LLETZ Specimen Fragmentation: Impact on Diagnosis, Outcome, and Implications for Training

Purpose

This study was designed to assess fragmentation of Large loop excision of the transformation zone (LLETZ) specimens, its influence on short-term cytological outcome, and the risk factors for specimen fragmentation, as we well as trainee performance on clinical outcome.

Method

This retrospective study was performed at a cancer center. Women who underwent LLETZ for suspected high-grade cervical intra-epithelial neoplasia (CIN) over a 5-year period were included. Patients were identified through a regional database. Data were obtained from hospital and regional databases. Fisher’s exact test was used.

Results

75 % of all specimens were obtained intact. When the LLETZ specimen was intact, 89 % of smear tests were reported as negative, against 86 % when the specimen was fragmented. Fragmentation was significantly associated with high-grade smear results at 6 months. Trainee status was significantly related to specimen fragmentation.

Conclusion

Fragmentation of LLETZ specimens is associated with an increased likelihood of obtaining a high-grade smear at 6 months post treatment. Enhancing the colposcopy training may help improve clinical outcome.     

C-LETZ versus large loop excision of the transformation zone for the treatment of cervical intraepithelial neoplasia: a randomized controlled trial

Objective

To compare large loop excision of the transformation zone (LLETZ) with contour-loop excision of the transformation zone (C-LETZ) in management of cervical intraepithelial neoplasia (CIN) with respect to number of specimens obtained, weight of specimen, surgical margin, treatment time, and morbidity associated with those procedures.

Method

Women were randomly allocated to receive LLETZ or C-LETZ. Inclusion criteria were the following circumstances: (1) presence of biopsy-proved CIN 2/3, (2) persistent biopsy-proved CIN 1, (3) discrepancy between cytology and histology, or 4) an endocervical curettage was positive.

Results

Ninety-eight women were eligible for the study. Mean weight of specimens in C-LETZ group was significantly more than LLETZ group (4.35?±?1.39 vs. 3.55?±?1.48?g, p?=?0.007). Duration of treatment were similar in both groups (p?=?0.39). After multiple logistic regressions were analyzed, C-LETZ was more likely to result in a single pathologic specimen (76 vs. 29.16?%, p?<?0.001; adjusted RR 8.33, CI 3.23–21.47). There was no statistical significant difference in the frequency of positive margins between the groups (40 vs. 39.5?%, p?=?0.64; adjusted RR 1.27, CI 0.46–3.50). The morbidity associated with those procedures was not different between the two groups.

Conclusion

C-LETZ has a clear clinical benefit in term of a higher rate of a single pathologic specimen. It removes more cervical tissue than LLETZ. The incidence of incomplete excision and complication seem to be similar in both groups.     

Surgical management of cervical intraepithelial neoplasia in HIV-infected women

Objective

Rates higher than 50% of positive margin after surgical treatment of cervical intraepithelial neoplasia (CIN) have been reported in HIV-infected women. We evaluated the efficacy of two excisional procedures, loop excision of the transformation zone (LLETZ) and electrosurgical conisation, in obtaining complete excision of CIN in HIV-infected patients.

Study design

Eighty HIV-infected women with CIN or suspicion of cervical cancer underwent 86 surgical excisions. The indication of surgical modalities depended on both the size and location of the lesion and on the length of the cervix. Univariate logistic regression was used to identify factors associated with positive surgical margins.

Results

Preoperative colposcopy failed to visualize the entire transformation zone in 39% of cases, and showed that 93% of the lesions had endocervical extension. LLETZ was performed in 30 cases and electrosurgical conisation in 56 cases. Resection was complete, with negative margins, in 77% of cases (95% confidence interval, CI: 62–92%) after LLETZ and in 71% of case (95% CI: 60–83%) after electrosurgical resection. Residual disease was mostly located in the endocervical portion of histological specimen. During follow-up late complications such as cervical stenosis or unsatisfactory colposcopy were not observed.

Conclusion

Endocervical extension of CIN being frequent among HIV-infected women, LLETZ should not be the preferred procedure. Appropriate surgical management leading in reducing the rate of positive margins may help decreasing the risk of persistence or recurrence of lesions.     

Bevacizumab in the treatment of ovarian cancer: a meta-analysis from four phase III randomized controlled trials

Background

The aim of this meta-analysis was to summarize the efficacy and safety of bevacizumab in the treatment of ovarian cancer.

Methods

We sought to identify randomised controlled trials (RCTs) by searching PubMed and Web of Science. Outcomes were objective response rate (ORR), progression-free survival (PFS), overall survival (OS), and adverse events.

Results

Four studies with 4,246 patients were included. Combination of bevacizumab and chemotherapy resulted in a statistically significant improvement in ORR (OR 2.165, 95 % CI 1.511–3.103) and in PFS (HR 0.691, 95 % CI 0.517–0.865), compared with chemotherapy alone. There was no evidence of a significant improvement in OS (HR 0.934, 95 % CI 0.826–1.041). It also had significantly increased risk of gastrointestinal events (OR 2.743, 95 % CI 1.580–4.763; P < 0.001), hypertension (OR 4.630, 95 % CI 3.737 to 5.737; P < 0.001), proteinuria (OR 4.872, 95 % CI 2.617–9.069; P < 0.001), and arterial thromboembolism (OR 1.994, 95 % CI 1.210–3.286; P = 0.007).

Conclusion

This meta-analysis suggests that the addition of bevacizumab to chemotherapy offers meaningful improvement in objective response rate and progression-free survival in ovarian cancer treatment, but does not benefit overall survival. It also significantly increased the occurrence of gastrointestinal events, hypertension, proteinuria, and arterial thromboembolism.     

Impact of conization type on the resected cone volume: results of a retrospective multi-center study

Purpose

The extent of conization seems to influence the risk of preterm birth. The aim of this study was to compare the cone volume after surgical resection with large loop excision of the transformation zone (LLETZ) and cold knife conization (CKC).

Methods

The present retrospective multi-center study comprises 804 consecutive women, who underwent LLETZ (n = 412) or CKC (n = 392) between 2004 and 2009. Univariate and multivariable analyses were performed to compare cone volumes removed by LLETZ and CKC and identify independent risk factors for large cone volume.

Results

The median resected cone volume after LLETZ was significantly smaller [1.6 cm³ (0.8–2.9)] than after CKC [2.1 cm³ (1.4–3.5)] (<0.0001). Complete resection rates were comparable in both groups. Conization method, cone depth, and institution type were independent risk factors for removal of a large cone volume.

Conclusion

CKC removes larger cone volumes than LLETZ without the advantage of higher complete resection rates.     

Birth outcomes of singleton vaginal deliveries to ART-treated,subfertile, and fertile primiparous women

Purpose

To determine whether differences in birth outcomes among assisted reproductive technology (ART)-treated, subfertile, and fertile women exist in primiparous women with, singleton, vaginal deliveries.

Methods

Society for Assisted Reproductive Technology Clinic Outcome Reporting System (SART CORS) data were linked to Massachusetts vital records and hospital discharges for deliveries between July 2004 and December 2010. Primiparous women with in-state vaginal deliveries, adequate prenatal care, and singleton birth at ≥?20 weeks (n?=?117,779) were classified as ART-treated (linked to ART data from SART CORS, n?=?3138); subfertile (not ART-treated but with indicators of subfertility, n?=?1507); or fertile (neither ART-treated nor subfertile, n?=?113,134). Outcomes of prematurity (<?37 weeks), low birthweight (<?2500 g), perinatal death (death at ≥?20 weeks to ≤?7 days), and maternal prolonged length of hospital stay (LOS >?3 days) were compared using multivariable logistic regression.

Results

Compared to fertile, higher odds were found for prematurity among ART-treated (adjusted odds ratio [AOR] 1.40, 95% confidence interval [CI] 1.25–1.50) and subfertile (AOR 1.25, 95% CI 1.03–1.50) women, low birthweight among ART-treated (AOR 1.41, 95% CI 1.23–1.62) and subfertile (AOR 1.40, 95% CI 1.15–1.71) women, perinatal death among subfertile (AOR 2.64, 95% CI 1.72–4.05), and prolonged LOS among ART-treated (AOR 1.33, 95% CI 1.19–1.48) women. Differences remained despite stratification by young age and absence of pregnancy/delivery complications.

Conclusions

Greater odds of prematurity and low birthweight in ART-treated and subfertile, and perinatal death in subfertile deliveries are evident among singleton vaginal deliveries. The data suggest that even low-risk pregnancies to ART-treated and subfertile women be managed for adverse outcomes.

     

A pilot study comparing efficacy of a cervical intraepithelial neoplasia excisor with loop electrosurgical excision procedure

Objective

To determine whether the proportion of incomplete resection of cervical intraepithelial neoplasia (CIN 1-3) may be reduced by CIN Excisor compared with loop excision of the transformation zone (LLETZ).

Study design

A prospective trial during a 2-year period at a district general hospital in London, United Kingdom, including 420 women scheduled for treatment due to CIN, after colposcopy guided biopsy results. This study was expected to demonstrate a statistically significant difference (p < 0.05) in the proportion of women with clear histopathological resection margins after treatment with CIN Excisor compared with LLETZ. Chi-square or Fisher's exact test were used to compare histopathological resection margins in the CIN Excisor and LLETZ groups.

Results

Overall, there is strong evidence of a difference in the proportion of histopathological specimens with clear resection margins for the CIN Excisor group, compared with the LLETZ group (201/210, 95.7% versus 180/210, 85.7%: p < 0.001). Sub-analysis within the two groups, of the proportion of histopathological specimens with clear resection margins in relation to CIN grades, revealed a statistically significant difference in favour of the CIN Excisor group for CIN 1 (99/103, 96.1% versus 82/95, 86.3%: p = 0.01), and CIN 2 (73/77, 94.8% versus 68/80, 85%: p = 0.04). There is a numerical difference in the proportion of clear resection margins in favour of the CIN Excisor for CIN 3 (29/30, 96.7% versus 30/35, 85.7%), but this difference was not statistically significant (p = 0.21). Perioperative complications were similar between the two groups.

Conclusion

CIN Excisor achieved better results than LLETZ for treatment of CIN 1-3 with respect to clear histopathological resection margins. However, further studies including a larger number of women treated for CIN 3 are needed before firm conclusions are drawn.     

Pregnancy outcomes in women with mitral valve prolapse and mitral valve regurgitation

Purpose

To examine pregnancy and perinatal outcomes in patients with mitral valve disorders [mitral valve prolapse and/or mitral regurgitation; mitral valve disorders (MVD)].

Methods

A retrospective comparative study was conducted comparing all singleton deliveries, during the years 1988–2010, of women with and without known MVD. Women lacking prenatal care were excluded. Stratified analysis using logistic regression was performed to control for confounds.

Results

Out of 233,194 singleton deliveries that occurred during the study period, 390 deliveries occurred in women with MVD. Using a multivariate analysis, advanced maternal age (OR = 1.06; 95 % CI 1.05–1.08; P < 0.001), recurrent abortions (OR = 1.62; 95 % CI 1.15–2.28; P = 0.005), hypertensive disorders (OR = 1.62; 95 % CI 1.17–2.26; P = 0.004) and Jewish ethnicity (OR = 2.21; 95 % CI 1.76–2.79; P < 0.001) were found to be significantly associated with MVD. Since cesarean sections (CS) were significantly higher in deliveries of patients with MVD (17.9 vs. 14 %; P = 0.025), another multivariate analysis was constructed, with CS as the outcome variable. MVD was not found to be an independent risk factor for CS (OR = 1.05; 95 % CI 0.79–1.37; P = 0.74).

Conclusions

MVD associated with advanced maternal age, recurrent abortions, Jewish ethnicity and hypertensive disorders were not found to be an independent risk factor for CS.     

The relationship between maternal serum prenatal screening combined with epidemiological study and early onset preeclampsia

Objective

To explore the major risk factors and early prediction methods in the pathogenesis of early onset preeclampsia through combining prenatal screening markers and epidemiological characteristics.

Methods

Prenatal screening was performed in second trimester using enzyme-linked immunosorbent assay in 1,011 gravidas and epidemiological correlation factors were got by telephone with prospective cohort study. Predictive model of early onset preeclampsia was established and evaluated by single and multiple factor logistic analysis in 30 cases of preeclampsia and 867 cases of normal gravidas.

Results

As compared with the control group, the maternal serum level of human chorionic gonadotropin (hCG) in second trimester of patients with early onset preeclampsia elevated significantly (P < 0.001). Pregestational BMI ≥ 24 kg/m² (OR = 3.649, 95 % CI 1.600–8.321, P = 0.002), history of hypertension, diabetes and nephritis (OR = 55.724, 95 % CI 8.223–377.614, P < 0.001), family history of hypertension (OR = 6.777, 95 % CI 2.917–15.742, P < 0.001), and risk coefficient for trisomy 21 (OR = 3.688, 95 % CI 1.013–13.429, P = 0.048) were major risk factors of early onset preeclampsia. The sensitivity and specificity of predictive model were 70.0 and 75.1 %, when cutoff point was 0.249. The diagnostic accuracy of the logistic model was better than hCG.

Conclusions

In order to early prevent the onset and development of EOPE, it is necessary to strengthen pregestational and prenatal care for women in these aspects including pregestational BMI ≥?24 kg/m², history of hypertension, diabetes, nephritis, family history of hypertension, and high risk for trisomy 21 syndrom.     

Association of homocysteine,vitamin B12, and folate with bone mineral density in postmenopausal women: a meta-analysis

Background

The relationship of homocysteine (Hcy), folate, and vitamin B12 with bone mineral density (BMD) has been investigated in postmenopausal women. However, the relationship is still controversial.

Purpose

To evaluate the association of Hcy, folate, vitamin B12 and BMD in postmenopausal women with a meta-analysis.

Methods

We searched for all published articles indexed in Medline (1950–2012), Embase (1974–2012), and China National Knowledge Infrastructure (1994–2012). Any case–control or cohort study relating to Hcy, vitamin B12, folate, and BMD was included, and the data were extracted independently by two reviewers. Criteria for inclusion were the assessment of Hcy, vitamin B12, folate, and BMD in postmenopausal women as outcomes. We performed this meta-analysis with Review Manager 5.1 software. Odds ratios and 95 % confidence intervals (CI) were used to evaluate the results.

Results

Six eligible studies were selected for meta-analysis. Our analysis suggested that vitamin B12 and Hcy levels were significantly higher in postmenopausal osteoporosis (PMOP) group than that in controls (P = 0.007, <0.05; 95 % CI 3.06–19.38 and P = 0.0003, <0.05; 95 % CI 0.75–2.52, respectively). Folate level was lower in PMOP group than that in controls, but this difference was not statistically significant (P = 0.09, 95 % CI ?3.33 to 0.25).

Conclusions

Hcy and vitamin B12, but not folate, were related to BMD in PMOP. Extra vitamin B12 may not play a protective role for osteoporosis in postmenopausal women. Future studies are needed to confirm them, especially the relationship between increased vitamin B12 and BMD.     

Endometrial polyps detected at ultrasound and rate of malignancy

Purpose

The vast majority of the evidence on the prevalence of malignancy in endometrial polyps was obtained irrespectively of the time of diagnosis, i.e. including both women who were diagnosed at pre-surgical ultrasound and those who were diagnosed at the time of hysteroscopy. We hypothesize that this may represent an inaccuracy of potential clinical relevance since physicians have to take decisions regarding the need of surgery at the time of ultrasound diagnosis.

Materials and methods

Medical records of 2,245 patients who underwent hysteroscopy during a 4-year period were reviewed. Inclusion criterion was a pre-operative diagnosis of endometrial polyps.

Results

1,284 women (57 % of the cohort) were selected, of whom 36 were diagnosed with malignancies (2.8 %, 95 % CI 2.0–3.8). This prevalence markedly differ in pre- and post-menopause, being higher in the latter group (OR = 9.0, 95 % CI 2.6–30.3, p < 0.001). Six out of 803 resulted positive in the pre-menopausal group (0.7 %, 95 % CI 0.3–1.5) compared to 30 out of 481 in the post-menopausal group (6.2 %, 95 % CI 4.3–8.6). In the pre-menopausal group, a younger age resulted protective. The risk of malignancy in women younger than 50 years was 0.3 % (95 % CI 0.04–0.9). In the post-menopausal group, abnormal uterine bleeding (AUB) was associated with a diagnosis of malignancy (OR = 4.0, 95 % CI 1.9–8.5). The prevalence of malignancy in symptomatic and asymptomatic post-menopausal women was 11.8 % (95 % CI 7.6–17.1) and 3.0 % (95 % CI 1.4–5.3), respectively.

Conclusions

The prevalence of malignancy among endometrial polyps detected at ultrasound is low and in line with the evidence obtained for a diagnosis made at the time of surgery. Some simple anamnestic information such as menopausal status, age and AUB helps identify women at higher risk and should be used in the decision-making process guiding the choice of surgery.     

Effect of metformin on ovulation and reproductive outcomes in women with polycystic ovary syndrome: a meta-analysis of randomized controlled trials

Purpose

To evaluate the effect of MET on ovulation and reproductive outcomes in patients with polycystic ovary syndrome.

Methods

Meta-analysis of available data from randomized controlled trials that examined the ovulation, pregnancy and live birth rate after the administration of clomiphene citrate (CC) or MET alone or combined.

Results

The ovulation rate was found to be higher in the group treated with MET combined with clomiphene citrate (CC) than only with CC, odds ratio (OR): 1.27, 95 % confidence interval (95 % CI) (1.03–1.56), while the pregnancy and live birth rate showed no significant difference between the two groups, OR: 1.19, 95 % CI (0.99–1.42) and OR: 0.99, 95 % CI (0.84–1.17), respectively. The MET + CC group produced a higher ovulation and pregnancy rate than MET group, OR: 2.10, 95 % CI (1.89–2.34) and OR: 2.08, 95 % CI (1.55–2.80), respectively, while between two groups the live birth rate showed no significant difference, OR: 1.50, 95 % CI (0.75–3.00). The ovulation rate was lower in MET than in CC group, OR: 0.65, 95 % CI (0.43–0.995), while between the two groups the pregnancy and live birth rate showed no significant difference, OR: 0.86, 95 % CI (0.42–1.74) and OR: 0.89, 95 % CI (0.71–1.13).

Conclusion

The current study indicated that combination of MET and CC could gain advantage over a single administration in the ovulation induction and pregnancy rate.     

Optimal cervical cytology mass screening interval for cervical cancer

Objective

To identify the optimal interval for repeat cervical cytology testing for screening of cervical cancer and dysplasia in healthy female adults.

Design and methods

A retrospective cohort study was conducted on 3,804 apparently healthy females without known cervical cancer at baseline from 2005 to 2010. Participants underwent annual health checkups, including cervical cytology testing. This data did not contain human papillomavirus status. Participants with cytological abnormality underwent further examination, including biopsy, to check for cervical cancer. The generalized estimating equation (GEE) was performed to analyze the longitudinal data.

Results

In the groups <40, 40–49, 50–59 and ≥60 years old, the 5-year cumulative incidences (95 % CI) of cytological abnormality were 11.2 % (8.8–13.9 %), 7.6 % (6.2–9.3 %), 4.4 % (3.3–5.7 %) and 2.8 % (1.8–4.2 %), respectively, and the cumulative incidences of cervical cancer were 0.9 % (0.3–2.0 %), 0.1 % (0.0–0.4 %), 0.1 % (0.0–0.5 %) and 0 %, respectively. The odds ratios of the incidence for cervical cancer and cervical dysplasia per year, with GEE models, were 1.5 (95 % CI:1.1–2.0), 1.2 (95 % CI:0.8–1.9), 2.2 (95 % CI:0.5–10.3) and 0 for cervical cancer, and 1.3 (95 % CI:1.2–1.5), 1.3 (95 % CI:1.2–1.5), 1.3 (95 % CI:1.1–1.5) and 1.4 (95 % CI:0.9–2.0) for cervical dysplasia, respectively.

Conclusions

For patients under 40 years old, the screening for cervical cancer every 2 years should be considered, while for patients of 40–59 years old screening every 2 or 3 years should be considered. Females over 60 years old may only need repeat screening every 5 years.     

The feasibilities of TruScreen for primary cervical cancer screening: a self-controlled study

Objective

Screening programs based on cytology testing led to the incidence reduction of cervical cancer mortality of about 70–80 % in industrialized countries. However, these favorable results have not been replicated in developing areas. Thus, we aim to evaluate the efficacy of TruScreen (Polartechnics, Sydney, Australia) in detecting of precancerous lesions in comparison with cervical cytology test.

Methods

A total of 181 outpatients were screened by TruScreen using the pathological results as the gold standard. The medical records of cytological smear within 6 weeks were obtained from 169 of these participants. The reliability and yield of TruScreen and cytological smear were assessed. The screening results of TruScreen were compared with those obtained from the conventional smear.

Results

The sensitivities for histologically confirmed cervical intraepithelial neoplasia (CIN) lesions by TruScreen and Pap, were 67.4 % (95 % CI 53.4–81.5) and 87.9 % (95 % CI 76.7–99.0), respectively. The specificities for histologically confirmed CIN lesions by TruScreen and Pap, were 68.1 % (95 % CI 60.3–75.9) and 74.3 % (95 % CI 70.0–81.4), respectively. In contrast to Pap smear, TruScreen was comparatively efficacious in screening of cervical cancer (χ ² = 0.0133, P = 0.9081).

Conclusion

TruScreen is a potential test for initial cervical screening in developing world regions.     

Perinatal outcomes of pregnant women with cervical intraepithelial neoplasia

Objective

To investigate the perinatal outcomes of pregnant women with cervical intraepithelial neoplasia (CIN).

Method

The women in this retrospective case–control study were recruited from Beijing Obstetrics and Gynecology Hospital from August 1, 2007 to February 28, 2010. All the cases were 13–32 gestational weeks, who were diagnosed by colposcopy conducted cervical biopsy. A total of 108 cases were followed-up to the day of delivery.

Results

(1) Complications of colposcopy conducted cervical biopsy: there were two cases of pregnant women, who suffered cervical local compression after undergoing colposcopy conducted cervical biopsy, as the bleeding could not be stopped, the wound was treated by local suture. The incidence of such event was 1.8 % (2/108), without any colposcopy and biopsy-related adverse event. (2) Cesarean section rate was 63.6 % (56/88) in CIN, which was higher than 30.0 % (6/20) in cervicitis, and the cesarean section rate increased as CIN grades elevated, and gestational weeks of delivery advanced.(P < 0.05). (3) We did not detect significant difference for the incidence of polyhydramnios, premature rupture of fetal membranes, placental abruption, cervical laceration and postpartum hemorrhage, low birth weight infants, amniotic fluid II–III degree, neonatal deformity and neonatal asphyxia between pregnant women with CIN and cervicitis (P > 0.05); however, the incidence of oligohydramnios and premature infants in pregnant women with CIN group were higher than that in cervicitis group (P = 0.007; P = 0.020). (4) Vaginal delivery and HR–HPV infection did not increase the incidence of perinatal complication; the volume of postpartum hemorrhage within 2 h after birth in vaginal delivery was less than in cesearean section for pregnancies with CIN (P = 0.000).

Conclusion

Pregnant women with CIN can be diagnosed by colposcopy conducted cervical biopsy, and they should be carefully monitored oligohydramnios and preterm during pregnancy. Pregnant women with CIN during pregnancy, excluding other obstetric operation indications may choose vaginal delivery first.     

Cervical cerclage in twin pregnancies

Purpose

To evaluate the outcomes of cervical cerclage (CC) in twin pregnancies.

Methods

Retrospective analysis of twin pregnancies undergoing CC between January 2001 and December 2009 at our Institution. CC was offered in case of a cervical length measurement ≤20 mm (ultrasound-indicated CC) or in case of cervical dilatation with membranes at or beyond the external cervical os (physical examination-indicated CC). Cervicovaginal and rectal swabs were obtained preoperatively. Perioperative antibiotics and tocolysis were administered.

Results

There were 28 cases of ultrasound-indicated and 14 of physical examination-indicated CC. Positive swab cultures were observed in 21 % of cases. The incidence of preterm delivery <34 weeks was 32 % [95 % confidence interval (CI) 16–52 %] and 50 % (95 % CI 23–77 %) in the ultrasound-indicated and physical examination-indicated CC group, respectively. The incidence of premature rupture of membranes <34 weeks was 21 % (95 % CI 8–41 %) and 29 % (95 % CI 8–58 %) in the ultrasound-indicated and physical examination-indicated CC group, respectively. Perinatal survival was 96 % (95 % CI 88–100 %) in the ultrasound-indicated CC group, and 86 % (95 % CI 67–96 %) in the physical examination-indicated CC group.

Conclusions

We showed a high-risk of preterm delivery in both groups, but with a high overall perinatal survival. Our data stress the importance of re-evaluating the efficacy of CC in twin pregnancies by properly designed clinical trials, particularly if it is physical examination indicated.     

Is serum placental growth factor more effective as a biomarker in predicting early onset preeclampsia in early second trimester than in first trimester of pregnancy?

Purpose

To determine whether maternal serum placental growth factor (PlGF) is more effective as a biomarker in predicting the occurrence of early onset preeclampsia in first trimester or early second trimester of pregnancy.

Methods

A prospective cohort study was conducted on women with singleton pregnancies, screened from the antenatal clinic. Serum PlGF estimation was done at 11–14 weeks of gestation on 1,244 women and at 22–24 weeks of gestation on 1,206 women from the initial study population. A cut-off value of <228 pg/ml for serum PlGF at 11–14 weeks of gestation and <144 pg/ml for serum PlGF at 22–24 weeks of gestation were determined by receiver operating characteristic (ROC) curve analysis for identifying pregnant women at risk of developing early onset preeclampsia (<32 weeks of gestation). Univariate logistic regression analysis was used to analyze the association between serum PlGF < 228 pg/ml at 11–14 weeks of gestation and <144 pg/ml at 22–24 weeks of gestation with the occurrence of early onset preeclampsia and odds ratio (OR) was computed. P value < 0.05 was considered statistically significant in this study.

Results

Maternal serum PlGF <144 pg/ml at 22–24 weeks of gestation had a stronger association (OR 18.83; 95 % CI 12.08–22.24; p = 0.000) than serum PlGF <228 pg/ml at 11–14 weeks of gestation (OR 2.76; 95 % CI 1.29–3.94; p = 0.007) with the occurrence of early onset preeclampsia. The sensitivity and specificity of serum PlGF <144 pg/ml at 22–24 weeks of gestation (84 and 78, respectively) were much higher than those of serum PlGF <228 pg/ml at 11–14 weeks of gestation (58 and 66, respectively) in predicting early onset preeclampsia.

Conclusion

Maternal serum PlGF may be more effective as a biomarker in early second trimester than in first trimester of pregnancy, in predicting the occurrence of early onset preeclampsia.     

Membrane stripping to prevent post-term pregnancy in Enugu, Nigeria: a randomized controlled trial

Objectives

This study aimed at evaluating the effectiveness and safety of membrane stripping at 40–41 weeks of gestation as a means of preventing post-term pregnancy and the need for formal induction of labor in Enugu, Nigeria.

Methodology

A randomized controlled trial of 134 post-date pregnant women at the University of Nigeria Teaching Hospital, Enugu, Nigeria, from February to November 2012. The intervention group received membrane stripping while the control group did not receive membrane stripping.

Results

The incidence of post-term pregnancy in the membrane stripping group was 16.1 % (10/62) versus 39.3 % (24/61) in the control group (RR 0.41; 95 % CI 0.22–0.78; P = 0.004; NNT = 4). Membrane stripping reduced the duration of pregnancy by 3 days (P < 0.001). The procedure also significantly reduced the need for ‘formal’ labor induction [7/62 (11.3 %) vs. 23/61 (37.7 %); RR 0.30; 95 CI 0.14–0.65; P = 0.002]. However, maternal and neonatal complications were similar between the two groups.

Conclusion

Membrane stripping reduces the incidence of post-term pregnancy and need for formal induction of labor in post-date pregnant women, without increased maternal or neonatal complications.     

Squamous intraepithelial lesions in HIV-infected women: prevalence, incidence, progression and regression

Purpose

To evaluate the impact of HIV immune depletion, highly active antiretroviral therapy (HAART) and patient characteristics on the occurrence of cervical squamous intraepithelial lesions (SIL).

Methods

A total of 898 HIV-positive women were evaluated at the time of their first Pap smear and 388 of them received additional Pap smears during follow-up in a cohort study. The patients were enrolled from July 1997 to April 2007. Prevalence and incidence of SIL in Pap smears were studied. Progression and regression were evaluated in follow-up of patients presenting low-grade SIL.

Results

Pap smear results at baseline were: 741 normal (82.5 %), 56 atypical squamous cells of indeterminate significance (ASCUS) (6.2 %), 78 low-grade SIL (8.7 %), 22 high-grade SIL (2.4 %), and 1 invasive cervical cancer (0.1 %). SIL cumulative incidence rate was 9.7 %. Progression and regression occurred in 15.9 and 62 %, respectively. Multivariate analysis of CD4 counts ≤200 cells/mm³ (aHR = 2.1; 95 % CI 1.3–3.5; P = 0.004) and age less than 30 years (aHR = 3.2; 95 % CI 1.5–6.8; P = 0.01) or less than 40 years old (aHR = 2.6; 95 % CI 1.2–5.7; P = 0.01) were significantly associated with SIL prevalence. CD4 counts ≤200 cells/mm³ (aHR = 3.0; 95 % CI 1.2–7.2; P = 0.01) and higher viral load counts (for each log increase) were associated with SIL incidence (aHR = 1.4; 95 % CI 1–1.9; P = 0.048).

Conclusions

Prevalence and incidence of SIL in HIV-positive women were associated with severity of HIV disease. Interventions to increase access to Pap smears and further diagnostic tests should be implemented and targeted to HIV-positive women.