[Gastroschisis: Prenatal ultrasonography and obstetrical criteria for predicting neonatal outcome]. / Laparoschisis : facteurs échographiques et obstétricaux prédictifs d'une évolution post-natale défavorable.

OBJECTIVE: Prenatal diagnosis of complex laparoschisis is difficult and yet it is associated with a significantly increased morbidity and mortality. The aim of the study was to define ultrasonographic factor and obstetrical criteria to predicting adverse neonatal outcome. METHODS: Retrospective cohort study over 10 years, of 35 gastroschisis cases in CHU of Reims (France). The primary outcome was the neonatal death due to gastroschisis. The sonographic markers was bowel dilatation intra- or extra-abdominale, amniotic fluid, intra-uterin growth. The obstetrical criteria was fetal vitality, fetal heart rate, type of delivery, the weight and the term of birth. RESULTS: There were 28 live births, 16 children with favorable outcome, 8 children with adverse perinatal outcome and 4 deaths. There were any sonographic criteria to predicting adverse neonatal outcome. Only the birth weight less than 2000g was associated with an increase gastrointestinal complications (P=0.049). The type of the delivery was not associated with an adverse prenatal outcome. CONCLUSION: The birth weight less than 2000g seems to be associate with an increase gastrointestinal complications. It is important to fight against prematurity in case of gastroschisis.

[Umbilicus in children]. / L'ombilic chez l'enfant.

The umbilicus is our first scar. It is the last remain of our life in utero. Besides the umbilical hernia, a common pathology during the first three years of life that rarely requires surgery, there are some rare congenital abnormalities such as gastroschisis and omphalocele, which occur in about 1-5/10,000 births. Gastroschisis is a birth defect of the anterior abdominal wall, through which the fetal intestines freely protrude and are not covered by any membranes. During the 13th week prenatal ultrasound, the umbilical cord can be seen to be properly attached while the intestines float freely in the amniotic fluid. This defect is most common in young women who smoke and/or use cocaine and is not typically associated with genetic disorders. Omphalocele is an average coelosomy, in which a visceral hernia protrudes into the base of the umbilical cord. Omphalocele is typically diagnosed during the prenatal phase, and occurs most commonly in older mothers. It is frequently associated with genetic and morphologic abnormalities, therefore a karyotype should automatically be performed. For these two pathologies, the surgical problem lies in managing, during the reintegration, the conflict container/content responsible to lower vena cava syndrome and disorders ventilatory. Deciding on the technique will depend on the clinical form, and on the tolerance to reinsertion. The success of the surgery is directly linked to the postoperative emergence care for the pre-, per- and postnatal phases. The umbilical cord is preserved in the case of a gastroschisis. A primary or secondary umbilicoplasty will be performed for an omphalocele closure. The umbilicoplasty aims to create an umbilicus in a good position by giving it a shape, ideally oval, but also and especially an umbilication. The primary or secondary umbilicoplasty remains a challenge in a growing abdomen (change in position, deformation, loss of intussusception with growth). Many techniques are described: cutaneous flaps randomly placed, excision and skin plasty, resection and controlled wound healing. The choice of technique is a matter of practice but must be done in a rational way, depending on the scar condition when secondary reconstruction, and with minimal scarring, for primary reconstruction. To avoid morphological changes associated with growth, secondary umbilicoplasty should be proposed after the age of five.

[Recurrence of pregnancies with gastroschisis: a case report]. / Récidive de grossesse avec fœtus atteint de laparoschisis : à propos d'un cas.

Gastroschisis, a parietal anomaly belonging to median celosomia, is characterized by right lateral-umbilical evisceration. Its frequency, estimated at 1 birth in 2700, shows an excellent final prognosis conditioned by the digestive ischemic damage found at birth whose therapeutic management is often limited. No genetic cause is currently incriminated in the genesis of gastroschisis, except syndromic group associations. In this original observation, we report the case of a couple with a normal history whose obstetric management of the first pregnancy showed a fetus with gastroschisis at 12 WG, with primary closure at birth. The same couple began a second pregnancy in post-partum with on the first-quarter echography showing gastroschisis. A boy was delivered vaginally with extraction, who died of a multivisceral failure at 48h of life. Although no genetic factor is currently identified in gastroschisis onset and although only environmental factors such as illicit substance consumption, young maternal age, and socio-economic precariousness explain the genesis of this parietal anomaly, our observation is original because of the recurrence of this anomaly in the same woman during two successive pregnancies. The early characteristic of the second pregnancy, starting as soon as menstruation returned, can explain the organogenesis of this second gestation in a similar environmental context.

VAC® therapy a therapeutic alternative in giant omphalocele treatment: a multicenter study.

Giant omphalocele is associated to morbidity and mortality because of the strain the reintegrated herniated mass places on the hemodynamic equilibrium and breathing functions of affected infants. Currently, care management consists in a reintegration in one time or progressive reintegration. We report here a multicenter retrospective study about alternative management by VAC® therapy for giant omphaloceles. The study included three patients (1 girl, 2 boys) presenting with giant omphaloceles, born at full term in three different University Hospitals (prenatal diagnosis, normal karyotype). VAC® therapy was implemented at different times according to the cases (at Day 11, Month 1 and Month 5 after birth). The initial pressure applied was -10 mmHg progressively increased to -50 mmHg. A middle size VAC GranuFoam Silver® Dressing was used in all cases. Wound healing occurred at Month 4 for the first case, Month 6 and Month 8 for the other two. VAC® therapy is a good alternative for the care management of giant omphaloceles with more advantages especially when using prosthetic material. We also aimed at refining the most adapted indications in these specific situations, and finally we envisioned a harmonization of care for these children.

Usefulness of HPV testing in the follow-up of untreated cervical low grade lesions.

The aim of the present work was to evaluate the usefulness of high-risk human papillomavirus (HR-HPV) testing for the follow-up of women with untreated low grade cervical squamous cell lesions (LSIL). For that, 412 women with a cytological diagnosis of LSIL at entry were monitored by cytology, HR-HPV testing with the Hybrid Capture II assay (HC-II) and colposcopy. Our primary endpoint was clinical progression defined by the presence of a high grade cervical intraepithelial neoplasia (CIN2 and CIN3) at the biopsy. At baseline, histological control revealed 10 CIN2 and 11 CIN3 only in the cohort of women HR-HPV+. In the follow-up, 4 CIN2 and 8 CIN3 were detected, always in the women initially HR-HPV+. Thus, the recurrence of a HR-HPV+ infection clearly selects a population at high-risk for CIN2-3. The semi-quantitative appreciation of the viral load with HC-II could not be used as a good prognostic factor for the follow-up of women with LSIL. HR-HPV testing reduces the number of cytology and colposcopy examinations in the follow-up of women aged >35 years when HPV testing is initially negative. Thus HR-HPV testing should be reserved for the follow-up of this population of women initially HR-HPV+ and proposed 6 to 12 months after the cytological diagnosis of LSIL.

Negative human papillomavirus testing in normal smears selects a population at low risk for developing high-grade cervical lesions.

High-risk human papillomaviruses (HR-HPV) are the necessary cause of cervical carcinomas and there is an increasing interest in using HR-HPV DNA detection in adjunction to cytological examination for primary cervical screening. To determine whether women with a normal smear negative for HR-HPV DNA detection with the Hybrid Capture II assay might represent a low-risk population for developing a high-grade squamous intraepithelial lesion (HSIL), 4401 women have been followed in a period of 12-72 months (median=34 months). During this follow-up, four HSIL and one microinvasive carcinoma have been detected in this cohort (three in the cohort of 3526 women >29 years). The global negative predictive value (NPV) of double-negative tests is thus of 99.9% (ninety-five percent confidence interval (95% CI): 99.8-100%), whereas cytology alone gives an NPV of 99.2% (95% CI: 98.9-99.5%). If we obtain a second negative HR-HPV test 1-2 years after the initial test, the NPV is 100%. The NPV is also of 100% in the cohort of women >49 years. We conclude that all these women could be safely screened at longer intervals between 3 and 5 years. This policy will offset the increased costs induced by an additional HR-HPV testing in primary screening.

[Local investigation concerning psychic and sexual functioning a short time after hysterectomy]. / Enquête régionale sur le retentissement psychique et sexuel à court terme de l'hystérectomie.

UNLABELLED: Hysterectomy is one of the most common operations done throughout the world. Patients' concerns about sexual functioning after hysterectomy is great. OBJECTIVE: We wanted to evaluate, through a local investigation based on a questionnaire, the psychosexual impact of this operation and to compare our data to those available in the literature. PATIENTS AND METHODS: 534 patients operated between of 01.01.1997 and 31.12.1997 for a benign uterine pathology (prolapse excluded) were included. Questions were about sexual and psychological functioning after hysterectomy. The main outcome measures were changes in the sexual life, sexual desire, orgasm, dyspareunia, frequency of sexual relations. Abdominal and vaginal surgical approaches were compared for some items when possible. RESULTS: After the operation, 83.3% of the patients felt better, 30.4% of the patients mentioned changes in their sexual life, 32% of low libido rates was noticed (and there was a significant difference between abdominal and vaginal surgical approaches), 27.6% of the patients had less frequent orgasm and only 8.8% experienced orgasm more frequently, 15% suffer from dyspareunia, and 15% were more engaged in sexual intercourse. CONCLUSION: Psychosexual impact of hysterectomy is limited and is not more frequent when vaginal surgery is performed, but pre- and post-operative prevention can be useful.

Preconception seroconversion and maternal seronegativity at delivery do not rule out the risk of congenital toxoplasmosis.

We describe two unusual cases of congenital toxoplasmosis, one occurring after preconception maternal infection with cervical adenopathies and the other occurring after maternal infection at the very end of pregnancy with maternal seronegativity at delivery. These documented cases of congenital toxoplasmosis demonstrate the value of extending the serologic monitoring period during pregnancy, according to the individual clinical context.

Human papillomavirus testing in primary screening for the detection of high-grade cervical lesions: a study of 7932 women.

High-risk human papillomaviruses (HR-HPV) are the necessary cause of cervical carcinomas. To determine whether HPR-HPV DNA detection in primary routine screening could represent a sensitive and reliable technique for the detection of high-grade squamous intraepithelial lesions (HGSIL), laboratory analysis using 2 cytologic techniques (conventional and liquid-based), HPV testing with Hybrid Capture II assay (HC-II), followed by colposcopic examination of women with abnormal cervical finding and/or persistent HR-HPV infection, was conducted in 7932 women who had routine cervical examination. The sensitivity of HPV testing for detecting a histologically proven HGSIL was 100%, higher than that of conventional (68.1%) and liquid-based (87.8%) cytology. The low specificities of 85.6% and 87.3% of HPV testing slightly increased to 88.4% and 90.1% if HPV testing was reserved for woman >30 years old. The quantitative approach provided by the HC-II assay for the assessment of the viral load was not reliable for predicting HGSIL in normal smears. HR-HPV testing could be proposed in primary screening in association with cytology. With conventional cytology it significantly improves the detection of HGSIL. With the use of the same cervical scrape for HPV testing and liquid-based cytology, HR-HPV testing would allow to select positive samples treated in a second time for cytology which gives a good specificity.

DNA image cytometry and human papillomavirus (HPV) detection help to select smears at high risk of high-grade cervical lesions.

Three samples were submitted from women undergoing routine screening (n=910): two smears (one for routine cytology and one for DNA image cytometry) and a scrape for human papillomavirus (HPV) testing. DNA histograms were classified as suspect in cases of aneuploidy, polyploidy, and/or diploidy with a high proliferation rate. Follow-up was available in 239 cases. The primary end-point was the presence of a high-grade squamous intraepithelial lesion (HGSIL) at biopsy. Seventy women (7.7%) had a high-risk (HR) HPV infection and a suspect DNA profile. In 77 women with cytological abnormalities, 28 HGSILs were detected: four with a prior diagnosis of ASCUS (all HR-HPV infected including three with a suspect DNA profile), three with smears evocative of LGSIL (all with HR-HPV infection and a suspect DNA profile), and 21 with smears evocative of HGSIL (all with HR-HPV infection and 20 with a suspect DNA profile). During the follow-up period, out of 239 women with a cytologically normal smear at first entry, five developed a HGSIL; all were HR-HPV-positive and four had a suspect DNA profile at the first smear. HR-HPV detection alone gives a sensitivity of 100% for the detection of HGSIL, with a specificity of 84.3%, whereas DNA measurement associated with HPV testing significantly enhances the specificity to 95.4%. Thus, the combination of HPV testing and DNA measurement provides a highly sensitive and specific evaluation of the risk of HGSIL on cervical smears.

Hybrid Capture II-based human papillomavirus detection, a sensitive test to detect in routine high-grade cervical lesions: a preliminary study on 1518 women.

Hybrid Capture II (HC-II) is a commercial human papillomavirus (HPV) detection test designed to detect 18 HPV types divided into high-risk and low-risk groups. We have tested 1647 scrapes from 1518 unselected women attending routine cytological screening by this assay for the detection of histologically proven high-grade lesions. The reliability of this test was also evaluated on 117 fresh cone biopsy samples. HPV DNA has been detected in 400 scrapes (24.3%), 296 containing a high-risk HPV (18.0%). All the smears evocative of high-grade lesions were positive for high-risk HPV, and high-risk HPV were detected in all the 34 cases presenting a histologically proven high-grade lesion and in 68 (97.1%) of the 70 cone biopsy samples showing a high-grade lesion or an invasive carcinoma. Thus, the sensitivity was superior to the sensitivity of cytology (85.3%). Nevertheless, the quantitative approach provided by the HC-II assay for the assessment of the viral load could not clearly distinguish among cases with or without high-grade lesions. Thus this assay is recommended for the screening of high-grade lesions on a large scale, in association with classic cytology.

[Delayed deliveries in multiple pregnancies: is this reasonable?]. / Accouchements différés dans les grossesses multiples: est-ce raisonnable?

Delivery of viable fetus with a long interval delay is an unusual occurrence. There is no clear attitude among obstetricians for such cases. We report a case of retention of the second and the third triplet after the delivery of the first one at 24 weeks of amenorrhea and 3 days. The duration of the retention was 6 days. Only the third infant survived. We attempt to outline the difficulties in managing such pregnancies.

Comparative analysis of human papillomavirus detection by hybrid capture assay and routine cytologic screening to detect high-grade cervical lesions.

A commercial HPV detection test, Hybrid Capture (HC), designed to detect 14 HPV types divided into high-risk and low-risk groups, has been evaluated. A total of 1064 scrapes from 1028 unselected women attending routine cytologic screening were tested and results were compared with those of classic cytologic screening and cervical biopsies. The reliability of the test was also evaluated on 38 fresh conization samples. HPV DNA was detected in 108 women (10.5%), including 90 infected by a high-risk HPV (8.8%); 25 high-grade lesions were detected histologically, and high-risk HPV was found in 16 of these 25 women (64%), and in 27 (71%) of the 38 conization samples. The overall sensitivity of HC in detecting high-grade SIL on cervical scrapes and conization samples was 71.2%, while its positive predictive value was 17.8%. Classic cytologic screening appeared to be the most sensitive method (84%) for detecting high-grade SIL, with a positive predictive value of 91.3%. The lower sensitivity of HC limits its use for screening high-grade lesions on a large scale, even though it may be useful for reducing cytologically false-negative results. Moreover, the quantitative approach provided by the HC assay for assessment of the viral load cannot clearly distinguish among cases with or without high-grade lesions.

Hybrid capture II, a new sensitive test for human papillomavirus detection. Comparison with hybrid capture I and PCR results in cervical lesions.

AIM: To test a new assay for the detection of human papillomavirus (HPV) DNA, hybrid capture II (HC II), compared with the previous commercialized hybrid capture I (HC I) and polymerase chain reaction (PCR) results on cervical scrapes from fresh cone excision biopsy samples. METHODS: The three methods were used on cervical scrapes from 42 fresh cone excision biopsy samples. There were nine metaplastic and inflammatory lesions, five low grade lesions, and 28 high grade lesions. PCR was performed using the general primers GP5+/GP6+. The viral load of high risk HPV DNA was estimated by the ratio of relative light units to positive control values in the samples. RESULTS: The sensitivity of HC I for the detection of high grade lesions was 71.4%, while it was 92.8% for HC II and 96.4% for the PCR. Considering only the absence of detectable cervical in situ neoplasia, the specificity was 88.9% for HC I, 66.7% for HC II, and 66.7% for PCR. With HC II, for a ratio of cervical sample to normal control of > 200, the sensitivity for the detection of high grade lesion was only 34.6% with a specificity of 66.7%. CONCLUSIONS: HPV detection with the HC II assay is more sensitive than the previous HC I and represents a more convenient and easier test than PCR for routine use. Nevertheless the viral load estimated with this test cannot be a reliable predictive indicator of high grade lesions.