of life as well as reduction in pelvic pain.

Intentional early delivery versus expectant management for preterm premature rupture of membranes at 28-32 weeks' gestation: A multicentre randomized controlled trial (MICADO STUDY).

OBJECTIVES: Preterm premature rupture of fetal membranes (PPROM) exposes the fetus to preterm birth, and optimal timing for delivery is controversial. The aim of this study was to compare intentional early delivery ("active management") with expectant management in very preterm birth (28-32 weeks). STUDY DESIGN: We conducted a prospective randomized controlled trial with intent-to-treat analysis, at 19 tertiary-care hospitals in France and 1 in Geneva, Switzerland. Inclusion criteria were women age ≥18 years, PPROM at 280/7 to 316/7 weeks' gestation, singleton pregnancy. Exclusion criteria were maternal/fetal indications for immediate delivery. All participants received prophylactic antibiotics (amoxicillin + gentamicin) and two doses of corticosteroids. Women in expectant management delivered at 34 weeks, sooner if medically indicated. Women in active management delivered 24 h after the second steroid dose. The primary outcome measure was a composite of neonatal death/severe adverse events: periventricular leukomalacia, intraventricular hemorrhage, sepsis, oxygen requirement at 36 weeks, and necrotizing enterocolitis. The secondary outcome was clinical chorioamnionitis. RESULTS: The trial was stopped prematurely, due to recruitment difficulties. Of 360 women assessed, 139 (40% of calculated sample size) were randomized: 70 to expectant management, 69 to active management. Mean gestational age at PPROM was similar in both groups (30 ± 1.3 vs. 30.2 ± 1.2 weeks, respectively). There were 35 cases of medical/suspected complications requiring delivery in expectant management vs. 4 in active management. Mean latency between PPROM and delivery was 11.7 ± 9.8 vs. 2.8 ± 0.6 days, respectively; P < 0.0001 (median 8.4 (1.8-44.2) vs. 2.7 (1.9-4.3)). There were more caesarean deliveries in active than expectant management (80% vs. 60%, respectively; P < 0.01). There were 2 chorioamnionitis cases, both in expectant management. One baby died in expectant management; 2 in active management (one with heart defect). There was no significant difference in sepsis rates. The combined neonatal death/severe adverse events measure was 12.9% for expectant management and 13.0% for active management (OR 0.98; 95% CI: 0.33-2.93, P = 0.97). CONCLUSION: For PPROM at 28-32 weeks, and with antenatal antibiotic and steroid therapy, there were no observed differences in neonatal health when comparing expectant management to early delivery. As expected, expectant management resulted in higher gestational age and birth weight. However, our study was underpowered to draw firm and reliable conclusions.

Opportunistic Salpingectomy at the Time of Benign Laparoscopic Hysterectomy: Assessment of Possible Complications and Histopathological p53-Signatures.

INTRODUCTION: The aim of this study is to assess the prevalence of tubal histopathological abnormalities (serous tubal intraepithelial carcinoma STIC and p53 signatures) and the prevalence of perioperative and postoperative complications related to opportunistic laparoscopic salpingectomy in a low risk population. MATERIALS AND METHODS: In this observational prospective cohort, prophylactic bilateral salpingectomy during benign laparoscopic hysterectomy was systematically performed in 100 consecutive women. Peri- and postoperative complications were registered. Duration of salpingectomy and post-salpingectomy blood loss were also measured. Histopathological and immunohistochemical analysis with anti-p53 antibody were performed on the whole fallopian tubes according to a specific and validated protocol. RESULTS: Laparoscopic salpingectomy was always possible without any peri- or postoperative complication attributable to the salpingectomy itself. The mean duration was 428 seconds (354 - 596) and the blood loss was 9 cm 3 (2 - 15). Using histopathological and immunohistochemical assessment with anti-p53 antibody on 199 fallopian tubes (99 bilateral salpingectomies and one unilateral salpingectomy because of previous salpingectomy for ectopic pregnancy), there was a prevalence of 5.52% (11/199) of p53 signatures. No STIC were observed and no associated cancer. CONCLUSIONS: Laparoscopic salpingectomy is both feasible and innocuous during benign hysterectomy. Meticulous histopathologic examination of the tubes may reveal specific abnormalities.

Opportunistic salpingectomy during vaginal hysterectomy for a benign pathological condition.

INTRODUCTION AND HYPOTHESIS: The objective was to evaluate the surgical feasibility of opportunistic salpingectomy or salpingo-oophorectomy during benign vaginal hysterectomy (HV) and the prevalence of occult tubal lesions. METHODS: In this prospective study from 1 September 2013 to 1 November 2015, the prevalence of bilateral salpingectomy with or without ovariectomy and the prevalence of histopathological and immunohistochemical tubal abnormalities were assessed. RESULTS: A total 115 patients were included. Bilateral salpingectomy was performed in 85 patients (73.92%; group A) and was technically impossible in 30 patients (26.08%; group B). Older patients (62.9 vs 57.5 years, p = 0.009), menopausal status (83.33% vs 62.35%, p = 0.03) and elevated BMI (27.58 vs 25.05 p = 0.03) were statistically associated with failure of salpingectomy. There was only one case of postoperative hemorrhage in group A. There was no difference with regard to intra- or postoperative complications, blood loss, and operating time between the two groups. Among the 67 fallopian tubes analyzed with a validated histopathological protocol, there were 8 (11.94%) immunohistochemical abnormalities with a "p53 signature." CONCLUSIONS: With the recent demonstration of a tubal origin of most ovarian cancer, opportunistic salpingectomy could be a theoretically relevant prevention strategy. Bilateral salpingectomy could be performed during benign vaginal hysterectomy by experienced surgeons. The advantages and disadvantages of exclusive salpingectomy during pelvic floor surgery should be discussed with the patients.

The genital prolapse of Australopithecus Lucy?

INTRODUCTION AND HYPOTHESIS: The female bony pelvis has to fulfil opposing functions: it has to be sufficiently closed to support the pelvic viscera in the upright position, while remaining sufficiently open to allow vaginal delivery. We aim to give an evolutionary perspective and the possible evolution of the bony pelvis from Lucy to the modern female with the implications in terms of genital prolapse. METHODS: Thirteen pelvimetric measurements were performed on 178 bony pelves: 1 fossil pelvis from Australopithecus Lucy, 128 female Caucasian modern adult pelves and 49 female Catarrhine pelves (29 gorillas and 20 chimpanzees). RESULTS: Lucy's pelvis shape was the most transversely oval, short and broad, termed platypelloid. Modern female pelves were transversely oval only at the inlet. A protruding ischial spine, fairly small ischial tuberosities and a sacral concavity made Lucy closer to Homo sapiens and less like the great apes. In the last group, pelvic planes were anteroposteriorly oval, except in the gorilla, where the outlet was round or slightly transversely oval. The subpubic angle was narrowest in Lucy, whereas it was greater than 90° in the great apes. CONCLUSIONS: The female pelvis is involved in both visceral support and parturition and represents a compromise. The narrower pelvis of Australopithecus Lucy provided protection against genital prolapse, but resulted in complex obstetrical mechanics. From an evolutionary perspective, the pelvis of Homo sapiens became modified to make parturition easier, but increased the risk of genital prolapse: the ilia became wide open laterally and the sacrum broadened with a shorter distance between the sacroiliac and coxofemoral joints.

[Prophylactic salpingectomy or salpingo-oophorectomy as an ovarian cancer prevention?]. / Salpingectomie prophylactique ou annexectomie prophylactique dans la prévention du cancer de l'ovaire ?

A recent hypothesis has stated that many ovarian cancers (especially high-grade serous histotype) could arise from the distal part of the fallopian tube. On one hand we know that risk-reducing salpingo-oophorectomy is the most effective prevention for ovarian cancer among BRCA mutation carriers. On the other, oophorectomy increases the relative risk for cardiovascular, osteoporotic psychosexual and cognitive dysfunctions in premenopausal women. This raises the question whether bilateral salpingectomy could be an effective strategy in the prevention of ovarian cancer in case of hereditary predisposition and in the general population. Here we discuss origin of ovarian cancer in the light of the latest molecular studies and the relative risks and benefits of a strategy of exclusive salpingectomy in comparison with the classical adnexectomy.

Does ultrasonic advanced energy reduce lymphocele incidence in laparoscopic para-aortic lymphadenectomy?

OBJECTIVE: To evaluate the use of ultrasonic advanced energy in reducing the occurrence of symptomatic lymphocele and its related complications in laparoscopic extra-peritoneal para-aortic lymphadenectomy in patients with gynecological cancer. STUDY DESIGN: A retrospective cohort study of consecutive patients in a tertiary referral center identified 2 groups of patients, undergoing laparoscopic extra-peritoneal para-aortic lymphadenectomy with or without the use of ultrasonic advanced energy. Surgery time, hospital stay, number of retrieved nodes and lymphocele requiring treatment were studied. Results were also compared between trained and trainee surgeons. RESULTS: 163 patients were scheduled for laparoscopic extra-peritoneal para-aortic lymphadenectomy: 81 treated using bipolar energy (control group: group 1) between August 1999 and January 2005, and 82 treated using ultrasonic advanced energy (study group: group 2) between July 2010 and March 2014. The main indication (90% in group 1, 61% in group 2) was advanced cervical carcinoma (stage IB2 and above). Ultrasonic advanced energy significantly decreased operative time (p=0.001) and intra-operative bleeding (p=0.01) and increased the number of para-aortic nodes retrieved (p=0.02). There was no significant difference in hospital stay or lymphocele requiring treatment (8.6% in group 1, 8.5% in group 2: p=0.98). For senior than for junior surgeons, surgery time was shorter but not significantly (p=0.80) and postoperative lymphocele rates were identical. CONCLUSION: Ultrasonic advanced energy may provide benefit in laparoscopic para-aortic lymphadenectomy, facilitating surgical ergonomics, but did not decrease post-surgery lymphocele.

Long-term outcome after overlapping anterior anal sphincter repair for fecal incontinence.

PURPOSE: The aim was to assess long-term results and quality of life following anterior anal sphincter repair for anal incontinence. PATIENTS AND METHODS: Twenty-three female patients underwent anterior anal sphincteroplasty over a 10-year period between January 1999 and January 2009 in a gynecological surgery department. Patients were asked to complete pre- and postoperative questionnaires comprising the Jorge and Wexner incontinence score. The secondary objective was to assess pre- and post-sphincteroplasty symptom severity and sexual quality of life. Mean follow-up was 87 months (median, 91.5 months). Kaplan-Meier time-to-event analysis was applied. RESULTS: Mean age was 52 years (±15.2), and mean postoperative Jorge and Wexner score, 7.5/20 (±4.1). Seventeen patients (85 %) declared themselves satisfied by the repair; 12 (60 %) showed good fecal continence. Fecal incontinence had a negative impact on quality of life for 15 % and on sexuality for 50 % of patients. Kaplan-Meier analysis showed 85 % conservation of anal continence correction at 1 year, 74 % at 48 months, 67 % at 60 months, and 48 % at 84 months. CONCLUSIONS: Overlapping anterior anal sphincter repair provided lasting improvement in fecal incontinence, with satisfactory long-term functional results. At 84 months' follow-up, 48 % of patients maintained good fecal continence, with a satisfaction rate of 85 %. Anal sphincteroplasty may be a first-line attitude in young female fecal incontinence patients with a recent sphincter defect following initially undiagnosed obstetric trauma and also restores perineal comfort.

Early preinvasive lesions in ovarian cancer.

Faced with the catastrophic prognosis for ovarian cancer due to the fact that it is most often diagnosed late at the peritoneal carcinomatosis stage, screening and early detection could probably reduce the mortality rate. A better understanding of the molecular characteristics of the different ovarian cancer subtypes and their specific molecular signatures is indispensable prior to development of new screening strategies. We discuss here the early natural history of ovarian cancer and its origins.

Female urinary incontinence and intravaginal electrical stimulation: an observational prospective study.

OBJECTIVE: To assess the efficacy of intravaginal electrical stimulation in the management of female urinary incontinence. STUDY DESIGN: 359 Women with urinary incontinence (207 with stress incontinence [group A], 33 with urge incontinence [group B] and 119 with mixed urinary incontinence [group C]) were included in this multicenter prospective observational study. Patients were managed by home intravaginal electrical stimulation of the pelvic floor for 20-30 min per day, 5 days a week, for a period of 10 weeks. Identical clinical assessments were performed before and after pelvic floor rehabilitation, comprising a voiding diary and validated symptom and quality of life scores. RESULTS: Objective assessment demonstrated an overall cure rate of 63.5% (228/359): 65.7% (136/207) for group A, 57.6% (19/33) for group B, and 61.3% (73/119) for group C. The overall significant improvement rate was 15.6% (56/359): 14.6% (30/207) for group A, 24.2% (8/33) for group B and 15.1% (18/119) for group C. All domains of quality of life were significantly improved after pelvic floor muscle training (p<0.0001) with a patient satisfaction rate of 83.6%. Treatment was well tolerated with 1.4% (5/359) of patients describing pain at the highest stimulation intensities. No significant difference was observed between the various types of electrodes used (p<0.0001). CONCLUSION: The quantitative and qualitative efficacy in terms of social and psychological consequences and quality of life of home pelvic floor muscle training stimulators probably make this treatment modality one of the first-line treatments for female stress urinary incontinence.

High risk HPV contamination of endocavity vaginal ultrasound probes: an underestimated route of nosocomial infection?

BACKGROUND: Endocavity ultrasound is seen as a harmless procedure and has become a common gynaecological procedure. However without correct disinfection, it may result in nosocomial transmission of genito-urinary pathogens, such as high-risk Human Papillomavirus (HR-HPV). We aimed to evaluate the currently recommended disinfection procedure for covered endocavity ultrasound probes, which consists of "Low Level Disinfection" (LLD) with "quaternary ammonium compounds" containing wipes. METHODS: From May to October 2011 swabs were taken from endovaginal ultrasound probes at the Gynecology Department of the Lyon University Hospital. During the first phase (May-June 2011) samples were taken after the ultrasound examination and after the LLD procedure. In a second phase (July-October 2011) swab samples were collected just before the probe was used. All samples were tested for the presence of human DNA (as a marker for a possible transmission of infectious pathogens from the genital tract) and HPV DNA with the Genomica DNA microarray (35 different HPV genotypes). RESULTS: We collected 217 samples before and 200 samples after the ultrasound examination. The PCR was inhibited in two cases. Human DNA was detected in 36 (18%) post-examination samples and 61 (28%) pre-examination samples. After the ultrasound LLD procedure, 6 (3.0%) samples contained HR-HPV types (16, 31, 2×53 and 58). Similarly, HPV was detected in 6 pre-examination samples (2.7%). Amongst these 4 (1.9%) contained HR-HPV (types 53 and 70). CONCLUSION: Our study reveals that a considerable number of ultrasound probes are contaminated with human and HR-HPV DNA, despite LLD disinfection and probe cover. In all hospitals, where LLD is performed, the endovaginal ultrasound procedure must therefore be considered a source for nosocomial HR-HPV infections. We recommend the stringent use of high-level disinfectants, such as glutaraldehyde or hydrogen peroxide solutions.

Pregnant French women living in the Lyon area are iodine deficient and have elevated serum thyroglobulin concentrations.

BACKGROUND: Iodine deficiency (ID) remains common in Europe, and may be especially detrimental during pregnancy. The aim of our study was to assess iodine status and thyroid function in healthy pregnant women in the Lyon metropolitan area. METHODS: In a cross-sectional study, healthy pregnant women (n=228) with no history of thyroid disease were consecutively recruited from an obstetric clinic during all trimesters. Thyrotropin (TSH), free thyroxine (FT4), anti-thyroid peroxidase (anti-TPO) antibodies, thyroglobulin (Tg), and urinary iodine concentration (UIC) (n=100) were measured. Thyroid functions were compared with those in a control group of nonpregnant adults. RESULTS: The median (range) UIC was 81 (8-832) µg/L, and 77% of pregnant women had a UIC <150 µg/L, indicating inadequate iodine intake. Overall, 11% of women had abnormal TSH or anti-TPO. The median FT4 (pmol/L) was 14.9, 12.6, and 11.5 in the first, second, and third trimesters, respectively. The median Tg in pregnant women was 16.2 µg/L, did not differ across trimesters, and was significantly higher than in the control group of nonpregnant adults (11.7 µg/L) (p=0.02). Controlling for maternal age and week of gestation, UIC was not a significant predictor of any of the thyroid function tests. CONCLUSIONS: Pregnant women in the Lyon area are iodine deficient and have increased serum Tg concentrations compared with nonpregnant controls, likely due to physiological thyroid hyperstimulation during gestation exacerbated by ID.

Diagnosis and management of adult female stress urinary incontinence: guidelines for clinical practice from the French College of Gynaecologists and Obstetricians.

Urinary incontinence is a frequent affliction in women and may be disabling and costly {LE1}. When consulting for urinary incontinence, it is recommended that circumstances, frequency and severity of leaks be specified {Grade B}. The cough test is recommended prior to surgery {Grade C}. Urodynamic investigations are not needed before lower urinary tract rehabilitation {Grade B}. A complete urodynamic investigation is recommended prior to surgery for urinary incontinence {Grade C}. In cases of pure stress urinary incontinence, urodynamic investigations are not essential prior to surgery provided the clinical assessment is fully comprehensive (standardised questionnaire, cough test, bladder diary, post-void residual volume) with concordant results {PC}. It is recommended to start treatment for stress incontinence with pelvic floor muscle training {Grade C}. Bladder training is recommended at first intention in cases with overactive bladder syndrome {Grade C}. For overweight patients, loss of weight improves stress incontinence {LE1}. For surgery, sub-urethral tape (retropubic or transobturator route) is the first-line recommended technique {Grade B}. Sub-urethral tape surgery involves intraoperative risks, postoperative risks and a risk of failure which must be the subject of prior information {Grade A}. Elective caesarean section and systematic episiotomy are not recommended methods of prevention for urinary incontinence {Grade B}. Pelvic floor muscle training is the treatment of first intention for pre- and postnatal urinary incontinence {Grade A}. Prior to any treatment for an elderly woman, it is recommended to screen for urinary infection using a test strip, ask for a bladder diary and measure post-void residual volume {Grade C}. It is recommended to carry out a cough test and look for occult incontinence prior to surgery for pelvic organ prolapse {Grade C}. It is recommended to carry out urodynamic investigations prior to pelvic organ prolapse surgery when there are urinary symptoms or occult urinary incontinence {Grade C}.

Neonatal outcomes after elective delivery management of preterm premature rupture of the membranes before 34 weeks' gestation (DOMINOS study).

OBJECTIVE: The objective was to compare the impact of the reason for delivery (elective delivery versus spontaneous onset of labor) on neonatal outcome after preterm premature rupture of the membranes (PPROMs). STUDY DESIGN: A regional prospective cohort study of all women with PPROM at between 24 and 34 weeks' gestation was conducted. We compared the effects of elective delivery (n=133), spontaneous labor (n=170), and admission for medical complications (n=169) like fetal distress, maternal hyperthermia, or placental abruption, on neonatal outcomes. Primary outcome measures were a composite of neonatal mortality and morbidity, which included periventricular leukomalacia, grade III/IV intraventricular hemorrhage, neonatal sepsis, and oxygen requirement at 36 weeks' gestation. RESULTS: Among 472 cases, mean gestational age at PPROM was 31.2+/-2.6 weeks. Neonatal outcomes improved as gestational age advanced, but a latency period of over 14 days did not improve outcomes. A logistic regression analysis showed that only elective delivery (OR 0.41, 95%CI: 0.19-0.87, P=0.02), maternal age >35 years (OR 2.13, 95%CI: 1.19-3.85, P=0.01), and gestational age at rupture remained associated with primary outcome. CONCLUSION: Elective delivery in women with PPROM can be associated with decreased neonatal morbidity compared to spontaneous labor.

Modeling the duration of the latency period after preterm premature rupture of the membranes according to maternal and pregnancy characteristics: DOMINOS study.

OBJECTIVE: The objective was to assess the effects of maternal and pregnancy characteristics on the rupture-to-delivery interval. STUDY DESIGN: DOMINOS study, a descriptive prospective population-based study, recorded the characteristics of 598 pregnancies with preterm premature rupture of the membranes (PPROM) between 24 and 34 weeks' gestation. Univariate and multivariate analyses was performed that were likely to affect the rupture-to-delivery interval. RESULTS: Sixty percent of babies were born within 1 week. Three factors shortened the delay: multiple pregnancies, preterm labor before PPROM, and PPROM after 32 weeks. The estimated median interval for a single pregnancy occurring between 32 and 34 weeks' gestation was 4.68 days (95% CI 3.90; 5.61). This interval was shorter in multiple pregnancies, but doubled with PPROM before 32 weeks' gestation. CONCLUSION: The estimate of the rupture-to-delivery interval according to maternal and pregnancy characteristics may help in comparing the benefit in terms of reduction of prematurity with the risk of complications such as chorioamnionitis or fetal distress.

Maternal leukocytosis after preterm premature rupture of membranes and infant neurodevelopmental outcome: a prospective, population-based study (Décrire L'ouverture des Membranes Inopinée le Nouveau-né et l'Organisation des Soins [DOMINOS] Study).

OBJECTIVE: To evaluate the relationship between maternal leukocytosis in women admitted after preterm premature rupture of the membranes (PPROM) and the neurodevelopmental outcomes of their infants at two years of age. METHODS: A prospective cohort study of women with PPROM occurring between 24 weeks and 33 weeks and 6 days of gestation was conducted in a region of France over two years. The primary outcome was a composite of neurodevelopmental variables, including motor impairment (an inability to stand without support, walk, run, or climb or descend stairs alone), auditory impairment, visual impairment, or the presence of monoplegia, diplegia, or hemiplegia at two years of age. Multiple logistic regression analysis was used to adjust for confounding factors. RESULTS: Of 394 cases, 6/64 neonates (9.4%) born to mothers with leukocytosis were no longer alive at the two-year follow-up, compared with 14/330 (4.2%) born to mothers with no leukocytosis (P = 0.09). At two years of age, 28 (56%), 22 (52%), 34 (49%), and 52 infants (37%) showed at least one of the primary outcome features for PPROM occurring at 24-27, 28-29, 30-31, and 32-33 weeks' gestation, respectively. In univariate analysis, PPROM at less than 30 weeks, leukocytosis, and cerclage were associated with a higher rate of the primary outcome. In logistic regression analysis, only leukocytosis remained significant (odds ratio [OR] 2.92; 95% confidence intervals [CI] 1.33-6.39, P = 0.02). Fewer infants whose mothers had a leukocyte count (WBC) .15 000/mm3 at the time of PPROM showed a feature of the primary outcome at two years of age than infants whose mothers had a higher WBC (P < 0.01). CONCLUSION: Maternal leukocytosis at admission is associated with higher adverse infant neurodevelopmental outcomes at two years of age. Guidelines for the management of women with PPROM who do not begin to labour should include consideration of the degree of leukocytosis.

Effect of latency period after premature rupture of membranes on 2 years infant mortality (DOMINOS study).

OBJECTIVE: To assess the impact of a short latency period after preterm premature rupture of the membranes (PPROM) on infant mortality. STUDY DESIGN: A prospective cohort study of women with PPROM between 24(0/7) and 33(6/7) weeks' in singleton gestation was performed in all maternity wards of the Rhône-Alpes Region. Neonatal and infant outcomes were compared according to the latency period (<48 h and > or =48 h). The primary outcome was the mortality rate and the secondary outcome was a composite variable of significant neurological disorders at 2 years of age. Outcomes was stratified according to gestational age at rupture. Univariate and multiple logistic regression analyses were used with SAS statistical software. RESULTS: Out of 471 women recruited in the study at a mean gestational age of 30.5+/-0.2 weeks, 170 (37%) presented with a <48-h latency period, and 301 (63%), a > or =48-h latency period. While prior to 30 weeks' gestation, the mortality rate was higher in neonates with a short latency period (16.3% versus 7.3%, p < 0.01) with pulmonary disease being the major cause of death, a short latency period was associated with a lower mortality rate after 30 weeks' gestation (0% versus 3.7%, p=0.02). After adjusting for confounding factors, a <48-h latency period remained an independent factor associated with infant mortality prior to 30 week's gestation (odds ratio 3.8, 95% confidence interval 1.3-11.7). Significant neurological disorders were not modified by the length of the latency period. CONCLUSION: For PPROM that occur before 30 weeks' gestation, a short latency period was associated with a higher infant mortality rate. Inversely, it was associated with a lower mortality rate after 30 weeks'. There is an urgent need for a thorough evaluation of expectant management of PPROM after 30 weeks' gestation.

Tension-free obturator tape (Monarc Subfascial Hammock) in patients with or without associated procedures.

The aim of the present study was to evaluate the safety and efficacy of the tension-free obturator tape (TOT) procedure in patients having concomitant hysterectomy and/or pelvic reconstructive surgery. A chart review from August 2002 to December 2004 identified 341 consecutive female patients with stress urinary incontinence who had undergone a TOT procedure alone (Monarc only group) or a TOT procedure associated with hysterectomy or other pelvic reconstructive surgery (Monarc + other surgery group). Intraoperatively, three cases of hemorrhage occurred. No transfusions were required. There were no cases of bladder injury or injury to obturator nerves or vessels during needle passage via the transobturator route. Three cases of vaginal erosion were found at 3 months follow-up, but no tape removal was required. Two hundred fifty-four patients (74.5%) were contacted by telephone for a second follow-up (average 17 months, range 6-32) and the validated short forms of the Urogenital Distress Inventory (UDI-6) questionnaire and of the Incontinence Impact Questionnaire (IIQ-7) were administered. Results showed a very good quality of life score (0-7) in 93.3% patients. Globally, only three (1.2%) patients had persistent urine leakage related to physical activity. Severe voiding dysfunction occurred in five (2%) patients. The cure rate, considered as the complete absence of urine leakage (score 0 in questions 2 and 3 of the UDI-6), was 73.7% in the Monarc only group vs 57.4% in the Monarc + other surgery group. Pelvic floor defects, benign uterine disorders, and stress urinary incontinence can be safely treated with transobturator tape, using the Monarc device, and concomitant vaginal procedures.

Identification of newborns with Fetal Growth Restriction (FGR) in weight and/or length based on constitutional growth potential.

This study was carried out to build statistical models for defining FGR (Fetal Growth Restriction) in weight and/or length after taking growth potential of an infant into account. From a cohort of pregnant women having given birth to 47,733 infants in 141 French maternity units, two statistical models gave individualized limits of birth weight and birth length (based on the 5th centile) below which, after adjustment for its individual growth potential, a newborn must be considered as FGR in weight and/or in length. A sample of 906 infants had measures taken of cord blood growth factors (IGF1, IGFBP3). The FGR(W) definition (weight<5th centile for growth potential) permitted the identification of infants who presented rates of maternal hypertension (13.6%) and of Apgar score at 5 min<6 (2.9%) higher than in the classical group SGA(W) (weight<5th centile for sex and gestational age) (9.6% and 2.2% respectively). By combining FGR(W) and SGA(W), a subgroup of infants, not currently recognized as SGA, presented very high rates of maternal hypertension (19.9%) and of low Apgar score (3.9%). Conversely a subgroup of infants, currently recognized as SGA(W), had rates as low as in the normal infants group, and had to be considered as "constitutionally small" (that is to say 24% of the SGA(W)). Combining FGR(W) and FGR(L) (length<5th centile of growth potential), 7.6% of infants appeared growth-restricted, and 1.8% appeared constitutionally small in weight and/or in length. The FGR(W)-FGR(L) infants showed the lowest mean values of IGF1 (126.2+/-3.2) and IGFBP3 (0.86+/-0.03). These new definitions of FGR(W) and FGR(L) could help to better identify infants at birth requiring neonatal care, and monitoring of growth catch-up and neurodevelopmental outcome.