Risk Factors of Inadequate Colposcopy After Large Loop Excision of the Transformation Zone: A Prospective Cohort Study

International audienceObjective: The aim of the study was to identify the risk factors of post-large loop excision of the transformation zone (LLETZ) inadequate colposcopy. Materials and Methods: From December 2013 to July 2014, a total of 157 patients who had a LLETZ performed for the treatment of high-grade intraepithelial lesion with fully visible cervical squamocolumnar junction were included. All procedures were performed using semicircular loops. The use of colposcopy made during each procedure was systematically documented. Dimensions and volume of LLETZ specimens were measured at the time of procedure, before formaldehyde fixation. All participants were invited for a follow-up colposcopy 3 to 6 months after LLETZ. Primary end point was the diagnosis of post-LLETZ inadequate colposcopy, defined by a not fully visible cervical squamocolumnar junction and/or cervical stenosis. Results: Colposcopies were performed in a mean (SD) delay of 136 (88) days and were inadequate in 22 (14%) cases. Factors found to significantly increase the probability of post-LLETZ inadequate colposcopy were a history of previous excisional cervical therapy [adjusted odds ratio (aOR) = 4.29, 95% CI = 1.12-16.37, p = .033] and the thickness of the specimen (aOR = 3.12, 95% CI = 1.02-9.60, p = .047). The use of colpos-copy for the guidance of LLETZ was statistically associated with a decrease in the risk of post-LLETZ inadequate colposcopy (aOR = 0.19, 95% CI = 0.04-0.80, p = .024) as the achievement of negative endocervical margins (aOR = 0.26, 95% CI = 0.08-0.86, p = .027). Conclusions: Although the risk of post-LLETZ inadequate colpos-copy is increased in patients with history of excisional therapy and with the thickness of the excised specimen, it could be reduced with the use of colposcopic guidance and the achievement of negative endocervical margins. L arge loop excision of the transformation zone (LLETZ) is a routine procedure worldwide, because it is the first-line treatment of high-grade intraepithelial lesion (HSIL) of the cervix. Quality criteria for optimal LLETZ include the completeness of excision with the achievement of negative margins, while producing the minimal excised volume and depth of excision to minimize subsequent obstetrical and neonatal morbidity. 1,2 Obtaining negative margins is important, because incomplete excision exposes women to a significant risk of posttreatment residual and/or recurrent disease, particularly when the lesion involves the endo-cervical canal. 3,4 However, this risk remains higher to the general female population, even when negative margins are achieved. Women who had had a LLETZ remain therefore exposed to a 3-to 4-fold increased risk of developing subsequent cervical cancer at least for 20 years. 5-8 Thus, prolonged and careful post-LLETZ follow-up is mandatory, whatsoever the margins status. For the last decade, the value of human papillomavirus testing has been demonstrated in this indication. Although a negative human papillomavirus test has now been admitted as the best test of cure for patients, colposcopy remains needed when this test is found to be positive. 9-12 Although being the key examination in this indication, the accuracy of colposcopy performed after previous excisional therapy of HSIL is however questionable because the healing process might result in changes in the appearance of the transformation zone (TZ). However, the main limitation of post-LLETZ colposcopic examination is the possibility of inadequate colposcopy due to the inability to visualize the entire TZ. Known risk factors for inadequate colposcopy include age, severity of lesion, and estrogen status of the patient. 13 However, inadequate colposcopy is also one of the main adverse effects of excisional therapies of the cervix, including LLETZ. 13 However, data on the precise risk factors for inadequate colposcopy after LLETZ are limited because most studies have focused on the sole risk of cervical stenosis without considering the position and visibility of the squamocolumnar junction. 14-17 This point is however crucial because it is clinically essential to identify how post-LLETZ inadequate colposcopy could be avoided, thus preserving the possibility for the follow-up of these women

The ANTENATAL multicentre study to predict postnatal renal outcome in fetuses with posterior urethral valves: objectives and design

Abstract Background Posterior urethral valves (PUV) account for 17% of paediatric end-stage renal disease. A major issue in the management of PUV is prenatal prediction of postnatal renal function. Fetal ultrasound and fetal urine biochemistry are currently employed for this prediction, but clearly lack precision. We previously developed a fetal urine peptide signature that predicted in utero with high precision postnatal renal function in fetuses with PUV. We describe here the objectives and design of the prospective international multicentre ANTENATAL (multicentre validation of a fetal urine peptidome-based classifier to predict postnatal renal function in posterior urethral valves) study, set up to validate this fetal urine peptide signature. Methods Participants will be PUV pregnancies enrolled from 2017 to 2021 and followed up until 2023 in >30 European centres endorsed and supported by European reference networks for rare urological disorders (ERN eUROGEN) and rare kidney diseases (ERN ERKNet). The endpoint will be renal/patient survival at 2 years postnatally. Assuming α = 0.05, 1–β = 0.8 and a mean prevalence of severe renal outcome in PUV individuals of 0.35, 400 patients need to be enrolled to validate the previously reported sensitivity and specificity of the peptide signature. Results In this largest multicentre study of antenatally detected PUV, we anticipate bringing a novel tool to the clinic. Based on urinary peptides and potentially amended in the future with additional omics traits, this tool will be able to precisely quantify postnatal renal survival in PUV pregnancies. The main limitation of the employed approach is the need for specialized equipment. Conclusions Accurate risk assessment in the prenatal period should strongly improve the management of fetuses with PUV

A predictive neonatal mortality score for women with premature rupture of membranes after 22-27 weeks of gestation

International audienceObjective: Premature rupture of the membranes (PROM) remains a leading cause of neonatal morbidity. The objectives of the present study were to analyze the outcomes of pregnancies complicated by PROM between 22 and 27(+6) weeks of gestation (WG) and to study antepartum risk factors that might predict neonatal death. Patients and methods: One hundred and seven pregnancies were analyzed over a 3-year period in a tertiary maternity hospital. The collected maternal and neonatal data were used to model and predict the outcome of PROM. Results: Prevalence of PROM (for live births) was 1.08%, and the overall survival rate was 59.8%. From preselected candidate variables, gestational age (GA) at PROM (p = .0002), a positive vaginal culture for pathogenic bacteria (p = .01), primiparity (p = .02), and the quantity of amniotic fluid (p = .03) were included in a multivariable logistic regression analysis. The corresponding adjusted odds ratios [95% confidence interval] were, respectively, 0.91 [0.87-0.96], 11.08 [1.65-74.42], 0.55 [0.33-0.91], and 0.97 [0.95-0.99]. These parameters were used to build a predictive score for neonatal death. Conclusions: The survival rate after PROM at 22-27(+6) weeks of gestation was 59.8%. Our predictive model (built using multivariable logistic regression) may be of value for obstetricians and neonatologists counseling couples after PROM

Impact of Age at Conization on Obstetrical Outcome: A Case-Control Study

International audienceObjective The aim of the study was to assess whether an age younger than 25 years at conization affected future pregnancy outcome as an independent factor. Materials and Methods A retrospective study of 115 women who underwent both loop electrosurgical excision procedure (LEEP) and subsequent pregnancy follow-up in a referral center was conducted. Two groups were considered: patients younger than 25 years at the time of LEEP (n = 42) and 25 years or older (n = 73). Analyzed data were occurrence of preterm adverse obstetrical event and, specifically, preterm labor (PL) and preterm rupture of membranes; stratification based on term of occurrence was performed: less than 37 weeks of amenorrhea (WA), less than 34 WA, and less than 26 WA. Results Patients characteristics were comparable in terms of excised specimen thickness and pathological analysis, as well as for tobacco intoxication during pregnancy. Although there was no difference of term at delivery or total number of preterm adverse obstetrical events, we found a significant increase of events (19% vs 4.1%) and PL (19% vs 0%) before 26 WA in the group of patients younger than 25 years. After adjusting for excised specimen thickness, the same results were found for thickness of 15 mm or less (respectively, 16.7% vs 3.3% and 16.7% vs 0%). For thickness of greater than 15 mm, only ratio of PL before 26 WA was higher in the group of patients younger than 25 years (33.3% vs 0%). Conclusions Age younger than 25 years at the time of LEEP seems to be is associated with a more frequent occurrence of extremely early preterm adverse obstetrical events, particularly PL. © 2017 The Author(s)

Impact of Age at Conization on Obstetrical Outcome: A Case-Control Study

OBJECTIVE: The aim of the study was to assess whether an age younger than 25 years at conization affected future pregnancy outcome as an independent factor. MATERIALS AND METHODS: A retrospective study of 115 women who underwent both loop electrosurgical excision procedure (LEEP) and subsequent pregnancy follow-up in a referral center was conducted. Two groups were considered: patients younger than 25 years at the time of LEEP (n = 42) and 25 years or older (n = 73). Analyzed data were occurrence of preterm adverse obstetrical event and, specifically, preterm labor (PL) and preterm rupture of membranes; stratification based on term of occurrence was performed: less than 37 weeks of amenorrhea (WA), less than 34 WA, and less than 26 WA. RESULTS: Patients characteristics were comparable in terms of excised specimen thickness and pathological analysis, as well as for tobacco intoxication during pregnancy. Although there was no difference of term at delivery or total number of preterm adverse obstetrical events, we found a significant increase of events (19% vs 4.1%) and PL (19% vs 0%) before 26 WA in the group of patients younger than 25 years. After adjusting for excised specimen thickness, the same results were found for thickness of 15 mm or less (respectively, 16.7% vs 3.3% and 16.7% vs 0%). For thickness of greater than 15 mm, only ratio of PL before 26 WA was higher in the group of patients younger than 25 years (33.3% vs 0%). CONCLUSIONS: Age younger than 25 years at the time of LEEP seems to be is associated with a more frequent occurrence of extremely early preterm adverse obstetrical events, particularly PL

Management of breech and twin labor during registrarship: A two-year prospective, observational study

International audienceIntroduction. - Breech presentation and twin pregnancy are regarded as stressful situations for medical staff. This stress is often associated with an increased likelihood of intervention during labor - especially when the on -shift obstetrician lacks experience. Material and methods. - We performed a 2-year prospective, observational study of cesarean section (CSDs) and assisted vaginal (AVDs) deliveries in a tertiary maternity unit for attempted vaginal deliveries of breech presentations and twin pregnancies. The obstetric management decisions taken by a group of four registrars were compared with those taken by a group of 11 experienced obstetricians. Changes over time in practice were also monitored. Results. - Registrars managed 66 and 52 breech presentations and twin pregnancies respectively (30 and 27 in the experienced group). Groups' neonatal outcomes were similar. There were no intergroup differences in proportions of CSDs for either breech presentations (25 [37.5%] vs. 15 [50%] in the registrar and experienced groups, respectively; P=0.26) or twin pregnancies (11 [21.1%] vs. 6 [22.2%], respectively; P = 0.91) or in proportion of AVDs for twin pregnancies (41 [78.8%] vs. 21 [77.8%], respectively; P= 0.91). Proportions of CSDs for breech presentation and AVDs for twin pregnancies did not change over time in either group. However, proportion of CSDs for twin pregnancies increased over time in the registrar group (P = 0.004). Discussion. - Well-trained registrars appeared to have acquired the skills required to safely manage an obstetric ward; this pleads to maintain clinical practice during residency to preserve low CSD and AVD rates. (C) 2018 Elsevier Masson SAS. All rights reserved

Risk factors for unsatisfactory colposcopy after large loop excision of the transformation zone: The results of a four-year multicenter prospective study

International audienceObjectivesNot being able to completely examine the cervical squamocolummar junction (SCJ) in colposcopy after large loop excision of the transformation zone (LLETZ) is an important issue regarding surveillance, as high-grade cervical intra-epithelial neoplasia recurrence risk is high. This study was conducted in order to identify risk factors for post-LLETZ unsatisfactory colposcopy.MethodsThis prospective multicenter observational study was performed in nine French University hospitals, with inclusions running from December 2013 to December 2017. All patients scheduled for LLETZ were included and were divided into two groups after the two to four months post-procedure colposcopic examination: a satisfactory and an unsatisfactory post-LLETZ colposcopy group.ResultsIn total, 601 cases were analyzed and 71 post-LLETZ colposcopies (12%) were described as unsatisfactory (including 19 cervical stenosis). In a univariate analysis, we only observed a statistically significant increase of the following parameters in the unsatisfactory post-LLETZ group in comparison with the satisfactory post-LLETZ group: parity (2.11 [±1.55] and 1.49 [±1.24] respectively, p < .01), depth of the LLETZ specimen (10.9 mm [±3.37] and 9.76 [±3.79] respectively, p < .01), age (45.9 years [±11.7] and 37.9 [±9.42] respectively, p < .001) and an unsatisfactory pre-LLETZ colposcopy (43 satisfactory pre-LLETZ colposcopies [61%] and 456 [86%] respectively, p < .001). In a stepwise binary logistic regression analysis, only the two latter parameters were found to be independently associated with unsatisfactory post-LLETZ colposcopies.ConclusionsSurgeons should consider other therapeutic strategies when contemplating iterative diagnosis-LLETZ in older women with initially invisible SCJ, as an appropriate post-LLETZ surveillance is at higher risk of being impossible to achieve

Should isolated fetal ventriculomegaly measured below 12mm be viewed as a variant of the norm? Results of a 5-year experience in a prenatal referral center

International audienceBackground: Fetal ventriculomegaly (VM) is defined as lateral ventricles measured above 10mm. Some authors believe VM <12mm are variants of the norm and need not be addressed for referral ultrasound.Methods: A retrospective continuous cohort study of 127 confirmed fetal VM was divided into three groups after initial referral sonographic assessment: isolated VM <12mm (group A), isolated VM 12mm (group B), and VM associated with other malformations (group C). We reviewed obstetric outcome and neonate evolution after 1 month with the aim of defining a pertinent prenatal workup.Results: We reported fetal infections in all groups (p=.24) and chromosomal abnormalities only in group C (p=.41). Fetal magnetic resonance imaging (MRI) found initially undiagnosed brain abnormalities in groups B and C (12.5 and 14.1%, p<.05). Ratios of healthy children after 1 month stemming, respectively, from groups A, B, and C were 66.7, 62.5, and 20.2% (p<.05).Conclusions: Our results are in favor of a systematic referral ultrasound for every fetal VM, regardless of size, as soon as definition criterion is met. Additional paraclinical assessment (maternal serologic status for toxoplasmosis and cytomegalovirus, amniocentesis, fetal cerebral MRI) should be discussed depending on the situation

Defining the Most Appropriate Delivery Mode in Women with Inflammatory Bowel Disease: A Systematic Review

International audienceIntroduction: High cesarean section (CS) rates are observed in patients with inflammatory bowel disease (IBD), but limited data are available to support this decision. We conducted a comprehensive review to evaluate the most appropriate mode of delivery in women with IBD according to disease phenotype and activity, as well as surgical history. Materials and Methods: We searched MEDLINE (source PubMed) and international conference abstracts, and included all studies that evaluated digestive outcome after delivery in patients with IBD. Results: A total of 41 articles or abstracts were screened, and 18 studies were considered in this review, with sample sizes ranging from 4 to 229 patients and follow-up ranging from 2 months to 7.7 years. Pooled CS rates in patients without Perianal Crohn's disease (PCD), healed PCD or active PCD, were 27%, 43%, and 46%, respectively. Regarding the median rate of new PCD (3.0% [IQR, 1.5-11.5] versus 6.5% [0-19.7]) or PCD recurrence (13.5% [3.2-32.7] versus 45% [0-58]), no increase was observed in patients with vaginal delivery compared to CS, but for patients with an active disease, worsening of symptoms was noted in two-thirds of cases. Episiotomy, perianal tears, and instrumental delivery did not influence the incidence of PCD. In patients with ileal pouch anal anastomosis, uncomplicated vaginal delivery seemed to moderately influence pouch function, with no significant difference in terms of overall continence, daytime, or night-time stool frequency, or incontinence. However, these parameters seemed negatively impacted by a complicated vaginal delivery. Conclusions: New long-term data from well-designed studies are needed, but our review suggests that systematic CS in patients suffering from IBD should probably be limited to women at risk of perineal tears and obstetric injuries, with an active PCD, or with ileal pouch anal anastomosis