Gynecological health and uptake of gynecological care after domestic or sexual violence: a qualitative study in an emergency shelter.

BACKGROUND: Domestic and sexual violence have been linked to adverse gynecological and obstetric outcomes. Survivors often find it difficult to verbalize such violence due to feelings of shame and guilt. Vulnerable or socially excluded women are frequently excluded from research, particularly qualitative studies on violence. This study aimed to characterize the perceived impact of domestic or sexual violence on the gynecological health and follow-up among women with complex social situations. METHODS: We analyzed the data following inductive thematic analysis methods. RESULTS: Between April 2022 and January 2023, we conducted 25 semi-structured interviews, lasting on average 90 min (range: 45-180), with women aged between 19 and 52, recruited in an emergency shelter in the Paris area. The women described physical and psychological violence mainly in the domestic sphere, their altered gynecological and mental health and their perception of gynecological care. The levels of uptake of gynecological care were related to the characteristics of the violence and their consequences. The description of gynecological examination was close to the description of coerced marital sexuality which was not considered to be sexual violence. Gynecological examination, likely to trigger embarrassment and discomfort, was always perceived to be necessary and justified, and consent was implied. CONCLUSION: This study can help question the appropriateness of professional practices related to the prevention of violence against women and gynecological examination practices. Any gynecological examination should be carried out within the framework of an equal relationship between caregiver and patient, for the general population and for women with a history of violence. It participates in preventing violence in the context of care, and more widely, in preventing violence against women.

Low uptake of gynecological consultation following domestic or sexual violence: A case-control study during pregnancy follow-up.

OBJECTIVE: The aim of this study was to examine the association between exposure to domestic and sexual violence and low uptake of gynecological consultation. STUDY DESIGN: Between October 2021 and October 2022, a case-control studywas conducted in mother andchild centers and sexual health centers in the Paris, France area. The case group included pregnant women who did not have a scheduled gynecological consultation in the past two years. The control group included pregnant women who had a scheduled gynecological consultation in the past two years. Pregnant women were interviewed using a standardized questionnaire about a history of domestic and sexual violence, the date of their last gynecological consultation and the gynecological health. RESULTS: A total of 405 pregnant women were included in the case group (n = 129) or in the control group (n = 276). After adjustment for age, couple, social security, supplementary health insurance, dyspareunia, abnormal vaginal discharge, dysmenorrhea, regular pelvic pain, mastodynia, vulvodynia and history of difficult delivery, a history of intimate partner violence was associated with the absence of a gynecological consultation in the past two years (OR 2.13; CI95% 1.21-3.73, p = 0.008). A history of sexual violence, regardless of age, was associated with the absence a gynecological consultation in the past two years (OR 1.92; CI95% 1.05-3.49, p = 0.03). The absence of a gynecological consultation was associated with dyspareunia and domestic or sexual violence (p < 0.0001 and p < 0.0001, respectively). CONCLUSIONS: This study highlighted the association between domestic and sexual violence and the absence of gynecological consultations in the past two years. It underlines the importance of screening for domestic and sexual violence during gynecological consultations and its impacts on mental health, in particular psychotraumatic symptoms, and on gynecological health, in particular dyspareunia.

Effectiveness and Costs of Molecular Screening and Treatment for Bacterial Vaginosis to Prevent Preterm Birth: The AuTop Randomized Clinical Trial.

Importance: Bacterial vaginosis (BV) is a well-known risk factor for preterm birth. Molecular diagnosis of BV is now available. Its impact in the screening and treatment of BV during pregnancy on preterm births has not been evaluated to date. Objective: To evaluate the clinical and economic effects of point-of-care quantitative real-time polymerase chain reaction screen and treat for BV in low-risk pregnant women on preterm birth. Design, Setting, and Participants: The AuTop trial was a prospective, multicenter, parallel, individually randomized, open-label, superiority trial conducted in 19 French perinatal centers between March 9, 2015, and December 18, 2017. Low-risk pregnant women before 20 weeks' gestation without previous preterm births or late miscarriages were enrolled. Data were analyzed from October 2021 to November 2022. Interventions: Participants were randomized 1:1 to BV screen and treat using self-collected vaginal swabs (n = 3333) or usual care (n = 3338). BV was defined as Atopobium vaginae (Fannyhessea vaginae) load of 108 copies/mL or greater and/or Gardnerella vaginalis load of 109 copies/mL or greater, using point-of-care quantitative real-time polymerase chain reaction assays. The control group received usual care with no screening of BV. Main Outcomes and Measures: Overall rate of preterm birth before 37 weeks' gestation and total costs were calculated in both groups. Secondary outcomes were related to treatment success as well as maternal and neonate health. Post hoc subgroup analyses were conducted. Results: Among 6671 randomized women (mean [SD] age, 30.6 [5.0] years; mean [SD] gestational age, 15.5 [2.8] weeks), the intention-to-treat analysis of the primary clinical and economic outcomes showed no evidence of a reduction in the rate of preterm birth and total costs with the screen and treat strategy compared with usual care. The rate of preterm birth was 3.8% (127 of 3333) in the screen and treat group and 4.6% (153 of 3338) in the control group (risk ratio [RR], 0.83; 95% CI, 0.66-1.05; P = .12). On average, the cost of the intervention was €203.6 (US $218.0) per participant, and the total average cost was €3344.3 (US $3580.5) in the screen and treat group vs €3272.9 (US $3504.1) in the control group, with no significant differences being observed. In the subgroup of nulliparous women (n = 3438), screen and treat was significantly more effective than usual care (RR, 0.62; 95% CI, 0.45-0.84; P for interaction = .003), whereas no statistical difference was found in multiparous (RR, 1.30; 95% CI, 0.90-1.87). Conclusion and Relevance: In this clinical trial of pregnant women at low risk of preterm birth, molecular screening and treatment for BV based on A vaginae (F vaginae) and/or G vaginalis quantification did not significantly reduce preterm birth rates. Post hoc analysis suggests a benefit of screen and treat in low-risk nulliparous women, warranting further evaluation in this group. Trial Registration: ClinicalTrials.gov Identifier: NCT02288832.

Development of a nomogram for individual preterm birth risk evaluation.

OBJECTIVE: This study aimed to develop a new tool for personalised preterm birth risk evaluation in high-risk population. STUDY DESIGN: 813 high-risk asymptomatic pregnant women included in a French multicentric prospective study were analysed. Clinical and paraclinical variables, including screening for bacterial vaginosis with molecular biology, cervical length, have been used to create the nomogram, based on the logistic regression model. The validity was checked by bootstrap. A downloadable calculator was build. RESULTS: Nine risk factors were included in this model: history of late miscarriage and/or preterm delivery, active smoking, ultrasound cervical length, term of pregnancy at screening, bacterial vaginosis, premature rupture of membranes, daily travel more than 30min. Discrimination and calibration of the nomogram revealed good predictive abilities. The area under the receiver operating characteristic curve was 0.77 (95% CI; 0.72-0.81). The mean absolute error was 0.018, which showed proper calibration. The optimal risk threshold was 23.2% with a sensitivity of 74%, a specificity of 72.7% and a predictive negative value of 90.6%. CONCLUSION: The nomogram can help to better define individual preterm birth risk in high-risk pregnancies.

Evaluation of current and new biomarkers in severe preeclampsia: a microarray approach reveals the VSIG4 gene as a potential blood biomarker.

Preeclampsia is a placental disease characterized by hypertension and proteinuria in pregnant women, and it is associated with a high maternal and neonatal morbidity. However, circulating biomarkers that are able to predict the prognosis of preeclampsia are lacking. Thirty-eight women were included in the current study. They consisted of 19 patients with preeclampsia (13 with severe preeclampsia and 6 with non-severe preeclampsia) and 19 gestational age-matched women with normal pregnancies as controls. We measured circulating factors that are associated with the coagulation pathway (including fibrinogen, fibronectin, factor VIII, antithrombin, protein S and protein C), endothelial activation (such as soluble endoglin and CD146), and the release of total and platelet-derived microparticles. These markers enabled us to discriminate the preeclampsia condition from a normal pregnancy but were not sufficient to distinguish severe from non-severe preeclampsia. We then used a microarray to study the transcriptional signature of blood samples. Preeclampsia patients exhibited a specific transcriptional program distinct from that of the control group of women. Interestingly, we also identified a severity-related transcriptional signature. Functional annotation of the upmodulated signature in severe preeclampsia highlighted two main functions related to "ribosome" and "complement". Finally, we identified 8 genes that were specifically upmodulated in severe preeclampsia compared with non-severe preeclampsia and the normotensive controls. Among these genes, we identified VSIG4 as a potential diagnostic marker of severe preeclampsia. The determination of this gene may improve the prognostic assessment of severe preeclampsia.

Antibacterial treatment of bacterial vaginosis: current and emerging therapies.

Bacterial vaginosis is a common cause of malodorous vaginal discharge. It is also associated with sexually transmitted infections and adverse pregnancy outcomes. The magnitude of the gynecological and obstetrical consequences has stimulated therapeutic research and led to the testing of several therapies. The objective of this work is to present the currently available therapeutic strategies for the treatment of bacterial vaginosis and associated recommendations, and discuss the emerging therapies.

High vaginal concentrations of Atopobium vaginae and Gardnerella vaginalis in women undergoing preterm labor.

OBJECTIVE: To estimate the relationship between vaginal quantification of the main microorganisms related with bacterial vaginosis and the risk of preterm delivery among women with preterm labor. METHODS: Molecular methods were used to prospectively quantify Lactobacillus species, Gardnerella vaginalis, Atopobium vaginae, and Mycoplasma hominis in vaginal fluid samples from women admitted for spontaneous preterm labor with intact membranes from July 2007 through July 2008. The primary outcome measure was the relationship between bacterial concentration at admission and preterm delivery, before 37 weeks of gestation. Sensitivity and specificity of molecular cutoff values and 95% confidence intervals (CIs) were calculated using the University of British Columbia Bayesian Calculator type 2. RESULTS: Of the 90 women included, 36 delivered before 37 weeks of gestation (40%). Preterm delivery was not associated with the presence of Lactobacillus species, G vaginalis, A vaginae, or M hominis. In contrast, molecular quantification detected high concentrations of A vaginae (10(6)/mL or more: 25.0% in the preterm group and 9.3% in the term group, P=.04) and G vaginalis (10(7)/mL or more: 16.7% and 3.7%, P=.03) more often in women with preterm deliveries compared with term deliveries. Moreover, high vaginal concentrations of these two microorganisms together were associated with a significantly (P=.03) shorter interval between preterm labor and delivery (46 days, 95% CI 30-61) than were lower concentrations (85 days, 95% CI 75-95). The hazard ratio for a short preterm labor-to-delivery interval was three times higher for high vaginal fluid concentrations of A vaginae and G vaginalis than for lower concentrations (hazard ratio 3.3, 95% CI 1.1-9.5, P=.03). CONCLUSION: The risk of preterm delivery is significantly associated with high vaginal concentrations of A vaginae and G vaginalis in women with preterm labor. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00484653. LEVEL OF EVIDENCE: III.

Cervical preparation with laminaria tents improves induction-to-delivery interval in second- and third-trimester medical termination of pregnancy.

BACKGROUND: The purpose of our study was to determine whether cervical preparation with laminaria tents would improve the procedure of second- and third-trimester medical termination of pregnancy (TOP) in terms of duration of abortion and hospitalization. STUDY: A retrospective comparative study of two historical periods of women undergoing second- and third-trimester medical TOP at a single tertiary care center from September 2004 to December 2006 was conducted. During Period A, patients received oral mifepristone and vaginal misoprostol, while during Period B, laminaria tents were added. Main outcome measures included initiation-to-delivery (ITD) time, induction-to-delivery interval and hospitalization time. RESULTS: Of 186 eligible women, 174 were enrolled in the study: 91 patients during Period A and 83 patients during Period B. The ITD time was reduced during Period B compared to Period A (43.2+/-6.2 h and 48.5+/-13.2 h, respectively; p=.001). Similarly, the induction-to-delivery interval was significantly shorter during Period B (7.5 h) compared to Period A (12.7 h; p=.001). A significant reduction in total hospital stay was observed during Period B (3 days) versus Period A (4 days; p<.001). CONCLUSION: Cervical preparation with laminaria tents significantly shortens the duration of medical TOP that uses mifepristone-misoprostol without adverse events or serious complications.

Molecular quantification of Gardnerella vaginalis and Atopobium vaginae loads to predict bacterial vaginosis.

BACKGROUND: Bacterial vaginosis (BV) is a poorly detected public health problem that is associated with preterm delivery and for which no reliable diagnostic tool exists. METHODS: Molecular analysis of 231 vaginal samples, classified by Gram stain-based Nugent score, was used to propose molecular criteria for BV; these criteria were prospectively applied to 56 new samples. A quantitative molecular tool targeting 8 BV-related microorganisms and a human gene was developed using a specific real-time polymerase chain reaction assay and serial dilutions of a plasmid suspension. The targeted microorganisms were Gardnerella vaginalis, Lactobacillus species, Mobiluncus curtisii, Mobiluncus mulieris, and Candida albicans (which can be identified by Gram staining), as well as Atopobium vaginae, Mycoplasma hominis, and Ureaplasma urealyticum (which cannot be detected by Gram staining). RESULTS: With use of the Nugent score, 167 samples were classified as normal, 20 were classified as BV, and 44 were classified as intermediate. Except for U. urealyticum, M. mulieris, and Lactobacillus species, DNA of the tested bacteria was detected more frequently in samples demonstrating BV, but the predictive value of such detection was low. The molecular quantification of A. vaginae (DNA level, > or = 10(8) copies/mL) and G. vaginalis (DNA level, > or = 10(9) copies/mL) had the highest predictive value for the diagnosis of BV, with excellent sensitivity (95%), specificity (99%), and positive (95%) and negative (99%) predictive values; 25 (57%) of the samples demonstrating intermediate flora had a BV profile. When applied prospectively, our molecular criteria had total positive and negative predictive values of 96% and 99%, respectively. CONCLUSIONS: We report a highly reproducible, quantitative tool to objectively analyze vaginal flora that uses cutoff values for the concentrations of A. vaginae and G. vaginalis to establish the molecular diagnosis of BV.

Development and validation of a nomogram to predict the risk of cesarean delivery in macrosomia.

OBJECTIVE: To develop and validate a nomogram that predicts individual probability of cesarean delivery in cases of macrosomia (>4,000 g). METHODS: The nomogram was built based on the data from 246 patients who delivered macrosomic infants at Conception Hospital (Marseille, France), and was validated on an external population of 206 patients. Logistic regression was used to construct a model to predict the probability of cesarean section. The calculations were based on actual birth weight. MAIN OUTCOME MEASURES: The accuracy of the model was evaluated by area under the receiver operator curve. RESULTS: In the multivariate analysis performed on the training set, maternal age (p=0.002), parity (p=0.003), and maternal height <1.65 m (p=0.01) were found to be significantly associated with the occurrence of cesarean delivery and included in the nomogram. The final variables included in the nomogram were: age (p=0.01), maternal height (p=0.02), parity (p<0.001), and previous cesarean section (p=0.009). Area under the ROCs was 0.80 and 0.78 in the training set before and after bootstrapping, respectively, and 0.88 in the validation set. The calibration of the nomogram was good. CONCLUSION: We have developed a nomogram based on actual birth weight that accurately predicts the risk of cesarean delivery in cases of macrosomia. This tool might be useful for decision-making.

Maternal morbidity associated with obstetrical maneuvers in shoulder dystocia.

OBJECTIVES: To determine whether shoulder dystocia and obstetrical maneuvers used for its relief have detrimental effects on perineum or immediate postpartum outcome. DESIGN: Case-control study. SETTING: Tertiary maternity ward in Marseille, France. POPULATION: A total 140 cases with shoulder dystocia and 280 controls without shoulder dystocia were enrolled by reviewing charts for the period between January 1999 and December 2004. METHODS: Demographic data including obstetrical history, age, height, weight before pregnancy and at the time of delivery, and respective body mass index (BMI) and obstetrical data including analgesic technique, duration of first and second stage of labor were compared in function of outcome and of the type and number of maneuvers used to relieve shoulder dystocia. RESULTS: Resolving shoulder dystocia required one obstetrical maneuver in 41 cases (29.3%) and two obstetrical maneuvers in 48 cases (34.3%). Third-degree tears occurred in one patient in the case group versus five in the control group. No correlation was found between the number of obstetrical maneuvers needed to relieve shoulder dystocia and risk for third-degree tear (OR: 0.8; 95% CI: 0.1-7.6). Mean hemoglobin values were 96.1 g/l in the case group and 96.0 g/l in the control group (p=0.95). There was no difference between the two groups regarding duration of postpartum hospitalization. The incidence of urinary incontinence was similar in the group that underwent obstetrical maneuvers: 4.7% (6/127) and in the control group: 3.7% (13/352). Only two patients reported de novo anal symptoms, both in the control group. CONCLUSION: Shoulder dystocia and obstetrical techniques used for its relief did not result in adverse maternal outcome.