Treatment of genital prolapse in young women: sacrohysteropexy or vaginal route?

Even if genital prolapse does particularly affect the elder woman, we often have to face a surgical demand with conservation of the uterus from a patient less than 50 years. Before making the decision of treating a non life-threatening symptom by a specific surgical technique, it is important to ask who should be operated and when. Then, the route of the surgery has to be chosen considering that the woman wants to preserve her fertility. In the past decade, some surgical acts, like the sacrohysteropexy, were known as having poorer results if the women got pregnant. Thus, if there was a persistent childbearing desire, more interventions allowing pregnancy (like the Manchester's or the Richardson's procedures) were preferred. Nowadays, the sacrohysteropexy is considered as the gold standard technique, but one question is coming out: could we substitute this traditional surgery by a vaginal repair with meshes? Despite the big diversity of the so-called "sacrohysteropexy", we think that it remains the first choice technique to cure a young woman. Vaginal meshes have too high a rate of morbidity (especially on sexual activity) to be considered as the best surgical treatment. But this question could probably find another answer in the future, when all the studies about the component of the meshes will be finished.     

Prospective evaluation of elective single-embryo transfer versus double-embryo transfer following in vitro fertilization: a two-year French hospital experience

OBJECTIVE: Multiple embryo transfer is responsible for a high rate of multiple pregnancies (ICSI), with subsequent risks of premature birth and perinatal death. This prospective non randomized study aimed to assess the ability of an elective single-embryo transfer (eSET) policy to reduce the twin pregnancy rate, compared to a double embryo transfer (DET) approach. PATIENTS AND METHODS: Between March 2005 and May 2006, 180 eligible women were proposed to benefit from an eSET transfer rather than a DET. Inclusion criteria were (i) age less than 37 years old; (ii) at least two good quality embryos available (three to five cells at day 2 or six to nine cells at day 3; less than 20% fragmentation and the absence of multinucleates blastomeres), after IVF or ICSI and (iii) no more than one previous failed treatment cycle. Outcome analysis included cycles with frozen-thawed embryo transfer (FET). RESULTS: According to patients' decision, 107 and 73 women had an eSET (59.4%) and a DET (40.6%) respectively. No differences were found between eSET and DET groups regarding demographics and biologicals parameters. The clinical pregnancy rate (PR) per transfer was 43.9% in eSET group and 57.5% in DET group (p=0.07). The twin pregnancy rates were 0 and 14.3%, in eSET and DET groups, respectively (p=0.007). The cumulative PR per patient, including the outcome of performed FET cycles, was 63.6% in eSET group and 61.6% in DET group. In this case, the cumulative twin pregnancy rates were 2.9 and 15.6% in eSET and DET groups, respectively (p=0.02). DISCUSSION AND CONCLUSION: Our data show that in a selected population of women, transferring one fresh embryo and then, if required, one or two frozen-thawed embryos significantly reduces the twin pregnancy rate without decreasing the overall pregnancy rate. This study supports the policy of eSET in this subgroup of patients.     

Outcome of anaemic monochorionic single survivors following early intrauterine rescue transfusion in cases of feto-fetal transfusion syndrome

Objective  To evaluate the outcome of severely anaemic monochorionic (MC) twins surviving the death of their co-twin following early intrauterine rescue transfusion in cases of feto-fetal transfusion syndrome (FFTS).
Study design  We reviewed all MC pregnancies complicated with FFTS following primary management, in which a single intrauterine fetal death (IUFD) was diagnosed with certainty within 24 hours between January 1999 and December 2006. We included MC survivors who presented ultrasound or Doppler features of fetal anaemia following the death of their co-twin. Intrauterine transfusion (IUT) was given to all survivors who were anaemic.
Results  Nineteen MC twin pregnancies presented a single intrauterine death (IUD) associated with an anaemic co-twin. Median gestational age at IUD was 23 [20–28] weeks. The median interval between IUD and IUT was 12 [8–24] hours. There were 58% (11/19) healthy survivors. Perinatal death rate was 26% (5/19) including 16% (3/19) intrauterine and 10% (2/19) neonatal deaths. Abnormal prenatal cerebral findings developed in 21% (4/19) cases, always within 1 month after the death of the co-twin. Considering occlusive techniques and other management separately, there were 64% (7/11) and 50% (4/8) healthy survivors, respectively, and perinatal death occurred in 36% (4/11) and 12.5% (1/8) of fetuses, respectively. Prenatal fetal cerebral lesions developed in 9% (1/11) of cases following occlusive techniques and in 37.5% (3/8) of fetuses when managed differently. The median gestational age at delivery in the survivors was 31 [25–38] weeks.
Conclusion  In cases of FFTS with single anaemic survivors, early IUT could be offered following extensive counselling and close follow up.     

Birth weight and size: charts and equations

Objectives

To construct new reference charts and equations for birth weight and birth size using a large and exhaustive sample of newborns. To compare this new references with previous ones.

Materials and methods

The study data were obtained from a single health authority (the birth registry of Yvelines, a French Territorial division of 1.4 million people) over 3 years. Multiple pregnancies were excluded. No data were excluded on the basis of abnormal biometry or birth weight. For each measurement, a least square regression model with high order polynomials was fitted to predict mean, standard deviation and therefore Z scores of birth weigh and birth size at any gestational age at birth from 25 to 42 weeks'.

Results

There were 58 934 and 56 956 measurements included for weight and size at birth respectively. New charts and equations for Z scores calculations, adjusted for sex, are reported based on polynomial regression methods.

Conclusion

We present new French reference charts and equations for birth biometrics. Because they were derived from a very large and unselected sample, there might be more relevant to clinical practice than others and can be easily used to compute centiles and Z-scores.     

Interest in agents for adhesion prevention after gynecologic surgery

Adhesion barriers are intraperitoneal agents, solid or fluid, developed in order to prevent postoperative adhesions. In this article, we evaluate the efficiency of these new barrier agents for adhesion prevention in gynaecologic surgery, undertaking a review of controlled clinical trials published. Several human clinical trials demonstrated the safety and efficiency of both Interceed and Seprafilm. As far as other barrier agents are concerned, data are still insufficient to recommend them for clinical use. There is a need for other randomised controlled trials in order to evaluate functional efficiency of anti adhesion agents.     

Paradoxical interactions between pregnancy and breast cancer

Interactions between pregnancy and breast cancer are complex and paradoxical. Epidemiological data show that nulliparity and late full-term pregnancy increase breast cancer risk. By contrast, early full-term pregnancy and multiparity are thought to be the most effective means of decreasing lifetime breast cancer risk. Paradoxically, young women diagnosed with breast cancer during pregnancy have a higher risk of dying from their disease. Moreover, there is a transient increase in risk of breast cancer in the first three to four years after pregnancy. After breast cancer treatment, there is no evidence that pregnancy increases the risk of breast cancer recurrence. Thus, it is not contraindicated in women previously treated for breast cancer and free of recurrence. Various physio-pathological mechanisms are involved in the protective effect of pregnancy, like cellular differentiation of mammary cells, mammary gland involution, circulating anti-mucin antibody and excretion in the milk of breast carcinogens. In the past, unfavorable effects of pregnancy were mainly attributed to precancerous cell proliferation induced by pregnancy-associated hormonal changes. However, recent studies suggest that the remodeling of cellular microenvironment and extracellular matrix during pregnancy and involution may contribute to enhanced invasive and metastatic potential of breast carcinomas.     

A dose adjustment in patients with rheumatoid arthritis not optimally responding to a standard dose of infliximab of 3 mg/kg every 8 weeks can be effective: a Belgian prospective study

OBJECTIVES: To analyse the effect of a dose increase in patients with severe rheumatoid arthritis (RA) with insufficient clinical response to 3 mg/kg infliximab every 8 weeks. METHODS: Patients suffering from active refractory RA despite methotrexate, were treated with i.v. infusions of infliximab (3 mg/kg) on week 0, 2, 6 and every 8 weeks thereafter. Based on the clinical judgement at week 22, patients received a dose increase of 100 mg from week 30 on. The American College of Rheumatology (ACR) core set for disease activity measures was regularly assessed. RESULTS: Five hundred and eleven RA patients were included. At week 22, 61.4, 34 and 14.1% of all patients met ACR 20, ACR 50 and ACR 70 criteria, respectively, and 6.1% of patients were in remission. A low swollen joint count at baseline was correlated with improvement at week 22 for ACR 20 (P < 0.06), ACR 50 (P < 0.06) and ACR 70 (P < 0.005). The change in HAQ score between weeks 0 and 22 was predictive for response at week 54 (P < 0.01). The dose of infliximab was increased by 100 mg in 22% of the patients. Most baseline values of patients requiring dose increase were higher (P < or = 0.001) than the baseline values of the remaining patients. Increasing the dose of infliximab by one vial from week 30 on could circumvent the partial loss of response in these patients. CONCLUSION: Infliximab use in this large out-patient cohort resulted in a significant clinical improvement. A subgroup that partially lost response during the first 22 weeks could regain response by adding 100 mg of infliximab to the subsequent doses. Due to the current study design, however, a regression to the mean like effect could not be ruled out.