Jean-Charles Pasquier

Suburethral tape via the obturator route: is the TOT a simplification of the TVT?

Suburethral meshes can be implanted via the classic retropubic route (TVT) or by a new insertion technique that passes the tape into the obturator foramen (TOT). In a retrospective study we compared one 18-month period of 94 TOT (tension-free obturator tape) and one 18-month period of 99 TVT (tension-free vaginal tape), which preceded the change in the approach route. All operations were performed by the same surgeon using the same Prolene mesh and withno other surgical procedure associated. These two series were similar in terms of patient age, previous surgical history, degree of incontinence and preoperative urethral closure pressure. The analysis shows morehemorrhagic complications in the TVT group (10%) than in the TOT group (2%), but the difference was not significant. Bladder injuries were more frequent in the TVT group (10%) than in the TOT group (0%), but there was one urethral injury in the TOT group. The mean follow-up was 29.5 months in the TVT group and 12.8 months in the TOT group. The urinary results were the same, with 90% and 95% cured, respectively. In conclusion, the obturator approach shows identical urinary results to the classic retropubic approach. Because of the nature of the procedure, major hemorrhage and bowel perforation are excluded in the TOT procedure. Thus simplicity, safety and continence result mean that the obturator approach represents the best method of suburethral tape insertion for the treatment of urinary stress incontinence.

Determinants of A (H1N1) vaccination: cross-sectional study in a population of pregnant women in Quebec.

BACKGROUND Because of the risk of complication, pregnant women were a priority target for vaccination during the A (H1N1) pandemic influenza. In Quebec, 63% of pregnant women were vaccinated, which is a higher rate than vaccination against seasonal influenza. However, the behaviour of pregnant women relative to the vaccination during the H1N1 pandemic is unknown. The present study was aimed at identifying factors influencing the decision-making of pregnant women regarding H1N1 vaccination. METHODS A cross-sectional survey was conducted in February 2010 in pregnant women or in early postpartum at the Sherbrooke University Hospital Centre using a self-administered questionnaire based on the Health Belief Model (HBM). Data items collected were: socio-demographic data, vaccination status, information sources consulted, knowledge on vaccination, and the HBM dimensions: effectiveness and risks of vaccination, severity and vulnerability towards the influenza. The associations between questionnaire variables and vaccination status were assessed by univariate and multivariate analysis. RESULTS Of the 250 women interviewed, 95% knew that the vaccination was recommended, but only 76% received the vaccine. Variables positively associated with vaccination were late vaccination during pregnancy (OR=7.3, 95% CI 2.1-25.3), belief in the efficacy of the vaccine (OR=7, 95% CI 2-23.4), and consultation of the Pandémie-Québec website (OR=4.5, 95% CI 1.5-13.4). However, the belief that the vaccine had not been adequately tested (OR=0.08, 95% CI 0.02-0.35) and consultation of mainstream websites (OR=0.22, 95% CI 0.06-0.81) were associated with lower vaccination rates. CONCLUSIONS The vast majority of pregnant women were aware of the recommendations relative to A (H1N1) vaccination. Internet media played an important role in their decision to get vaccinated. Better information on the safety of the vaccine must be prepared for future pandemics.

Maternal and Cord-Blood Thyroid Hormone Levels and Exposure to Polybrominated Diphenyl Ethers and Polychlorinated Biphenyls During Early Pregnancy

Thyroid hormones play a critical role in the growth of many organs, especially the brain. Polybrominated diphenyl ethers (PBDEs) and polychlorinated biphenyls (PCBs) interact with the thyroid pathway and may disturb neurodevelopment. This prospective study was designed to examine associations between maternal blood PBDEs and PCBs in early pregnancy and levels of thyroid hormones in maternal and umbilical-cord blood. Levels of low-brominated PBDEs, 3 PCB congeners, total and free thyroid hormones (triiodothyronine (T3) and thyroxine (T4)), thyroid-stimulating hormone, thyroid peroxidase antibodies, iodine, selenium, and mercury were measured in 380 pregnant women in the first trimester who were recruited at the University Hospital Center of Sherbrooke (Quebec, Canada) between September 2007 and December 2008. Thyroid hormone levels were also assessed at delivery and in cord blood (n = 260). Data were analyzed on both a volume basis and a lipid basis. At less than 20 weeks of pregnancy, no relationship was statistically significant in volume-based analysis. In lipid-based models, an inverse association between maternal PBDEs and total T3 and total T4 and a direct association with free T3 and free T4 were observed. At delivery, in both analyses, we observed negative associations between maternal total T4, free T3, cord-blood free T4, and PBDEs and between maternal free T3 and PCBs. Our results suggest that exposure to PBDEs and PCBs in pregnancy may interfere with thyroid hormone levels.

A Cluster-Randomized Trial to Reduce Cesarean Delivery Rates in Quebec

BACKGROUND In Canada, cesarean delivery rates have increased substantially over the past decade. Effective, safe strategies are needed to reduce these rates. METHODS We conducted a cluster-randomized, controlled trial of a multifaceted 1.5-year intervention at 32 hospitals in Quebec. The intervention involved audits of indications for cesarean delivery, provision of feedback to health professionals, and implementation of best practices. The primary outcome was the cesarean delivery rate in the 1-year postintervention period. RESULTS Among the 184,952 participants, 53,086 women delivered in the year before the intervention and 52,265 women delivered in the year following the intervention. There was a significant but small reduction in the rate of cesarean delivery from the preintervention period to the postintervention period in the intervention group as compared with the control group (change, 22.5% to 21.8% in the intervention group and 23.2% to 23.5% in the control group; odds ratio for incremental change over time, adjusted for hospital and patient characteristics, 0.90; 95% confidence interval [CI], 0.80 to 0.99; P=0.04; adjusted risk difference, -1.8%; 95% CI, -3.8 to -0.2). The cesarean delivery rate was significantly reduced among women with low-risk pregnancies (adjusted risk difference, -1.7%; 95% CI, -3.0 to -0.3; P=0.03) but not among those with high-risk pregnancies (P=0.35; P = 0.03 for interaction). The intervention group also had a reduction in major neonatal morbidity as compared with the control group (adjusted risk difference, -0.7%; 95% CI, -1.3 to -0.1; P=0.03) and a smaller increase in minor neonatal morbidity (adjusted risk difference, -1.7%; 95% CI, -2.6 to -0.9; P<0.001). Changes in minor and major maternal morbidity did not differ significantly between the groups. CONCLUSIONS Audits of indications for cesarean delivery, feedback for health professionals, and implementation of best practices, as compared with usual care, resulted in a significant but small reduction in the rate of cesarean delivery, without adverse effects on maternal or neonatal outcomes. The benefit was driven by the effect of the intervention in low-risk pregnancies. (Funded by the Canadian Institutes of Health Research; QUARISMA Current Controlled Trials number, ISRCTN95086407.).

QUARITE (quality of care, risk management and technology in obstetrics): a cluster-randomized trial of a multifaceted intervention to improve emergency obstetric care in Senegal and Mali

BackgroundMaternal and perinatal mortality are major problems for which progress in sub-Saharan Africa has been inadequate, even though childbirth services are available, even in the poorest countries. Reducing them is the aim of two of the main Millennium Development Goals. Many initiatives have been undertaken to remedy this situation, such as the Advances in Labour and Risk Management (ALARM) International Program, whose purpose is to improve the quality of obstetric services in low-income countries. However, few interventions have been evaluated, in this context, using rigorous methods for analyzing effectiveness in terms of health outcomes. The objective of this trial is to evaluate the effectiveness of the ALARM International Program (AIP) in reducing maternal mortality in referral hospitals in Senegal and Mali. Secondary goals include evaluation of the relationships between effectiveness and resource availability, service organization, medical practices, and satisfaction among health personnel.Methods/DesignThis is an international, multi-centre, controlled cluster-randomized trial of a complex intervention. The intervention is based on the concept of evidence-based practice and on a combination of two approaches aimed at improving the performance of health personnel: 1) Educational outreach visits; and 2) the implementation of facility-based maternal death reviews.The unit of intervention is the public health facility equipped with a functional operating room. On the basis of consent provided by hospital authorities, 46 centres out of 49 eligible were selected in Mali and Senegal. Using randomization stratified by country and by level of care, 23 centres will be allocated to the intervention group and 23 to the control group. The intervention will last two years. It will be preceded by a pre-intervention one-year period for baseline data collection. A continuous clinical data collection system has been set up in all participating centres. This, along with the inventory of resources and the satisfaction surveys administered to the health personnel, will allow us to measure results before, during, and after the intervention. The overall rate of maternal mortality measured in hospitals during the post-intervention period (Year 4) is the primary outcome. The evaluation will also include cost-effectiveness.Trial RegistrationThe QUARITE trial is registered on the Current Controlled Trials website under the number ISRCTN46950658 http://www.controlled-trials.com/.

Thyroid Disruption by Low-Dose BDE-47 in Prenatally Exposed Lambs

The purpose of this study was to evaluate whether polybrominated diphenyl ethers (PBDE) at levels reported for human populations affect the thyroid state in pregnant sheep and lambs. Pregnant sheep were exposed to vehicle or BDE-47 (0.2, 2 and 20 μg/kg b.w.) from the 5th to 15th week of gestation by intravenous injections weekly. Thyroid hormone levels and BDE-47 content in the blood of sheep and lambs and adipose tissue were analyzed. We observed a significant decrease in total T4 and T3 in exposed lambs without any effect in pregnant sheep. Our finding indicates that prenatal low-dose PBDE exposure results in PBDE storage in fat of offspring and can affect thyroid metabolism in the developing fetus.

Factors associated with postpartum urinary/anal incontinence in primiparous women in Quebec.

OBJECTIVE To identify the factors associated with urinary incontinence (UI), anal incontinence (AI), and combined UI and AI (UI/AI) in primiparous women in Quebec at six months postpartum. METHODS A questionnaire was mailed to 2492 primiparous women at six months postpartum to collect data on incontinence status, sociodemographic characteristics, elimination habits, lifestyle, and severity index scales. Obstetric characteristics were obtained via Quebecs Med-Echo databank. Pearson chi-square, t test, analysis of variance, univariate regression, and stepwise modelling techniques were used for data analysis. RESULTS The prevalence of UI in responders was 29.6%, of AI, 20.6%, and of combined UI/AI, 10.4%. Significant adjusted odds ratios were (1) for UI, English spoken (2.04 [95% confidence intervals 1.13-3.69]) and shoulder dystocia (2.90 [1.09-7.69]); (2) for AI, age > 35 years (2.13 [1.12-4.03]), duration of second stage of labour (1.67 [1.11-2.51]), and third or fourth degree tears (4.00 [2.32-6.89]); and (3) for UI and AI, age (2.00 [1.04-3.83]), English spoken (2.55 [1.25-5.19]), shoulder dystocia (4.91 [1.76-13.71]), instrumental delivery (2.28 [1.30-3.99]), third or fourth degree tears (3.58 [1.95-6.57]), and episiotomy (2.24 [1.162-4.33]). Caesarean section was associated with less UI (0.45 [0.28-0.72]), and smoking was associated with less AI (0.38 [0.19-0.76]). CONCLUSION Combined UI/AI is associated with several obstetrical factors. The association of UI and AI is observed more frequently after complicated delivery (requiring the application of forceps) or involving perineal damage and episiotomy. As most of the identified factors are modifiable, a preventive treatment policy is advisable.

In vitro study of tocolytic effect of rofecoxib, a specific cyclo‐oxygenase 2 inhibitor. Comparison and combination with other tocolytic agents

Objective The aim of this work was to study and compare the tocolytic effects of rofecoxib with indomethacin, ritodrine, nicardipine and atosiban. We also studied the combination of rofecoxib with each agent.

3D Cohort Study: The Integrated Research Network in Perinatology of Quebec and Eastern Ontario.

Abstract Background The 3D Cohort Study (Design, Develop, Discover) was established to help bridge knowledge gaps about the links between various adverse exposures during pregnancy with birth outcomes and later health outcomes in children. Methods Pregnant women and their partners were recruited during the first trimester from nine sites in Quebec and followed along with their children through to 2 years of age. Questionnaires were administered during pregnancy and post‐delivery to collect information on demographics, mental health and life style, medical history, psychosocial measures, diet, infant growth, and neurodevelopment. Information on the delivery and newborn outcomes were abstracted from medical charts. Biological specimens were collected from mothers during each trimester, fathers (once during the pregnancy), and infants (at delivery and 2 years of age) for storage in a biological specimen bank. Results Of the 9864 women screened, 6348 met the eligibility criteria and 2366 women participated in the study (37% of eligible women). Among women in the 3D cohort, 1721 of their partners (1704 biological fathers) agreed to participate (73%). Two thousand two hundred and nineteen participants had a live singleton birth (94%). Prenatal blood and urine samples as well as vaginal secretions were collected for ≥98% of participants, cord blood for 81% of livebirths, and placental tissue for 89% of livebirths. Conclusions The 3D Cohort Study combines a rich bank of multiple biological specimens with extensive clinical, life style, and psychosocial data. This data set is a valuable resource for studying the developmental etiology of birth and early childhood neurodevelopmental outcomes.

Les membranes fœtales : développement embryologique, structure et physiopathologie de la rupture prématurée avant terme

Fetal membranes development is a complex process. The amniotic and exo-celomic cavities are appearing first. The rapid growth of the amniotic cavity is leading to the disappearance of the exo-celomic cavity and the chorion is merging with the decidua. Fetal membranes consist of three layers: the amnion and the chorion, issued from fetal tissues and the decidua issued from maternal tissue. A balance between the synthesis and the degradation of membranes components is physiologic throughout the gestation. Two main mechanisms are involved in the degradation process: apoptosis in the cellular compartment and matrix metalloproteinase (MMP) in the extracellular matrix. Regulation of MMP is depending on factors increasing their expression (cytokines) and factors decreasing their activity tissue inhibitor of metalloproteinases (TIMPS). Particular conditions can induce an unbalance between synthesis and degradation leading to the weakening of the membranes. Different factors can be associated to induce this unbalance: infection, hormonal factors, default in membranes fusion, oxidative stress and mechanic factors. In fine, the spontaneous rupture of the membranes is always occurring in regard of the uterine cervix after a process started several weeks before.