[Use of human papilloma virus testing in primary cervical cancer screening in rural Madagascar]. / Intérêt du test HPV dans le dépistage primaire du cancer du col en milieu rural à Madagascar.

BACKGROUND: Testing for high-risk human papilloma virus (HR-HPV) is an effective approach to the prevention of cervical cancer. This study in the Atsinanana area of Madagascar aimed to compare the management of women screened by visual inspection after coloration with acetic acid (VIA) and the management of women screened by HPV with VIA as a triage test. METHOD: During the last two screening campaigns, the first patients (between 28 and 120 women par center) were sampled using a dry swab, just before the acetic acid application, to test 14 genotypes of HR-HPV using Roche Diagnostics Cobas® Test. We compared current management practices based on primary VIA to those that would have been implemented if the clinician had followed the recommendations of the World Health Organization for HPV-based primary screening. We used a regression Poisson model with random effect and robust variance. RESULTS: Among the 250 screened-women, 28 (11.2%) had acidophilic lesions of the uterine cervix or suspected lesions of invasive cancer (IVA +). The HPV test was positive in 62 cases (24.8%). The HPV-based screening strategy would have reduced by 52% the number of women needing thermo-coagulation treatment: 24 women (9.6%) with primary VIA-based screening vs. 13 women (5.2%) with primary HPV-based screening; RR: 0.52 and 95%CI: 0.27-1.02. The diagnosis of severe dysplastic lesion or invasive cancer would not have changed. CONCLUSION: Primary HPV-based screening is a strategy that could be useful for low-resource countries like Madagascar. It would reduce the rate of false positives and unnecessary treatments compared to the current strategy based on primary IVA. The questions of the feasibility and cost-benefit of this strategy should be further explored.

[Cervical cancer screening in rural Madagascar: Feasibility, coverage and incidence]. / Dépistage du cancer du col utérin en milieu rural à Madagascar : faisabilité, couverture et incidence.

OBJECTIVES: To assess the implementation of a cervical cancer screening strategy in rural Madagascar. MATERIALS AND METHODS: A mobile unit, equipped with a cold-coagulator, visited every six months the main health care centers in the Atsinanana area between 2013 and 2015. Cervical cancer screening was based on visual inspection with acetic acid (VIA). The lesions suggestive of intraepithelial neoplasia and limited to the cervix were coagulated on the same day. Non-eligible patients for immediate treatment were referred for appropriate investigations. We assessed the feasibility and the coverage of the screening strategy and estimated the incidence of cervical cancer in the targeted population. RESULTS: One thousand five hundred and sixty-nine (18%) of 8959 women aged between 25 and 65 years old were screened. Three hundred and fifty-seven (23%) were VIA positive and 322 (21%) were eligible for immediate treatment. No serious adverse effects were observed among patients treated on the same day. Among the 35 patients not eligible for immediate treatment and referred to the hospital, 16 (46%) were lost to follow up. CONCLUSION: When a cervical cancer screening by HPV or cytology is not possible, VIA remains a feasible and acceptable option in a disadvantaged environment. The effectiveness of this approach is still limited by the problems of access to care for patients who are not eligible for immediate treatment.

[Institutional review board of the French college of obstetricians and gynecologists (CEROG).]. / Le Comité d'éthique de la recherche en obstétrique et gynécologie (CEROG).

OBJECTIVE: To report the rules and the activity of the institutional review board of the French college of obstetricians and gynecologists (Comité d'éthique de la recherche en obstétrique et gynécologie [CEROG]) created in 2008. The submission requirements are also described. METHODS: Retrospective study. RESULTS: The Ethical Review Committee [institutional review board of the French college of obstetricians and gynecologists (CNGOF)] CEROG have examined 65 project studies in 2008. The median number of submitted studies was 5.5 per month (IQR: 3.75-6.25). The origins of the submission were as follows: tertiary care university hospitals (n=63, 97 %), Inserm (n=1), INRA (n=1). Researches were found to be in conformity with the French laws and regulations, to conform to generally accepted scientific principles and medical research ethical standards in 44 cases (68 %). In 13 cases (20 %), the study has been forwarded to the Persons Protection Committee (PPC) since it concerned biomedical research or "usual care research" (soin courant). In six cases (9 %), the investigators have not responded to IRB suggestions. In two cases (3 %), the information form has been judged unsatisfactory. CONCLUSION: The CEROG is the first national IRB in obstetrics and gynecology. This new committee clarifies IRB submission procedure in France concerning non-interventional studies in the field of obstetrics and gynecology.

[Evaluation of maternal morbidity after drug-induced termination of pregnancy (TOP) after 12 gestation weeks]. / Evaluation de la morbidité maternelle après interruption médicamenteuse de grossesse à partir de 12 semaines d'aménorrhée.

OBJECTIVE: The number of TOP for medical indications has increased regularly over the last ten years. At the same time, the methods used for TOP have evolved. The purpose of this study was to assess the frequency of complications after drug-induced termination of pregnancy in order to determine whether using this method for interrupting pregnancy during the second or third trimester adds further danger for the mother in terms of early severe risk (uterine rupture, hysterectomy) or less severe long-term risk (infection). MATERIAL AND METHODS: This metaanalysis included all articles devoted to pregnancy interruption from 12 gestation weeks retrieved from the Medline database and published between 1989 and 1999 in the United States, Canada, Australia, New Zealand, or the European Union. After excluding articles that included in utero death (n=8), isolated case reports and series involving a high-risk of maternal somatic complications (n=16), and surgical methods for pregnancy termination (n=4), we retained 23 articles for analysis. These articles had included 58,891 drug-induced terminations of pregnancy. For each article, we recorded the following complications: bleeding requiring transfusion, uterine rupture, ovular or placentar retention, and infection. A classical homogenicity test was performed for each type of complication. When this test was not significant, a mean rate, weighing by size of the study, was calculated. RESULTS: One study reported maternal deaths (3/143000). The weighted mean rate for late retention (>24 hr) was 1.5 [CI95: 1.1%-1.9%]. For infections, the rates were very variable between studies (from 0.7% to 3.6% with one study reporting 8%). For bleeding with transfusion, the weighted mean rate was 0.7% [CI95: 0.5%-0.9%]. This rate was significantly higher than the rate observed in 1999 in France after delivery excepting medically terminated pregnancy (p<10(-3)) but probably is a reflection of the variable transfusion practices during the eighties in these different countries. Th rate of uterine rupture after medically terminated pregnancy was 0.1% [CI95: 0.07%-0.17%] and would be higher after delivery (excepting terminations) but not significantly (p=0.07). CONCLUSION: This metaanalysis demonstrates that the risk of severe complications (uterine rupture and bleeding requiring transfusion) are rare but are more prevalent than after delivery except pregnancy termination. The metaanalysis approach is justified due to the low incidence of these severe complications. A prospective multicentric study of the complications using a geographical base would be useful to obtain unbiased data on risk level. A risk analysis by gestational age, maternal age, parity, and product used would thus be possible, as would long-term monitoring of maternal outcome.

[Birth mortality and pregnancy terminations: how can collected Diagnosis Related Group System data be used?]. / Mortinatalité et interruptions de grossesse: comment peut-on utiliser les données du PMSI?

In France since 1995, information on diagnoses and care are routinely collected for each patient hospitalised in a public or private hospital, using the Diagnosis Related Group system. Information on birth events constitutes a good example of possible use of this information for other aims than economic activity evaluation. In this paper, in order to highlight possible epidemiological use, some recommendations are proposed for collecting data on stillbirths and pregnancy terminations. The lack of usual knowledge on these two adverse events is the reason for this choice. While the improvements in prenatal diagnosis lead to an increase in pregnancy terminations, a minimum common core of collected data should allow routine epidemiological monitoring of these adverse perinatal events.

[Cytomegalovirus infection in pregnant women. Seroepidemiological prospective study in 1,018 women in Isere]. / Infection à cytomégalovirus chez la femme enceinte. Etude séro(-)épidémiologique prospective chez 1,018 femmes en Isère.

Cytomegalovirus (CMV) is the leading cause of viral congenital infections. In children, the consequences may be severe, especially in case of maternal primary infection during pregnancy. A prospective study was carried out in the department of Isère, in 1,018 pregnant women, in order to establish the seroprevalence of CMV, the frequency of primary infections during pregnancy and the associated risk factors. The overall seroprevalence was 51.5%; it increased significantly with age, parity, and low socioeconomic status. It was higher in women born in the South of France (51.6%) than in those born in the North (37.4%). Among a total of 878 women with serological follow-up, 7 primary infection cases (0.8%) were observed. Seventeen women (1.9%) presented border IgM values in the first serum, and these values were not related to recent infection. Extrapolation of the results to the whole department of Isère, suggests that each year about 100 pregnant women would be concerned by CMV primary infection, with 2 or 3 cases of death or severe sequelae in children. In light of these results, the interest of serological screening is discussed.

[Propositions for a better practice. Point of view of a specialist]. / Propositions pour une meilleure pratique. Point de vue du spécialiste.

Pregnancy management is a typical medical shared follow up, between general practicioner and the specialist, in charge of birth process, in the Obstetrical Center. To improve this health care net coordination, propositions are made based upon most frequently done errors analysis, practicioner and specialist errors too.

[Value and limits of estrioluria in cases of retarded fetal growth]. / Valeur et limites de l'oestriolurie dans les retards de croissance du foetus.

On the basis of personal experience of 56 cases of retarded intra-uterine growth (RIUG) followed during the course of pregnancy by means of repeated estriol determinations (213 values), the authors note that : In 2/3 of the cases the urinary estriol level was higher than the lower limit of normality. The urinary estriol levels were not related to the severity of the RIUG. The estriol level has a limited value in the diagnosis of RIUG. The authors emphasize the prognostic value of the curves of estrioluria in this pathology and propose a course of obstetrical management based on interpretation of the curves.