Les médecins traitants devant le défi du dépistage et de la prise en charge de l’endométriose : résultats d’une enquête

ObjectiveTo evaluate the knowledge of general practitioners concerning the endometriosis diagnostic and care.Population and methodsSurvey enrolling 100 general practitioners of the 76th Seine Maritime French department (region of Upper Normandy) who usually perform gynaecological follow up, asked to answer an irreversible 36 item step-by-step questionnaire.ResultsAmong them, 44% perform more than one gynaecological consultation each week. They were 63% to feel ill at ease in the diagnosis and follow up of women presenting with endometriosis. One half of physicians could not cite three main symptoms of the disease out of dysmenorrhea, dyspareunia, chronic pelvic pain and infertility. Only 38% of general practitioners perform a clinical gynaecological examination when they suspect the endometriosis, and 28% of them recommended MRI to confirm the diagnosis. They are 24% to refer the patient without delay, but only 52% to the universitary hospital, which is the tertiary regional referral center, while 68% of them refer to a fellow practicing in a private facility. They were 64% to believe that therapeutic amenorrhea is on the bottom of the medical therapy. General practitioners were more likely to accurately answer the questionnaire when they attended gynaecological advanced courses during previous 5 years and when they followed up more than three patients previously managed for endometriosis.Discussion and conclusionGeneral practitioners’ knowledge about endometriosis is limited, with possible direct consequences on the delay of the diagnosis. The attendance of gynaecological advanced courses and the exchange of information between gynaecologic surgeons and general practitioners who follow up the patients appear to be two-way to improve the accuracy of the answers to the questionnaire.     

Diagnostic prénatal de la trisomie 21 : le vécu des patientes pendant l’attente des résultats

Background

Down syndrome (DS) screening has been made available to all pregnant women in France since 1997. In the event of Down syndrome being diagnosed, the most women consider the possibility of a therapeutic abortion. The diagnosis?? result is given after amniocentesis.

Aim

To explore the personal experience of women of a DS risk group, while awaiting the diagnosis. Design: A qualitative study, based on interviews with 13 patients having undergone an amniocentesis after being identified as belonging to a higher DS risk group and for whom the final results were negative.

Results

Patients?? knowledge of the subject is both insufficient and vague. There is a common confusion between screening and diagnosis testing. It would appear that medical information on these issues is somewhat incomplete. Pregnant women agree to undergo analysis of their maternal serum markers in order to reassure themselves and do not expect an unfavourable result. The announcement of the possibility of giving birth to a trisomic baby is followed by a period of stress during which the subjects tend to dissociate themselves from their pregnancy and consider the possibility of a therapeutic abortion.

Conclusion

DS screening is not a simple process. The anxiety generated by the result of such testing is clearly palpable. The iatrogenic nature of screening should also be considered. Would improving medical information on the subject help reducing its deleterious impact?     

Intérêt de la fibronectine couplée à la mesure échographique du col utérin en cas de menace d’accouchement prématuré

Background

Today, transvaginal ultrasound measurement of cervical length (CL) is done in all women presenting with threatened spontaneous preterm labor (PTL). Rapid measurement of fetal fibronectin (fFN) in the cervicovaginal secretions is proposed for a better screening of the PTL.

Material and methods

All pregnant women with spontaneous PTL received care including: digital cervical examination, external tocodynamometry for the monitoring of uterine contractions and measurement of CL. If CL was between 15 and 25 mm, fFN testing was added. Clinicians used the results of the test to guide therapeutic decisions.

Results

Were included 188 patients with spontaneous PTL between 24 and 34 SA. For the screening of prematurity < 37 WG or delivery within seven days, a CL < 15 mm had respectively a sensitivity of 56 and 79%, a specificity of 70 and 66% and a negative predictive value (NPV) of 81 and 98%. The association of fFN testing for the women with a CL between 15 and 25 mm give similar performance (sensitivity between 68 and 86%, specificity between 61 and 56% and VPN between 84 and 98%). Positive and negative likehood ratios were low.

Conclusion

To predict PTL, a cervical length < 25 mm had low performances. A CL cutoff value of ≤ 15 mm did better, but had low sensitivity. The addition of fNF detection for the women with a CL between 15 and 25 mm had better performances for the screening of prematurity.     

Métrorragie révélatrice d’un cancer du sein bilatéral synchrone : à propos d’un cas

Genital metastases are very rarely indicative of breast cancer; they are exceptionally located at the cervix. These atypical locations are more common when it comes to a metastatic breast cancer or a histological infiltrating lobular type. The simultaneous association of a lobular and a ductal infiltrating cancer under a synchronous bilateral breast cancer still remains a rare entity. In this work, we report the observation of a woman aged 48 who has a synchronous bilateral breast cancer, of different histological types, and who reported at first a genital bleeding which is caused by a metastasis in the cervix of the uterus.     

Impact psychologique à long terme d’une hémorragie sévère du postpartum

The objective of our retrospective study was to estimate the long-term psychological impact of severe postpartum hemorrhage in women whose uterus was preserved. All consecutive women who underwent embolization for postpartum hemorrhage between 1994 and 2007 and whose uterus was preserved were included. Data were retrieved from medical files and semi-structured telephone interviews. In semi-structured interviews, women were asked about their perceptions and memories of the experience. Follow-up was successful for 68 of the 91 (74.7%) women included. Of the 46 (67.6%) who reported negative memories of the delivery and postpartum period, the main memory for 24 was a fear of dying (35.3%). Of the 28 (41.2%) who reported continued repercussions, 16 (23.5%) thought about this delivery and its complications at least once a month. Of the 15 women who had a subsequent full-term pregnancy, 9 (60%) reported intense anxiety throughout the pregnancy, and 1 (6.7%) developed depression requiring antidepressant treatment during pregnancy. Our study implies that severe postpartum hemorrhage can be at the origin of long-term psychological impact even if the uterus is preserved.     

Choix de la technique d’Assistance médicale à la procréation en fonction du spermocytogramme

Semen analysis is routinely part of the evaluation of male fertility and includes sperm morphology. How sperm morphology can be a diagnostic tool to decide which ART to apply for infertile couples (insemination, classical IVF or ICSI)? Teratozoospermia has been reported to be one of the most relevant semen parameters of clinical interest compared with sperm concentration and sperm motility. However, the true potential of this parameter has some limitations because of several methodological factors: differences in the classification systems, influence of the staining method used, subjective nature of evaluation of sperm morphology, regular decreasing of the WHO threshold. According to Tygerberg strict criteria that is the most frequently used classification worldwide, poor fertilization has been reported when the rate of normal forms was less or equal to 4%, suggesting to perform ICSI. However, influence of sperm morphology on fertilization outcome remains much debated. Regarding David's classification, the threshold of 30% does seem helpful to discriminate in the prediction of fertilization success and should probably be reconsidered.     

Allaitement maternel et pratiques à l’officine : intérêt d’une formation pour les pharmaciens et préparateurs en pharmacie

Objectives

Breastfeeding rates in France remain low compared to those in other European countries. Encouragement of breastfeeding and education by healthcare providers improve breastfeeding initiation and duration. This study evaluated the impact of a breastfeeding educational intervention on the knowledge of pharmacists and pharmacy technicians.

Methods

A before and after study was conducted in March 2012. Pharmacists and pharmacy technicians from the Nord department in France, on a voluntary basis, attended the conference. The topics were based on the specific needs of mothers and pharmacists and had been defined in an earlier study: use of a breast pump, preservation and reheating of breast milk, insufficient milk supply, cracked nipples, engorgement and mastitis, breastfeeding and medication, and effective breastfeeding. Baseline knowledge and change in knowledge were assessed by pretest and immediate posttest questionnaires.

Results

Of the 311 pharmacists and pharmacy technicians invited, 107 attended the conference. Ninety-five people completed the pretest questionnaire and 83 completed the posttest questionnaire. The knowledge of the pharmacists and pharmacy technicians on breastfeeding significantly increased after the intervention: 55.1/100 (95% CI: [51.6–58.7]) before the intervention and 84.4 (95% CI: [83.2–85.7]) after the intervention (P < 0.001). Their knowledge significantly improved on all topics (P < 0.0005). The mean score of pharmacy technicians was significantly lower than that of the pharmacists before and after the intervention (P = 0.02). Seventeen participants who underwent prior training in breastfeeding had higher baseline knowledge (64.4, 95% CI: [56.5–72.3]) than the rest of the group (P = 0.02) and they improved significantly after the intervention (87.3, 95% CI: [83.7–90.9]) (P < 0.001). Sixty-three participants (76%) had a posttest score of at least 80/100.

Conclusion

An educational intervention on breastfeeding significantly improved the knowledge of pharmacists and pharmacy technicians. Increasing the knowledge of healthcare providers is the first step in improving clinical practice that is necessary for the management of breastfeeding women.

     

Appréhension et vécu d’une grossesse obtenue après un don d’ovocyte anonyme

ObjectivesThis qualitative study focuses on feelings of women who receive an anonymous oocyte donation.Patients and methodsA heterogeneous group of 12 women who were mothers or pregnant following a oocyte donation or who were waiting for a donation took part in the study. All women participated in a face to face or a telephone semi-directive interview. Questions dealt with desire for children, feelings about difficulties to have a child, place of the oocyte donor and position about revelation of origins.ResultsSeveral key ideas about the experience of oocyte donation can be brought out from the analysis of those interviews, particularly the psychological process implied in losing one's hope for a biological child, ambivalence towards donors, and questionings about this specific mode of conception.Discussion and conclusionWomen's satisfaction when the project for having a child is brought to its completion, hides neither complexity nor psychological questionings entailed by the donation process which includes a third during the conception. This study underlines the need for psychological accompaniment.     

Prise en charge du don d’ovocytes : réglementation du don,la face cachée du tourisme procréatif

In France egg donation is not sufficient to meet the needs of infertile couples. As a consequence there is a long waiting time for those couples who may be driven to search solutions abroad. Nonetheless in some countries practice of egg donation raises medical and ethical questions regarding the quality of care provided to the recipients as well as the recruitment and follow-up of egg donors. Meanwhile the scope of this type of “cross-border reproductive care” remains difficult to assess, even though this trend seems to be growing and is reinforced by a recent regulation facilitating the free movement of people seeking cross-border health care within the European Union. These observations lead to question the possible causes of “cross-border reproductive care” in the light of national laws, to identify potential consequences in order to suggest possible actions at both national and international level.     

Existe-t-il une corrélation anatomoclinique entre endométriose minime et endométriose sévère ?: Premiers résultats du registre régional d’Auvergne de l’endométriose

OBJECTIVE: With a prospective study, to evaluate the existence of two distinct clinical diseases in the endometriosis syndrome, by comparing pain symptoms and quality of life from patients with minimal endometriosis (AFS-R<5) and data from patients with severe disease (deep infiltrating nodules and/or ovarian endometrioma). PATIENTS AND METHODS: Patients with minimal disease (group A with AFS-R<5) and severe endometriosis (group B) are selected from the Auvergne Endometriosis Registry which started in January 2004. They have never been treated before for endometriosis. A surgical laparoscopic and a pathological diagnosis are required for the subjects to be included. Pelvic pain is assessed using a standardized questionnaire, and a visual analogue scale, quality of life using SF-36. The two groups are compared for the incidence and the severity of pelvic pain and for the impairment of their quality of life. RESULTS: Forty-seven patients have a minimal disease, whereas 111 have a severe endometriosis. Demographic characteristics are similar in both groups. Quality of life (SF-36) and pelvic pains included chronic pelvic pain, dyspareunia, dysuria, and defecation disorders are as common and severe in both groups. However, dysmenorrhea is more affected in group B than in group A (p=0.03). DISCUSSION AND CONCLUSION: We find no relationship between severity of symptoms, quality of life, and the extent of endometriotic lesions at surgery. There would be no differences between minimal and severe disease. It could be explained by different painful mechanisms between minimal and severe endometriosis.