Asymmetric pelvis and term breech presentation: is planned vaginal delivery still a safe option?

PURPOSE: To evaluate the obstetrical prognosis of term breech delivery in case of asymmetric pelvis. METHODS: An observational, comparative, retrospective, bi-centric study of 559 patients who had a computer tomography pelvimetry prior to delivery of a term breech presentation was conducted between August 2013 and August 2019. Patients with an attempted vaginal delivery were divided into two groups: a group of asymmetric pelvis (AP) when the difference between the lengths of both oblique diameters was ≥ 1 cm and a group of symmetric pelvis (SP) when the two oblique diameters differed by < 1 cm. The primary outcome was the rate of vaginal delivery. Secondary outcomes were a composite variable of neonatal and maternal morbidity and mortality. RESULTS: Of the 370 patients who attempted a vaginal breech delivery, 8% (n = 29) had an AP and 92% (n = 341) had a SP. In the AP group, the vaginal delivery rate was higher (93% versus 78%, p = 0.05). There was no statistically significant difference in neonatal (3% versus 1% in the AP and SP groups, respectively, p = 0.4) and maternal (17% versus 23% in the AP and SP groups, respectively, p = 0.5) morbidity and mortality. CONCLUSION: When a pelvimetry is performed before an attempt of vaginal breech delivery, a difference of less than two centimetres between both oblique diameters does not seem to reduce the rate of vaginal birth and is not an indication for an elective caesarean section.

[Demelin's maneuver for arm entrapment during vaginal breech delivery]. / Manœuvre de Demelin pour le relèvement des bras lors d'un accouchement voie basse d'une présentation du siège.

OBJECTIVES: To evaluate Demelin's maneuver for arm entrapment's dystocia during vaginal breech deliveries after failure of the usual Lovset maneuver. METHODS: We led a retrospective cohort study in two French maternities. Between January 2013 and June 2020, we included all vaginal breech deliveries of live newborns after 32 weeks of gestation requiring Demelin's maneuver for persistent arm entrapment despite the Lovset maneuver. The primary endpoint was the Demelin's maneuver success without the existence of a neonatal trauma related to the maneuver. RESULTS: Among 1611 vaginal breech deliveries, 29 with Demelin's maneuver for an arm entrapment were enrolled (prevalence 0,02%). No failure of this maneuver was found. There was 10 nulliparous (34.5%). Mean gestational age was 38±2.4 weeks of gestation. The success of Demelin's maneuver without trauma related to it was estimated at 82.8%. No serious neonatal trauma was noticed. Five fractures (17.2%), one humeral and four clavicular, without sequelae were diagnosed. Mean weight of newborns was 2945.5 grams and the median arterial pH was 7.17. The median 5-minutes-Apgar score was 10. Maternal morbidity was low: one case (3.4%) of obstetric anal sphincter injuries (type III). CONCLUSION: Demelin's maneuver seems to be an effective and safe method to treat an arm entrapment's dystocia during vaginal breech delivery after failure of the Lovset's maneuver.

Evaluating the morbidity and long-term efficacy of laparoscopic sacrocolpopexy with and without robotic assistance for pelvic organ prolapse.

OBJECTIVE: The aim of our study was to compare the morbidity and long-term efficacy after laparoscopic sacrocolpopexy with and without robotic assistance. METHODS: We conducted a retrospective chart review of all laparoscopic or robotic sacrocolpopexies for POP-Q stage 2-4 vaginal prolapse performed between September 2015 and October 2018 in 2 Gynecologic Surgery Departments of France. Patients were separated into two groups: a laparoscopic sacrocolpopexy group (LS) and a robotic-assisted sacrocolpopexy group (RAS). The primary outcome measure was reoperation procedures for recurrent pelvic organ prolapse (POP). RESULTS: Two hundred and fourteen patients were included, 160 patients (75%) in the LS group and 54 patients (25%) in the RAS group. After a mean follow-up of 32.8 months, reoperation rate for recurrent POP and the recurrent POP rate were greater in the RAS group (9.2% versus 1.2%, p = 0.01 and 25.9% versus 7.5%, p = 0.0003, respectively). No significant difference was found in terms of immediate intraoperative (3.1% versus 1.8%, p = 1) and postoperative complications (1.9% versus 1.8%, p = 1). On comparing the 2 groups by bivariate analysis, RAS significantly increased the odds of reoperation for POP recurrence (OR = 7.8 CI 95% [1.5-41.6], p = 0.02) and the odds of global reoperation (OR = 3.8 CI 95% [1.4-10.4], p = 0.0095). Similarly, multivariate logistic analysis showed that RAS increased the risks of global reoperation (OR = 3.8 CI 95% [1.3-10.6], p = 0.01) after controlling high-grade prolapse. CONCLUSION: Robotic sacrocolpopexy does not appear to give long-term clinical benefits. Recurrent POP and reoperation procedures seem to be more frequent in case of robotic-assisted surgery.

[Borderline Ovarian Tumours: CNGOF Guidelines for Clinical Practice - Pregnancy]. / Tumeurs frontières de l'ovaire. Recommandations pour la pratique clinique du CNGOF ­ Grossesse.

OBJECTIVE: To determine the place of imaging, tumour markers, type of treatment and surgical route, follow-up, delivery mode, and re-staging in case of BOT during pregnancy, in order to provide guidelines. METHOD: A systematic bibliographical analysis on BOT during pregnancy was performed through a PUDMED search on articles published from 1990 to 2019 using keywords « borderline ovarian tumour and pregnancy ¼. RESULTS: Pelvic ultrasound is the gold standard and first-line examination for the detection and characterization of adnexal masses during pregnancy (grade C). Pelvic MRI is recommended from 12 gestational weeks in case of indeterminate adnexal masses and should be concluded by a diagnostic score (grade C). Gadolinium injection should be minimized because of proven risk to the fetus and should be discussed on a case-by-case basis after patient information (grade C). In the absence of data in the literature, it is not possible to recommend the use of any tumour marker for the diagnosis of BOT during pregnancy. In case of a surgical treatment of BOT during pregnancy, there is insufficient evidence to recommend either a cystectomy or an oophorectomy. For BOT, the laparoscopic approach should be preferred during pregnancy if it is feasible (grade C). Surgical route and type of surgery should be chosen after taking into account the tumour size, the obstetrical term, and the subsequent desire for pregnancy, following discussion in a multidisciplinary meeting. In the absence of sufficient data in the literature, it is not possible to make any recommendation on the follow-up of a BOT suspected during pregnancy. There is not enough evidence in the literature to change obstetrical management for delivery in patients with BOT. In case of incomplete staging of a BOT treated during pregnancy, restaging can be discussed as for non-pregnant patients (grade C). CONCLUSION: The diagnosis of BOT occurring during pregnancy remains rare despite systematic screening of adnexal masses in the first trimester of pregnancy and an increasing maternal age. There is limited data in the literature concerning the management of BOT during pregnancy. All decisions must be taken after discussion in a multidisciplinary meeting.

[Functional or aesthetic labia minora reduction: Complications, revision surgeries and results - a comparative study]. / Nymphoplasties de réduction fonctionnelle ou esthétique. Complications, réinterventions, résultats : étude comparative.

OBJECTIVE: To evaluate and compare the complications, the rate of revision surgeries and the long-term patient postoperative satisfaction level for the two main indications of labia minora reduction: aesthetic or functional. METHODS: A comparative, retrospective and multicentered study was carried out in Belfort and Montbéliard hospitals between January 2010 and January 2017. Ninety-two primary labia minora reductions for labia minora hypertrophy have been listed. Each patient has been requested to fill in a questionnaire about the main indication of labiaplasty, any potential complication, a revision surgery and her level of the satisfaction. Patients who had agreed to respond were divided into two groups: a "functional indication" group (FI) and an "aesthetic indication" group (AI). RESULTS: Thirty-seven patients (40%) answered the survey: 19 (51%) have been included in the FI group and the remaining 18 (49%) in the AI group. The mean postoperative follow-up duration was 3.2 years. We identified 13 patients (35%) who encountered a postoperative complication. It predominates in the FI group (53% versus 17%, P=0.04). Seven patients (19%) were treated by revision surgeries. All of them belonged to the IF group. Whatever the indication of the labiaplasty, 86% of the patients have been satisfied by the outcomes. CONCLUSION: A labia minora reduction is a highly appreciated surgical treatment on the long term whatever the initial surgical indication. However, postoperative complications and revision surgeries are not negligible especially when the main indication is functional.

[Self-evaluation of conization indications since the introduction of the French colposcopy and cervico-vaginal pathology quality charter in 2 colposcopy centers]. / Auto-évaluation des indications de conisation depuis l'instauration de la charte de qualité en colposcopie et pathologie cervico-vaginale.

OBJECTIVES: Analyze the efficiency of the implementation of the colposcopy and cervico-vaginal pathology quality charter. The question was to determine whether the criteria of more than 70% of excisional conizations containing CIN2+ lesions (cervical intraepithelial neoplasia 2 or 3 or carcinoma in situ) had been reached and demonstrate a reduction of the conization rate is possible. METHODS: An epidemiological descriptive, retrospective and multicenter study was performed in "Nord Franche-Comté Hospitals" (Belfort and Montbéliard, France) during the period from November 2013 to January 2015. Inclusion criteria were patients over 25 years undergoing cervical excisions for diagnostic and/or therapeutic purposes after Pap smear screening followed by colposcopically directed biopsies. The files were selected from a data collection and studied using the computerized patient record. RESULTS: In total, 116 conizations were performed: 103 by four French Society of Colposcopy and Cervico-Vaginal Pathology (SFCPCV) members and 13 by four SFCPCV non-members. The overall result of the primary outcome showed 53% of CIN2+ lesions found in cervical conization specimens, which can be broken down to 55% for the group of SFCPCV members and to 38% for the group of SFCPCV non-members. The statistical analysis indicates a significant difference (P=0.02) in the percentage of CIN2+ lesions discovered on the surgical specimen for the group of SFCPCV members. CONCLUSIONS: This self-evaluation shows that it is essential to be a SFCPCV member and to adhere to the charter. By complying with the charter and associating the new National Cancer Institute recommendations (December 2016), it is possible to reduce the conization rate and even to surpass the target of more than 70% of excisional conizations containing CIN2+ lesions.

Gestational age determination and prevention of HIV perinatal transmission.

OBJECTIVE: To compare different methods of gestational age (GA) measurement for ensuring effective zidovudine (ZDV) prophylaxis to prevent mother-to-child transmission of HIV. METHODS: For 1398 HIV-infected women enrolled in a perinatal prevention trial, gestation durations were calculated based on GA estimated using ultrasound (US), date of last menstruation period (LMP), first fundal height (FH(1)), and a specific algorithm was developed to provide a "reference" GA. The performance of each GA estimate was evaluated by the percentage of women who would have received > or =8 weeks ZDV, if prophylaxis was initiated at 28 weeks. RESULTS: The performances of the algorithm, US, LMP, and FH(1) were 95.5%, 94.8%, 88.4%, and 83.7%, respectively. US and FH(1) were significantly better when estimated before and after 24 weeks, respectively. CONCLUSION: In situations where no US is available and LMP is not or imprecisely known, FH(1) can be used after 24 weeks to schedule ZDV initiation date.

Mother-to-child transmission of HIV-1 in Congo, central Africa. Congolese Research Group on Mother-to-Child Transmission of HIV.

OBJECTIVE: To assess the risk of mother-to-child transmission of HIV-1 in a central African population and to study maternal factors associated with perinatal transmission. DESIGN: Prospective cohort study of infants born to HIV-1-positive women and controls born to HIV-1-negative women enrolled sequentially in two prenatal clinics and one maternity hospital in Brazzaville, Congo. SUBJECTS AND METHODS: A total of 118 exposed and 208 control infants were followed from birth for at least 2 years. Assessment of infection in children and computation of transmission rate were made according to the European Economic Community/World Health Organization Ghent guidelines (1992). RESULTS: The transmission rate was 40.4% [95% confidence interval (CI), 30.7-50.1]. Maternal age, parity, history of adverse pregnancy outcome or history of decreased children were not associated with transmission. However, independently, women whose relationship with their infant's father was less than 1 year, or women who had symptoms of HIV-1 during pregnancy had an increased risk of transmission [adjusted odds ratios, 11.1 (95% CI, 2.4-50.2) and 10.3 (95% CI, 2.9-37.1), respectively]. CONCLUSION: The transmission rate observed in Congo is in the upper range of the rates reported in Africa. The uneven distribution of cofactors for perinatal transmission, such as the presence of symptoms of HIV disease during pregnancy, may explain some of the variation observed across studies.

Bacillus Calmette-Guérin immunization in infants born to HIV-1-seropositive mothers.

During the prospective follow-up of 64 babies at risk for perinatal HIV-1 infection because their mothers were seropositive, and of 130 control babies whose mothers were seronegative, we studied the occurrence of complications of bacillus Calmette-Guérin (BCG) immunization and its ability to induce cutaneous reactivity to tuberculin. Babies born both to HIV-1-positive and HIV-1-negative mothers received BCG immunization during their first month of life according to the Expanded Programme on Immunization (EPI) recommendations. Local and regional complications of BCG vaccine were looked for at 3, 6 and 9 months after inoculation. A tuberculin skin test was performed at 6 or 9 months of age. Most babies born to HIV-1-positive mothers were later classified as infected or uninfected according to their clinical condition and/or serological status at 18 months of age. The mean duration of the follow-up was 36 months (range 30-40 months). No chronic or deep ulcerations at the site of injection or disseminated forms of BCG infection were observed. The frequency of BCG-related lymphadenitis in the group of HIV-1-infected children (24%) did not differ significantly from the group of uninfected children (19%; Fisher test: P = 0.73). In contrast, the tuberculin skin test responses were positive less often in the group of HIV-1-infected children (33%) than in the uninfected group (83%; Fisher test: P = 0.007). Because BCG vaccine appears to be safe--even when given to perinatally infected babies--continuation of the BCG immunization policies of the EPI is justified, especially in view of the growing incidence of tuberculosis as a complication of HIV infection.

Contribution of AIDS to the general mortality in Central Africa: evidence from a morgue-based study in Brazzaville, Congo.

OBJECTIVE: To accurately measure AIDS-related mortality relative to other causes and its impact on life expectancy in Brazzaville, Congo. DESIGN: Investigation of all deaths during a 1-month period in Brazzaville. METHODS: From 10 July to 9 August 1996, all bodies handled by Brazzaville's three morgues were examined by a physician. Relatives were interviewed on the circumstances of death, while additional clinical data were gathered from hospital files. Blood samples were systematically drawn from the bodies in two of the three morgues and tested for HIV antibodies. RESULTS: Amongst the 756 bodies examined at the three morgues, 149 (19.7%) AIDS cases were identified. HIV-1 prevalence was 26.2% (38 out of 145) amongst the subjects in the two morgues where HIV serology was systematically performed. AIDS was the leading cause of death in adults (age > or = 15 years), with 25.1% (122 out of 487) of the adults diagnosed with AIDS. The proportion of adult female AIDS cases was significantly higher than the proportion of male cases (30.2 versus 21.0%; P < 0.05). Moreover, female AIDS cases were significantly younger than male cases (median age, 32 versus 42 years; P < 0.00001). Overall AIDS mortality rate amongst adults was 2.8 per 1000 for men and 3.2 per 1000 for women. The impact of AIDS on life expectancy at birth is 4.3 years for women and 3.3 years for men. CONCLUSION: Our study provides a direct measure of AIDS contribution to mortality relative to other causes, using a rapid, low cost, reliable and replicable method. Clearly, the impact of AIDS is strongest on female life expectancy.

PIP: As of December 1997, UNAIDS estimated that 20.8 million people were infected with HIV in sub-Saharan Africa. Brazzaville, Congo, has an estimated population of 850,000, according to the 1996 national census, and an estimated HIV-1 prevalence rate of approximately 5% in the general reproductive-age population. Findings are presented from a study conducted to accurately measure AIDS-related mortality relative to other causes and its impact upon life expectancy in Brazzaville, Congo. From July 10 to August 9, 1996, all bodies handled by Brazzaville's 3 morgues were examined by a physician. Relatives were interviewed on the circumstances of death and additional clinical data were collected from hospital files. Blood samples were systematically drawn from the bodies in 2 of the 3 morgues and tested for HIV antibodies. 149 of the 756 bodies (19.7%) examined at the morgues had AIDS. 38 of the 145 (26.2%) subjects in the 2 morgues in which HIV serology was systematically performed were infected with HIV-1. AIDS was the leading cause of death among people aged 15 years and older, with 122 of the 487 (25.1%) adults diagnosed with AIDS. 30.2% of the adult female deaths were due to AIDS, compared to only 21.0% of the male cases. The median age of female AIDS cases was 32 years, compared to 42 years for male cases, a highly significant difference. The overall AIDS mortality rate among adults was 2.8/1000 for men and 3.2/1000 for women. The impact of AIDS upon life expectancy at birth is 4.3 years for women and 3.3 years for men.

Mother-child transmission of HIV-1 and infant survival in Brazzaville, Congo.

The aim of this study was to compare the probability of survival of infants born to anti-HIV-1-positive and anti-HIV-1-negative mothers. One thousand, eight hundred and thirty-three pregnant women, recruited sequentially in two mother-child clinics in Brazzaville, were screened for anti-HIV-1 (by enzyme-linked immunosorbent assay with confirmation by Western blot). Each seropositive mother (71 out of 1833, 3.9%) was matched for age, presumed date of delivery and place of residence with two seronegative mothers. Sixty-four babies born to anti-HIV-1-positive mothers and 130 control babies born to anti-HIV-1-negative mothers were followed up for 12-22 months (mean, 18 months). The probabilities of survival were estimated by the Kaplan-Meier method. At birth, the two groups of babies did not differ with regard to rate of stillbirths, gestational age, sex ratio and weight. Among babies born to seropositive mothers, the probability of survival was 0.87 (s.d. 0.04) at 3 months, 0.71 (s.d. 0.06) at 6 months, 0.68 (s.d. 0.06) at 9 months and 0.61 (s.d. 0.06) at 12.5 months. In the controls the probability of survival was 0.98 (s.d. 0.01) at 3 months and 0.97 (s.d. 0.02) at 12 months. The excess of mortality in the babies born to anti-HIV-1-positive mothers is highly significant (P less than 0.001). The deaths occurred more frequently and earlier than in similar cohort studies performed in developed countries.

Characteristics associated with HIV-1 infection in pregnant women in Brazzaville, Congo.

Maternal human immunodeficiency virus type 1 (HIV-1) infection in sub-Saharan Africa is a major public health concern because of the high prevalence among women of childbearing age and the poor prognosis for perinatally infected children. Characteristics associated with HIV seroprevalence were studied in a population of 1,833 pregnant women seen in two large mother-child clinics in Brazzaville, Congo. The prevalence of HIV infection was 3.9% (95% confidence interval, 3.0-4.9%) and differed significantly according to the district of residence, marital status, duration of the relationship with the current partner, number of sexual partners in the year prior to pregnancy, number of living and dead children, and history of blood transfusion and/or hospitalization. Logistic regression analysis identified six significant factors independently associated with seropositivity; age, history of blood transfusion and/or hospitalization, district of residence, duration of the relationship, number of living children, and number of decreased children. However, the predictive value of the model was poor: while 80% of the truly positive women were correctly predicted positive by the model, 50% of the truly negative women were misclassified. Among pregnant women attending these clinics it is therefore difficult to identify a subgroup at risk toward which specific actions could be targeted.

Malaria, cause of ahaptoglobinaemia in Africans.

The lack of serum haptoglobin in Africans has been investigated in the Congo, Central Africa, where HpO prevalence is about 30%. This study shows that it is possible to suppress ahaptoglobinaemia within a few weeks by antimalarial chemoprophylaxis, that it does not occur in protected individuals, that ahaptoglobinaemia reappears at its original incidence levels after interruption of chemoprophylaxis, and that some individuals are more susceptible in relation to Hp2 gene. Malaria is the only significant cause of ahaptoglobinaemia in subjects both with and without detectable parasitaemia. The possible mechanisms involved are discussed.

Whose blood is safer? The effect of the stage of the epidemic on screening for HIV.

BACKGROUND: With improvements in HIV antibody test (ELISA) performance, the window of time between infection and seroconversion becomes a major source of error in HIV screening. The authors examined its impact on the false-reassurance rate (FRR). METHODS: Test sensitivity was modeled as the product of two factors: the inherent sensitivity (sensitivity when antibody is present) and the probability that antibody is present in infected blood. A model of HIV and AIDS incidence was used to derive an estimate of the probability of remaining in the seronegative window (pw) among those who are infected. With plausible assumptions, this probability approaches 0.03. The FRR was then estimated as a function of the probability of remaining in the seronegative window, the prevalence of HIV, and the inherent sensitivity of the ELISA test were estimated. RESULTS: The FRRs for two blood donor groups, one with an HIV prevalence of 0.004 and a typical probability of remaining in the seronegative window (pw = 0.03) and the other with a higher prevalence of 0.017 but fewer donors in the window (pw = 0.003), are equal (140 per million donors) if the blood is negative on a single ELISA test. After two negative tests or a single test that can detect antibody more reliably, however, the FRR is much higher in the group with the higher pw (= 120 per million compared with 50 per million), because the greater numbers of donors in the window more than offsets the lower prevalence. CONCLUSION: With improvements in inherent sensitivity of ELISA by virtue of technical progress or retesting, the prevalence of HIV infection may no longer play the critical role in degrading the results of blood screening. As inherent test performance improves, tests are increasingly likely to miss infected blood because of the seronegative-window error rather than because of measurement error. Window error plays a proportionally greater role during the early stages of HIV dissemination in a population where the incidence of new HIV infection is high relative to the incidence of AIDS. These findings may explain, in part, the recent observation that cases of transfusion of contaminated blood often take place in areas where AIDS epidemics have started recently. They also suggest that the traditional strategy of soliciting blood donors from low-prevalence populations may not always be optimal, unless such populations are truly low-risk.

[Spina-bifida and anencephaly. Geographic distribution, correlation with HLA system (author's transl)]. / Spina-bifida et anencéphalie. Répartition géograhique, corrélation avec le système HLA.

Geographical variation in the incidence of an Anencephaly and Spina-Bifida is well documented. The highest rates for these malformations were found in Ireland, Wales, Scotland and in Western regions of England. These rates decrease progressively towards eastern Europe. In France the highest rates were found in some regions of Brittany. The geographical correlations between the mortality rates of Spina-Bifida and incidence of Spina-Bifida and Anencephaly and the HLA antigen frequencies are studied. There is a positive correlation with A1 and B8 and a negative one with B5 and BW35. The role of the HLA system in these associations is discussed.

[The evaluation of the critical levels of malaria transmission in a stable endemic area (author's transl)]. / L'évaluation des seuils critiques de transmission du paludisme en zone d'endémie stable.

During a longitudinal survey done in the degraded forest area south of Brazzaville (People's Republic of the Congo), it appeared that plasmodic index of preschool children was always lower than 50% in spite of an inoculation rate of about one infected bite per child per night all along the year. The actual incidence rate estimated with Muench model was h = 0,015 while the recovery rate was r = 0,032 (i.e. about three times faster than the usual values admitted since Mac Donald work) for young children (0 to 4 years old). A computer study has shown that an incidence of h1 = 0,0012 was enough for the "infection" of children (Ross model) while an incidence of h2 = 0,0014 would induce a situation of superinfection (Dietz et al. model). Therefore the actual incidence was 10 to 12 times higher than the critical values of the incidence rate. To decrease the malaria transmission at a level lower than the critical values i.e. to obtain a reproduction rate below I the calculations and graphs have shown that anopheline density or human gametocytaemia have to be reduced by about 90% while the survival rate of the vectors must be reduced by about 12%. Therefore it appeared that the determination of the critical levels of every parameters of malaria transmission is a needful stage for a better planification of any malaria control programme.