Trajectories of women's physical and psychosocial health following obstetric fistula repair in Uganda: a longitudinal study.

OBJECTIVES: To explore trajectories of physical and psychosocial health, and their interrelationship, among women completing fistula repair in Uganda for 1 year post-surgery. METHODS: We recruited a 60-woman longitudinal cohort at surgical hospitalisation from Mulago Hospital in Kampala Uganda (Dec 2014-June 2015) and followed them for 1 year. We collected survey data on physical and psychosocial health at surgery and at 3, 6, 9 and 12 months via mobile phone. Fistula characteristics were abstracted from medical records. All participants provided written informed consent. We present univariate analysis and linear regression results. RESULTS: Across post-surgical follow-up, most women reported improvements in physical and psychosocial health, largely within the first 6 months. By 12 months, urinary incontinence had declined from 98% to 33% and general weakness from 33% to 17%, while excellent to good general health rose from 0% to 60%. Reintegration, self-esteem and quality of life all increased through 6 months and remained stable thereafter. Reported stigma reduced, yet some negative self-perception remained at 12 months (mean 17.8). Psychosocial health was significantly impacted by the report of physical symptoms; at 12 months, physical symptoms were associated with a 21.9 lower mean reintegration score (95% CI -30.1, -12.4). CONCLUSIONS: Our longitudinal cohort experienced dramatic improvements in physical and psychosocial health after surgery. Continuing fistula-related symptoms and the substantial differences in psychosocial health by physical symptoms support additional intervention to support women's recovery or more targeted psychosocial support and reintegration services to ensure that those coping with physical or psychosocial challenges are appropriately supported.

Pregnancy and contraception in systemic and cutaneous lupus erythematosus.

A causal link has long been described between estrogen and systemic lupus erythematosus activity. Contraceptive and pregnancy management is now common for lupus patients, but pregnancy continues to be associated with higher maternal and fetal mortality/morbidity in systemic lupus erythematosus patients than among the general population. Potential complications include lupus flares, obstetric complications (fetal loss, in utero growth retardation, premature birth) and neonatal lupus syndrome. Association with antiphospholipid antibodies or antiphospholipid syndrome increases the risk of obstetric complications. Anti-SSA and/or anti-SSB antibodies put fetuses at risk for neonatal lupus. Improving the outcome of such pregnancies depends upon optimal systematic planning of pregnancy at a preconception counseling visit coupled with a multidisciplinary approach. Absence of lupus activity, use of appropriate medication during pregnancy based on the patient's medical history and risk factors, and regular monitoring constitute the best tools for achieving a favorable outcome in such high-risk pregnancies. The aim of this review is to provide an update on the management of contraception and pregnancy in systemic lupus erythematosus, cutaneous lupus and/or antiphospholipid syndrome in order to reduce the risk of complications and to ensure the best maternal and fetal prognosis.

[Evaluation of patient transfer system in the health district of Bla]. / Evaluation du systeme de reference ­ evacuation dans le district sanitaire de Bla.

The rapid access of the population to basic and comprehensive health care determines the prognosis of the disease and decreases mortality and morbidity. METHODOLOGY: we carried out a prospective study over 12 months at the Bla Reference Health Center. All patients evacuated for obstetric complications were included. Women admitted on an emergency basis by self-referral were not included. The data was analyzed from the software Epi Info version: 3.5.4, the text entry from the software version Word 2013. RESULTS: We recorded 430 evacuations or 42.36% of admissions to the maternity hospital in Bla. The patients were young under 20 years 17.9% (n = 77), nulliparous 22.1% (n = 95). They had not performed an antenatal consultation in 30.7% of cases (n = 132). Matrons evacuated in 50.2% of cases (n = 216). The transfer diagnosis was hemorrhage in 14.2% of cases. The main intervention performed was cesarean section (92.3% of cases). The evacuation time was greater than one hour in 95.1% (n = 21). The actors for the financing of the fund were the district council, the town halls and the Community Health Associations (ASACO). The mobilization rate of ASACOs was 82%, that of town halls 17%. The circle council did not pay its quota. CONCLUSION: A better financial involvement of the communities in the management of the evacuation reference system in the health district of Bla is a necessity.

L'accès rapide de la population aux soins de santé de base et complet détermine le pronostic de la maladie et diminue la mortalité et la morbidité. MÉTHODOLOGIE: nous avons mené une étude prospective sur 12 mois au Centre de Santé de Référence de Bla. Ont été incluses toutes les patientes évacuées pour complications obstétricales. Les femmes admises en urgence par autoréférence n'ont pas été incluses. Les données ont été analysées à partir du logiciel Epi Info version : 3.5.4, la saisie des textes à partir du logiciel version Word 2013. RÉSULTATS: Nous avons enregistré 430 évacuations soit 42,36% des admissions à la maternité de Bla. Les patientes étaient jeunesmoins de 20 ans 17,9% (n=77), des nullipares 22.1% (n=95). Ellesn'avaient pas réalisé de consultation prénatale dans 30,7%des cas (n=132). Les matrones ont évacué dans 50,2% de cas (n=216). Le diagnostic de transfertétait l'hémorragie dans 14,2% de cas. La principale intervention pratiquée était la césarienne (92,3%des cas). Le délai d'évacuation était supérieur à une heure dans 95,1% (n=21). Les acteurs pour le financement de la caisse étaient le conseil de cercle, les mairies et les Associations de Santé Communautaires (ASACO). Le taux de mobilisation des ASACO a été de 82%, celui des mairies de17%. Le conseil de cercle n'a pas payé sa quote-part. CONCLUSION: Une meilleure implication financière des collectivités dans la gestion du système de référence évacuation dans le district sanitaire de Bla est une nécessité.

[Cell-free DNA fraction: Can it be used to evaluate the risk of obstetrical issues?] / L'ADN fœtal libre circulant : un outil d'évaluation du risque de survenue de complications obstétricales ?

OBJECTIVE: The aim of the study was to evaluate if fetal cell-free DNA (cfDNA) fraction circulating in maternal blood at the beginning of the second trimester is associated with obstetrical complications. METHODS: This is a retrospective unicentric study conducted at the hospital of Poissy Saint Germain between the 1st January 2015, and the 31st. December 2016, Each woman who had a genetic counseling in order to realize a non-invasive prenatal test (NIPT) was included. Only singleton pregnancies with a documented-issue were analysed. The primary criteria was a composite criteria, defined as the occurrence of preeclampsia, in utero fetal growth, or a spontaneous preterm delivery. A descriptive analyse was first conducted, secondly completed by a sub-group one: "high fetal fraction" (>90th percentile) group, "low fetal-fraction" group (<10th percentile) and "medium fetal-fraction" (control group) group. RESULTS: A total of 417 women had a cfDNA test, which was performed at a mean gestational age of 17.1 weeks of gestation. A total of 17% of pregnancies met the primary criteria. Among them, there were 8 (1.9%) pre-eclampsia, 49 (11.8%) intra-uterine growth restriction and 14 (3.4%) preterm births. There was no significant difference for the occurrence of the primary criteria (P>0.99) and of each obstetrical complication between each group. CONCLUSION: Fetal cf-DNA fraction measured at the beginning of the second trimester is not associated with common obstetrical complications.

[About a case of uterine per-partum rupture, 37months after resection of a rectovaginal endometriosis nodule]. / À propos d'un cas de rupture utérine per-partum, 37 mois après une résection d'un nodule recto-vaginal d'endométriose.

Endometriosis is a common condition in women, whose main repercussions are painful symptoms. In addition, it was shown that endometriosis was a major cause of infertility and various obstetric complications could be related to this pathology. Uterine rupture is a rare but serious complication whose incidence tends to decrease with the screening of women at risk, however, its fetal, maternal morbidity and mortality causes remains important. We were confronted with a case of posterior uterine rupture in a patient of 36 years, primipare term exceeded in immediate postpartum period. The patient's primary antecedent of uterine surgery torus was responsible for infertility endometriosis. The outcome was favorable for the mother, after a surgical treatment by laparotomy, and for the child. In the literature, two cases have been reported of uterine rupture after endometriosis surgery, which is why we found it interesting to report this rare case. Given the increase in surgical management of this disease, it seems relevant to ask whether, in the future, we should be more vigilant in monitoring pregnancy for these women.

[Risk of perinatal complication and egg donation: Role of resorting to cross-border care?] / Les risques périnataux sont-ils plus importants après don d'ovocytes à l'étranger ?

OBJECTIVES: In France, egg donation is covered by Social insurance among women<43 years old. Because of shortage of egg donor, women aged 43 years or more cannot resort to egg donation in French infertility centers, leading them to turn to the foreign centers having practices different and less regulated than in France. We are thus brought to take care of the pregnancy and of the delivery of these women. Our objective was to estimate if the perinatal risks are more important after egg donation abroad than in case of egg donation in a French center. MATERIAL AND METHODS: Retrospective study between January, 2010 and April, 2013, comparing women having had an egg donation to Cochin then having delivered in the maternity hospital of their choice (n=88) and the women having had an egg donation abroad then having delivered in the Port-Royal maternity (n=121). First, the modalities of egg donation were compared between the Cochin hospital and the foreign centers. Second, the obstetric and perinatal outcomes were compared between both groups, then by stratifying according to the type of pregnancy (singleton or multiple). RESULTS: Among women having had an egg donation abroad, the age of the donor was lower (25.7 vs. 31.7, P=0.001), the average number of embryos transferred higher (2.1±0.6 vs. 1.7±0.5, P=0.001) and the rate of multiple pregnancies higher (47.9% vs. 9.1%, P=0.001) than among women having had an egg donation at Cochin. We observed after egg donation abroad compared to egg donation at Cochin, a birth weight significantly lower (2678±745g vs. 3045±682g, P=0.001) and a prevalence of intrauterine growth retardation higher (11.1% vs. 4.2%, P=0.04). Among singletons, abnormal placentation was more frequent in case of egg donation abroad (17.5% vs. 5.1%, P=0.02). In case of twin pregnancy, we highlighted very high rates of complications, without significant difference according to the place where egg donation was practiced. CONCLUSION: We observed an increased risk of intrauterine growth retardation after egg donation abroad, which could essentially be explained by the association between advanced maternal age and multiple gestation. For other obstetric and perinatal complications, the differences between both groups were less important than expected, but very high in both groups, whether the egg donation was realized in France or abroad. The complications seem mainly due to the multiple gestations, justifying the transfer of a single embryo whenever possible.

[Obesity and primiparity: Risky delivery?]. / Obésité et primiparité: accouchement à risque ?

OBJECTIVES: To evaluate the risk of materno-foetal complications in obese primiparous women (Body Mass Index (BMI)≥30) MATERIALS AND METHODS: A retrospective study was conducted in our tertiary referral labour ward from 1st January 2009 to 31st December 2010, including primiparous women delivering living cephalic singleton pregnancies after 37 weeks of amenorrhea. Two groups were compared: obese patients (BMI≥30) and non-obese (BMI<30). Obstetrical and neonatal data were collected. RESULTS: Among 1636 primiparous women, 132 (8%) had a BMI≥30. Induction of labor, prolonged pregnancy and post-partum hemorrhage were significatively more frequent in obese group (P<0.001). Those patients have an increased risk of cesarean section (P<0.001). Mean birth weight of newborns from obese mothers is significatively higher (3493g vs 3265g, P<0.001), as is the frequency of macrosomia (16.7% vs 5.2%, P<0.001). CONCLUSION: Obesity is associated with obstetrical complications in primiparous obese women, who are to be considered risky patients at their arrival in the labour ward, and specific obstetrical management must be planned to improve maternal and neonatal outcomes.

[Systemic lupus erythematosus and antiphospholipid syndrome: How to manage pregnancy?]. / Lupus systémique et syndrome des antiphospholipides : comment prendre en charge la grossesse ?

Pregnancy in systemic lupus erythematosus patients is a common situation that remains associated with higher maternal and fetal mortality/morbidity than in the general population. Complications include lupus flares, obstetrical complications (fetal loss, in utero growth retardation, prematurity) and neonatal lupus syndrome. The association with antiphospholipid antibodies or antiphospholipid syndrome increases the risk of obstetrical complications. Improving the care of these pregnancies depends upon a systematic pregnancy planning, ideally during a preconception counseling visit and a multidisciplinary approach (internist/rheumatologist, obstetrician and anesthetist). The absence of lupus activity, the use of appropriate medications during pregnancy adjusted to the patient's medical history and risk factors, and a regular monitoring are the best tools for a favorable outcome for these high-risk pregnancies. The aim of this review article is to perform an update on the medical care of pregnancy in systemic lupus erythematosus or antiphospholipid syndrome to reduce the risk of complications and to ensure the best maternal and fetal prognosis.