Epidemiology and survival of cervical cancer in the French West-Indies: data from the Martinique Cancer Registry (2002-2011).

BACKGROUND: The Caribbean ranks seventh among world regions most affected by cervical cancer. Social health inequalities, such as differences in access to screening services, engender disparities in incidence and mortality between low- and middle-income countries and industrialized countries. The French National Cancer Plan 2014-2019 focuses on reducing inequalities in cervical cancer. OBJECTIVE: The aim of this study was to describe the geographical distribution and overall survival of cervical cancer, based on data from a population-based cancer registry in Martinique (French West-Indies). METHODS: We included all cases of cervical cancer diagnosed between 2002 and 2011. The geographical distribution was described by zone of residence and by aggregated units for statistical information (IRIS). Based on the results of the model, standardized incidence rates (SIRs) were calculated using a Gamma Poisson model. Survival rates were calculated using the Kaplan-Meier method. Cox proportional hazards models were used to investigate the risk factors for cervical cancer mortality. RESULTS: A total of 1253 cases were analyzed (947 in situ tumors and 306 invasive cancers). 1230 cases with geolocalization were used to map the distribution of the incidence of in situ and invasive cervical cancers. Five IRIS were significantly over-incident. The 5-year overall survival rate was 55%, with a median survival of 6.5 years [95% CI: 4.9-10.1]. Multivariate analysis confirmed age at diagnosis (HR = 2.15 [1.50-3.09]; p < 0.0001), FIGO stage (HR = 3.53 [2.50-4.99]; p < 0.0001) and zone of residence (HR = 1.51 [1.06-2.13]; p = 0.02) as risk factors. CONCLUSIONS: Prognostic factors suggest that cervical cancer needs to be diagnosed at an early stage. Our results could allow cervical cancer screening programs to clearly identify geographical areas that would benefit from targeted interventions with a view to reducing incidence and mortality of cervical cancer in the Caribbean.

[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.

[Assessment of imminence of unplanned out-of-hospital deliveries in Guadeloupe: experience of the mobile emergency and resuscitation service of Pointe-à-Pitre]. / Évaluation de l'imminence de l'accouchement inopiné extra-hospitalier en Guadeloupe : expérience du service médical d'urgence et de réanimation de Pointe-à-Pitre.

OBJECTIVES: Medical tools to determine the imminence of unplanned out-of-hospital birth have not been validated. The main goal of this study was to analyze assessments of the imminence of these deliveries, by methods such as the Manilas score and the need to push. PATIENTS AND METHODS: All calls made to the Emergency Medical Aid Service in Guadeloupe concerning risks of unplanned delivery between January 1st and June 30th 2011 were reviewed retrospectively, and 69 of the 85 cases cared for by the hospital mobile emergency unit were included. RESULTS: Risks of unplanned out-of-hospital deliveries represented 1.9% of the calls during the study period. The Malinas score was used for dispatching in only 13% and was not used for intervention in any case. It was estimated that the need-to-push feeling was used for 58% (dispatching) and 54.5% (intervention) of patients. Its sensitivity, specificity and predictive values were higher than those of the Malinas score in dispatching and substantially higher in intervention. CONCLUSION: These results argue for the development of tools for estimating the imminence of unplanned delivery. Such tools should be applicable in extra-hospital emergency situations to ensure their use in practice.

[Sociodemographic and medical features of abortion among underage people in Guadeloupe (French West Indies)]. / Caractéristiques sociodémographiques et médicales des interruptions volontaires de grossesse des mineures en Guadeloupe.

OBJECTIVE: In France, contraception is available for everybody; however, the number of abortion does not decrease, especially among young people. The aim of our study is to analyze, in the Guadeloupian context, the characteristics of underage people who ask for an abortion. METHODS: This retrospective study, analyses sociodemographic and medical characteristics of 129 teenagers, who had an abortion in 2010 in our abortion center. For 67 of them results of interviews with the psychologist were also reported. RESULTS: Preferentially from large single parent families, these underage people had a mean age of 15.9 years (± 1.12), 96.1% were born in France, 10.9% had had a previous pregnancy, 67.2% had an over 18 partner, 64.4% used contraception before the abortion. Main motivations for abortion were continuing studies and young age. Abortion occurs after 9 weeks of amenorrhea in 55.1% and 43.3% of underage people reported psychological problems linked to the abortion. CONCLUSION: From this profile, our study suggests some reflection which could help the fight against unwanted pregnancies in this particular population of underage people.

[Transgenerational evolution of age of the main stages of reproductive life in Guadeloupe]. / Évolution transgénérationnelle de l'âge des principales étapes de la vie reproductive en Guadeloupe.

OBJECTIVE: The aim of this study was to assess changes in the ages at which the main stages of reproductive life, including first sexual intercourse in particular, occur in Guadeloupe (French West Indies). PATIENTS AND METHODS: We conducted a transverse study of three generations of men and women over the age of 20 years. We recorded age at first intercourse and at first child for all subjects, plus age at menarche, at first pregnancy and at menopause for the women. RESULTS: We collected information for 803 women and 169 men. For women, median age at menarche and at first intercourse had decreased significantly, reaching 12 and 17 years, respectively. The risk of first intercourse occurring before the median age was linked to the earliness of menarche. Age at first pregnancy, at menopause for women and at first intercourse for men remained roughly stable. A non-significant trend towards increasing age at the birth of the first child was observed in both sexes. DISCUSSION AND CONCLUSION: Age indicators for the main stages of reproductive life in Guadeloupe follow the trends reported in most Western countries, including mainland France. However, most of the ages recorded for particular stages are below those in mainland France. The link between age at menarche and sexual precocity may justify targeted awareness programs.

[Pregnancies among underage girls in Guadeloupe: a new inventory]. / Grossesses évolutives chez les mineures en Guadeloupe : nouvel état des lieux.

OBJECTIVES: In Guadeloupe (French West Indies), fecondity rate of teenagers is higher than in mainland France. The aim of our study was to analyze sociodemographic characteristics and perinatal indicators among underage girls and to compare them to those of a previous study also conducted in our maternity unit in 1993 and 1994. MATERIALS AND METHODS: The sociodemographic, medical, obstetrical and neonatal data of 163 underage pregnant girls delivered from 2009 to 2010 at the University hospital of Pointe-à-Pitre/Abymes were collected retrospectively and compared with the previous study. RESULTS: In 16 years, in contrast to perinatal indicators, which did not significantly evolve, the sociodemographic characteristics of this population have changed. In addition, the increase of neonatal morbidity seems to be related to late initiation of obstetrical care, which also still remains insufficient. CONCLUSION: Our results are close to those described in the other French regions and have hardly evolved since our previous study. The differences found for the obstetric and perinatal risks seem to be related to sociodemographic factors surrounding these underage pregnancies. Those factors should be taken into consideration in any approach aiming to reduce incidence and prevent complications of pregnancies among teenagers.

Medical and sociodemographic risk factors for preterm birth in a French Caribbean population of African descent.

There appears to be an incompressible high rate of preterm births among populations of African origin irrespective of their geographic location. The objective of this study was to assess the risk factors for preterm birth in a French Caribbean population of African descent, offered medical care comparable to that on the French mainland, but presenting a higher rate of preterm birth. The study was based on a birth cohort at maternity hospitals in Guadeloupe (French West Indies) including 911 singleton pregnancies enrolled during their third trimester check-up visits. Associations between risk factors and the risk of preterm delivery (spontaneous and induced) were assessed using a multivariate Cox model. In addition, prevalences of sociodemographic and medical factors in Guadeloupe were compared with those on the French mainland. 144 women (15.8 %) delivered preterm, medically induced in 52 %. Women delivering preterm were more often over 35 years old (37 %), single (54 %), and had higher prevalence of prior preterm birth (20 %), prior miscarriage (37 %), lupus (3 %), asthma (14 %), gestational hypertension (26 %), gestational diabetes (13 %) and urinary tract infection (24 %) than women with term births. In the whole cohort, these risk factors were also more frequent than in mainland France. Our results suggest highly prevalent medical risk factors for preterm births in Guadeloupe. This observation combined with specific social risk factors (older maternal age, single living) less frequent on the French mainland probably explains a large part of a higher prevalence of preterm births in this population despite similar medical provision.

[Illegal abortion with misoprostol in Guadeloupe]. / Avortements illégaux par le misoprostol en Guadeloupe.

OBJECTIVES: The aim of this study was to describe the typical profile, and to assess the motivations of women who underwent illegal abortion with misoprostol in Guadeloupe (French West Indies). MATERIALS AND METHODS: We conducted a 1-year prospective study on women who consulted after failure or complication of an illegal abortion with misoprostol. RESULTS: Fifty-two cases of illegal abortion with misoprostol were recorded. The most common profile was an unemployed woman, who was unmarried, foreign-born, had no medical insurance, and a low level of education; the median age was 28 (range 17 to 40). The justifications given were that the legal procedure was considered to be too slow, the young age of the woman, the ease of the self-medication procedure, a history of illegal abortion by misoprostol in the woman's country of origin, ignorance of the legal process, and financial and/or administrative problems. CONCLUSION: The problem of illegal abortion is probably underestimated in Guadeloupe and possibly France. This description of the profile of the population concerned and the justifications for choosing illegal abortion by misoprostol provides elements allowing better focus of education concerning abortion, contraception and family planning. Access to legal abortion centers should also be improved.

[Do the quality of prenatal care have an impact on obstetrical outcomes?]. / La qualité du suivi de la grossesse interfère-elle avec les issues de la grossesse, en Guadeloupe ?

OBJECTIVES: To assess the rate of pregnant women not having accurate prenatal care utilization. The others goals were to assess the impact of an inadequate quantitative or qualitative prenatal care on obstetrical outcomes. PATIENTS AND METHODS: Historical cohort study with a prospective data registration. Hospitalised patients at the maternity ward of the University Hospital of Pointe-à-Pitre were eligible if they gave birth after 22 weeks (or≥500g) at home, outside a maternity ward or in another maternity ward. Early postpartum maternal transfers were included but not medical abortions. The principal outcome was preterm birth (before 37 weeks' gestation). RESULTS: Patients without an appointment before 15weeks or without an appointment each month before their delivery represented 27.4% of women (n=2344). We stressed more preterm deliveries outside the maternity ward among the group with an inadequate prenatal care utilization vs. the other group (3,89% vs. 0,88%) (p<0,0001). We did not find any difference concerning the perinatal outcomes among the women with an inadequate quality prenatal care. DISCUSSION AND CONCLUSION: Our study did not stress a difference concerning perinatal outcomes among women with an inadequate quantitative or qualitative prenatal care utilization.

[Identification of barriers to routine HIV testing prescription by midwifes and doctors in Guadeloupe]. / Identification des freins à la prescription du test de dépistage de l'infection au VIH par les sages-femmes et médecins en Guadeloupe.

OBJECTIVES: Guadeloupe is the second highest French area for diagnosis and prevalence of HIV infection and AIDS. In October 2009, the French High Health Authority has published guidelines for a more systematic HIV screening. The goal of this study is to identify the limitations in HIV testing prescription by the Guadeloupian prescribers according to these new recommendations. MATERIALS AND METHODS: Data were collected with a questionnaire submitted to physicians and midwives after random selection. RESULTS: Among 285 randomly selected prescribers, 67 midwives and 40 physicians participated from August to December 2010. The main limitations to HIV testing prescription were: a consultation for another purpose, patient or his life style were known, and lack of HIV infection symptoms. Some characteristics of more easily screened patient did not match with those who had been newly diagnosed in Guadeloupe. Finally, both quantitative and qualitative knowledge of these new recommendations was insufficient. CONCLUSION: Implementation of these new testing recommendations should give emphasis to the systematic and annual nature of HIV testing for whole population. It should also insist on distinction between HIV testing and diagnosis of a symptomatic patient.

Cervical intraepithelial neoplasia and invasive cancer risks in women infected with HIV in the French West Indies.

OBJECTIVE: The aim of the study was to assess whether HIV infection is associated with a higher risk of invasive cervical cancer (ICC). METHODS: We conducted a region-wide, population-based observational cohort study of 1232 HIV-infected women over the age of 15 years in Guadeloupe, a French Caribbean archipelago, during the period 1999-2006. The observed numbers of incident cases of cervical intraepithelial neoplasia (CIN) and ICC were compared with the expected numbers of cases based on the incidence rates for the general population, and the standardized incidence ratios (SIRs) and 95% confidence intervals (CIs) were calculated. RESULTS: The incidence rate of CIN was higher in the HIV-infected women than in the general population for all grades (SIR 10.1, 95% CI 6.8-14.6 for CIN grade 1; SIR 9.9, 95% CI 6.1-15.3 for CIN grade 2; and SIR 5.2, 95% CI 3.4-7.7 for CIN grade 3). However, no increase in the risk of ICC was observed (SIR 1.7, 95% CI 0.3-4.9). CONCLUSIONS: Despite an increase in the occurrence of cervical cancer precursors, no increase in the risk of cervical cancer was found in a population of HIV-infected women who receive treatment for their infection and have access to ICC prevention services.

[Prognosis of uterine rupture during labor: a 293-case series compiled at the Bouake University Hospital Center (Ivory Coast)]. / Pronostic de la rupture utérine au cours du travail: à propos de 293 cas colligés au CHU de Bouaké (Côte d'Ivoire).

The purpose of this retrospective comparative study carried out between January 1, 1996 and December 31, 2001 was to determine the incidence of uterine rupture in the maternity ward of the Bouake University Hospital Center and evaluate prognosis for the mother and child in function of transportation distance to the Center. Patients were divided into two groups, i.e., patients transported from an arbitrarily defined safety zone within a 100-kilometer radius of the city and patients from outlying areas beyond the safety zone. The overall incidence of uterine rupture was 2.44%, i.e., one of 41 deliveries. Hysterectomy was performed more often in women from outlying areas: 83.34 % versus 28.57% (p = 0.0000). Mortality secondary to uterine rupture was 411.26% overall with a higher rate in patients from outlying areas than patients from the safety zone: 29.91% versus 8.97% respectively (p = 0.0052). Fetal mortality was 100% for patients from outlying areas. The prognosis of uterine rupture is less favorable for both the mother and child in patients transported from outlying areas.

Pronostic de la rupture utérine au cours du travail : à propos de 293 cas colligés au CHU de Bouaké (Cote d'Ivoire)

L'objectif a été de préciser la fréquence de la rupture utérine au sein de la maternité du CHU de Bouaké et de déterminer le pronostic en fonction de l'éloignement du CHU de Bouaké. Il s'agit d'une étude rétrospective et comparat ive qui s'est déroulée du 1er janvier 1996 au 31 décembre 2001. Cette étude a comparé les caractéristiques et le pronostic materno-fœtal de deux types de patientes : celles issues d'un périmètre de sécurité sanitaire arbitraire défini de 100 kilomètres autour de la ville et celles issues de localités situées au-delà. La fréquence de la rupture utérine a été de 2,44 % soit une rupture utérine pour 41 accouchements. L'hystérectomie a été plus pratiquée dans la population des femmes issues de localités situées au-delà du p é ri m è t re de sécurité sanitaire : 83,34 % contre 28,57 % (p < 10- 4). La létalité de la ru p t u re utérine a été de 11,26 % pour l'ensemble des patientes avec une surmortalité pour celles venues de localités au-delà du périmètre de sécurité sanitaire : 29,91% c o n t re 8,97 % pour celles du péri m è t re de sécurité sanitaire (p = 0,0052). La mortalité fœtale a été de 100 % pour les patientes hors du périmètre de sécurité sanitaire. Les patientes présentant une rupture utérine et évacuées de localités situées au-delà du périmètre sécurité sanitaire ont un pronostic materno-fœtal beaucoup plus sombre

Delayed delivery of second twin: a multicentre study of 35 cases.

OBJECTIVE: The aim of this study was to conduct a statistical analysis to determine the outcome of conservative treatment after delivery of a first fetus in multiple pregnancy and thus define new prognostic factors. STUDY DESIGN: Multicentre retrospective study involving 12 centers over a 10-year period. RESULTS: Twenty-eight twin pregnancies and seven triplet pregnancies which were managed conservatively. In twin pregnancies, 79% of the delayed-delivery fetuses survived; only 7% of the first delivered fetuses survived. The mean interval between deliveries was 47 days. No statistical difference was found concerning cerclage, antibiotic therapy, tocolysis and hospitalization. Earlier delivery of the first twin and premature rupture of membranes for the second twin were significantly related to a longer interval between deliveries. CONCLUSION: Delayed delivery in multifetal pregnancies can be successful if there are no contraindications and these pregnancies are managed in a tertiary perinatal center. Publications limited to successful cases have undoubtedly introduced some bias in assessment.

Evaluation of neonatal sepsis screening in a tropical area Part III: Neonatal sepsis in meconium stained deliveries.

Of the 6,060 consecutive live births delivered at the University Maternity Unit of Guadeloupe (French West Indies) during a 30-month period, 635 newborns (10.4%) presented with meconium stained (MS) amniotic fluid, of which 595 (94%) received bacteriological screening at birth (light MS, n = 543; thick MS, n = 52). Thirty (5%) of MS newborns had a bacteraemia (n = 13, group B streptococcus, GBS), and 128 (21.5%) a bacterial positive gastric aspirate (n = 54, GBS). Sixty-six newborns among MS babies needed tracheal suctioning (11%) in the delivery room for meconium inhalation. Among these 595 screened MS newborns, 286 (48%) presented clinical signs of postmaturity at birth, having therefore an explanation for their MS condition. For the other MS newborns without the postmaturity explanation, we experienced twofold increased risk of neonatal sepsis (OR 1.88 for bacteraemia and 2.61 for external carriage p < 0.02, Chi square) as compared with their MS postmature counterparts. We conclude that when meconium stained deliveries are associated with postmaturity signs, one may not need to initiate prophylactic antibiotic treatment at birth unless they present with other traditional risk factors for neonatal sepsis such as intrapartum fever and prolonged rupture of membranes.

Evaluation of neonatal sepsis screening in a tropical area. Part II: Evaluation of intrapartum chemoprophylaxis protocol.

The authors report on an analysis of a chemoprophylaxis protocol at the University Hospital of Guadeloupe in the Caribbean. This study comprised 6,060 consecutive deliveries and was initiated to assess the application of an intrapartum chemoprophylaxis protocol, evaluate its results, and try to identify possible necessary modifications to the existing protocol. Although more than 90% of women had at least one bacterial screening (vaginal or urinary) during the last trimester of pregnancy, approximately 75% of mothers who were heavily colonized group B streptococcus (GBS) at delivery were not detected by this systematic screening. As is also reported in other tropical areas where a great proportion of neonatal sepsis occurs in term babies, low birthweight was not a specific risk factor in this study when controlling for other major risk factors such as fever and premature rupture of membranes. Intrapartum chemoprophylaxis was associated with an approximate threefold decrease in the risk of GBS neonatal bacteraemia among at risk deliveries. The results suggest that, in our tropical context, prolonged rupture of membranes of at least 12 hours' duration should be considered as a cause for intrapartum chemoprophylaxis as it accounted for the majority of cases of neonatal bacteraemia that escaped the existing protocol.

Evaluation of neonatal sepsis screening in a tropical area Part III: Neonatal sepsis in meconium stained deliveries

Of the 6,060 consecutive live births delivered at the University Maternity Unit of Guadeloupe (French West Indies) during a 30-month period, 635 newborns (10.4) presented with meconium stained (MS) amniotic fluid, of which 595 (94) received bacteriological screening at birth (light MS, n = 543; thick MS, n = 52). Thirty (5) of MS newborns had a bacteraemia (n = 13, group B streptococcus, GBS), and 128 (21.5) a bacterial positive gastric aspirate (n = 54, GBS). Sixty-six newborns among MS babies needed tracheal suctioning (11) in the delivery room for meconium inhalation. Among these 595 screened MS newborns, 286 (48) presented clinical signs of postmaturity at birth, having therefore an explanation for their MS condition. For the other MS newborns without the postmaturity explanation, we experienced twofold increased risk of neonatal sepsis (OR 1.88 for bacteraemia and 2.61 for external carriage p < 0.02, Chi square) as compared with their MS postmature counterparts. We conclude that when meconium stained deliveries are associated with postmaturity signs, one may not need to initiate prophylactic antibiotic treatment at birth unless they present with other traditional risk factors for neonatal sepsis such as intrapartum fever and prolonged rupture of membranes.

[Clinical and paraclinical monitoring of a normal pregnancy]. / Suivi clinique et paraclinique d'une grossesse normale.

The objective of this work was to improve physician's knowledge concerning medical and laboratory screening practices for pregnant women in France. We used the French legislation and the French guidelines on pregnancy screening.

Evaluation of neonatal sepsis screening in a tropical area. Part II: Evaluation of intrapartum chemoprophylaxis protocol

The authors report on an analysis of a chemoprophylaxis protocol at the University Hospital of Guadeloupe in the Caribbean. This study comprised 6,060 consecutive deliveries and was initiated to assess the application of an intrapartum chemoprophylaxis protocol, evaluate its results, and try to identify possible necessary modifications to the existing protocol. Although more than 90 of women had at least one bacterial screening (vaginal or urinary) during the last trimester of pregnancy, approximately 75 of mothers who were heavily colonized group B streptococcus (GBS) at delivery were not detected by this systematic screening. As is also reported in other tropical areas where a great proportion of neonatal sepsis occurs in term babies, low birthweight was not a specific risk factor in this study when controlling for other major risk factors such as fever and premature rupture of membranes. Intrapartum chemoprophylaxis was associated with an approximate threefold decrease in the risk of GBS neonatal bacteraemia among at risk deliveries. The results suggest that, in our tropical context, prolonged rupture of membranes of at least 12 hours' duration should be considered as a cause for intrapartum chemoprophylaxis as it accounted for the majority of cases of neonatal bacteraemia that escaped the existing protocol.

Transvaginal ultrasonography of the uterine cervix in hospitalized women with preterm labor.

OBJECTIVE: The aim of this study was to examine the relation between cervical length and the presence of funneling and the risk of preterm delivery. METHOD: This prospective blind cohort involved 200 hospitalized women with preterm labor in a tertiary care hospital. Women were recruited for a single transvaginal ultrasonography to assess cervical length and presence of funneling. The main outcome measures were: (1) relative risks (RR) and adjusted odds ratios of preterm delivery (<37 weeks' gestation); (2) time interval between the cervical ultrasonography date to 37 weeks' gestation or to-preterm birth. RESULTS: The RR of preterm delivery according to the cervical length (cut-off of <30 mm) was 2.79 (95% CI 1.70--4.59). The RR according to the presence of funneling (cut-off of >5 mm) was 1.39 (95% CI 0.99--1.95). The adjusted odds ratio was 3.92 (95% IC 1.75--8.75) for cervical length and 0.77 (95% CI 0.35--1.67) for funneling. Women with a cervical length of <30 mm had a significantly shorter interval from ultrasonography date up to 37 weeks' gestation than did women with a cervical length of >30 mm (P<0.003). CONCLUSION: Ultrasonographic mensuration of the cervix provides predictive information on the risk of preterm delivery.