José Bajo-Arenas

Efficacy of the HPV-16/18 AS04-Adjuvanted Vaccine Against Low-Risk HPV Types (PATRICIA Randomized Trial): An Unexpected Observation

Background. Public Health England has reported a decrease of up to 20.8% in new diagnoses of external genital warts (GWs) among women aged <19 years since the national vaccination program with the human papillomavirus (HPV)-16/18 AS04-adjuvanted vaccine began in 2008. A post hoc analysis of the phase III PATRICIA (PApilloma TRIal against Cancer In young Adults) trial (NCT00122681) was performed to ascertain whether protection against low-risk HPV types was apparent. Methods. Vaccine efficacy (VE) at 48 months was assessed against 6-month persistent infection (6MPI) with low-risk HPV types in the total vaccinated cohort (TVC) and in the TVC naive (for 25 HPV types tested) populations. Results. In the TVC naive cohort, VE against 6MPI (95% confidence interval) was 34.5% (11.3 to 51.8) for HPV-6/11, 34.9% (9.1 to 53.7) for HPV-6, 30.3% (−45.0 to 67.5) for HPV-11, and 49.5% (21.0 to 68.3) for HPV-74. Conclusions. The HPV-16/18 AS04-adjuvanted vaccine appears to have moderate efficacy against persistent infections with a number of low-risk HPV types (HPV-6/11/74), which are responsible for the majority of external GWs, and recently, antibody and cell-mediated immune response to HPV-6/11 have been observed. These findings may help to explain the decrease in external GW diagnoses seen in England.

Renal Angiomyolipoma during Pregnancy: Review of the Literature

The incidence of renal angiomyolipoma (RA) is 0.3% in the general population, and even more infrequent during pregnancy. Pregnancy can increase the risk of rupture, although the causal mechanism is still not clearly defined. We completed a Medline literature search for articles on RA and pregnancy and its complications. We identified 16 articles (all case reports), but selected only 13 because of unavailable data in the 3 other articles. We report the case of a 30-year-old primiparous woman who presented at the emergency ward with a non-reassuring pattern at fetal monitoring; an urgent cesarean section was decided and carried out. After surgery, a wide retroperitoneal hematoma was observed caused by the rupture of an RA. Conservative management by means of arterial embolism was done and the patient was discharged on postoperative day 10. RAs seem to have a higher risk of rupture during pregnancy, but they should be managed conservatively when hemodynamically possible. Individualization of each case is necessary in order to achieve the best outcome for both the mother and fetus.

Hemodynamic changes during pregnancy and postpartum: a prospective study using thoracic electrical bioimpedance.

Objective. To describe hemodynamic changes in normal pregnancy and postpartum by means of thoracic electrical bioimpedance (TEB). Methods. Eighteen healthy pregnant women were included in the study. Eight different hemodynamic variables were measured by thoracic electrical bioimpedance, from 12th week of gestation until 6th month of postpartum period. Data along pregnancy and postpartum were analyzed with SAS statistical software to compare the different values, so normality curves are reported. Results. Systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR), and peripheral vascular resistances (PVRs) seem to significantly decrease until 24th week of gestation, and then they seem to increase until delivery, recovering normal values gradually during postpartum period. End-diastolic volume (EDV), systolic volume (SV), cardiac output (CO), and ejection fraction (EF) seem to decrease until 48 h after delivery; statistical significance was found. Conclusions. Thoracic electrical bioimpedance may be the most appropriate and accurate technique to measure normal hemodynamic changes during pregnancy and postpartum.

Tibolone and risk of endometrial polyps: a prospective, comparative study with hormone therapy.

Objective To assess the incidence of endometrial polyps during postmenopausal replacement therapy with tibolone, using an appropriate control group. Design A total of 485 postmenopausal women were included in this open, prospective, comparative study for a duration of 36 months. Of this group, 249 women received 2.5 mg/day of tibolone and 244 women served as controls, receiving continuous-combined estrogen-progestogen therapy (HT). Transvaginal ultrasound, hysteroscopy, and directed biopsies were performed before treatment was initiated and at the end of the study. Results Two hundred twenty-one of the women receiving tibolone and 203 receiving continuous-combined HT completed the study. Endometrial polyps were detected in 74 women (33.4%) from the tibolone group and in 22 women (10.8%) from the HT group (P < 0.01). The vaginal bleeding rate did not differ between the groups. The frequency of atrophic polyps was significantly higher in the tibolone group (P < 0.01). No difference was found in the size of the polyps. Conclusions Tibolone increases by threefold the risk for endometrial polyps.

Laparoscopic management of a cavitated noncommunicating rudimentary uterine horn of a unicornuate uterus: a case report

IntroductionA unicornuate uterus with a rudimentary horn is the most uncommon uterine anomaly of the female genital tract. It has an estimated frequency of one in 100,000 among the fertile female population. This anomaly results from the abnormal maturation of one Müllerian duct with the normal development of the contralateral one.Case presentationWe report here the case of a 14-year-old Caucasian girl who came to our hospital with intense dysmenorrhea. Imaging techniques revealed a unicornuate uterus with a rudimentary horn and a large hematosalpinx. We performed a laparoscopic removal of this uterine anomaly without any complication in the postoperative period.ConclusionIn our case report, we demonstrate that laparoscopy is the best approach for the treatment of IIb Müllerian abnormalities. Laparoscopy resulted in anatomical and reproductive results equivalent to those offered by a laparotomic approach, but with the additional advantages of minimally invasive surgery, such as better cosmetic results and postoperative period, which are essential for very young patients.

Periovulatory follicular volume and vascularization determined by 3D and power Doppler sonography as pregnancy predictors in intrauterine insemination cycles

To evaluate the relationship between volume and vascularization of the periovulatory follicle and subfollicular area measured by three‐dimensional power Doppler ultrasound (US), and ovulation and pregnancy in patients undergoing intrauterine insemination (IUI).

Pneumomediastinum during the Fourth Stage of Labor

Postpartum spontaneous pneumomediastinum (Hamman’s syndrome) is a very rare event with an estimated incidence of 1 in 100,000 deliveries. It occurs mainly in the second stage of labor and is potentially lethal. We report the case of a 29-year-old primiparous woman during the immediate puerperium (Leff’s fourth stage of labor) presenting with acute chest pain, dyspnea and petechiae. She was admitted to the intensive care unit with a suspected diagnosis of amniotic fluid embolism. A chest radiograph revealed a pneumomediastinum that finally resolved with oxygen therapy and supportive management in 3 days.

Large Meckel's diverticulum complicating pregnancy with an intestinal obstruction.

The incidence of acute abdomen during pregnancy is 1 in 500 600 pregnancies (1) and intestinal obstruction occurs only in 1:3,000 to 1:16,000 pregnancies (2). The presence of a Meckel’s diverticulum as the cause of obstruction is extremely rare. It requires always the extirpation of the diverticulum and bowel resection in 23% of cases and fetal mortality rate may be around 20% (3). Anatomic and physiologic changes during normal pregnancy can alter the presentation of symptoms making recognition of the disease more difficult (4). We recently observed a 35-year-old primigravida who presented in her 27th week of gestation with diffuse upper abdominal pain and vomiting, total intolerance to liquids and solid aliments during the previous five days, but no fever. The pregnancy had been normal. The clinical examination, blood analysis, fetal sonography, and monitoring at the emergency ward were all normal. After 24 hours of observation and conservative therapy, an increase of vomiting with fecaloid and bilious features was observed. Surgical intervention became necessary because of aggravation of her symptoms. Repeated sonography and magnetic resonance as well as leucocytosis lead to a suspicion of appendicitis. A small bowel obstruction related to a 10 cm Meckel’s diverticulum which leaned against the intestinal surface and obstructing it was found (Figure 1). Address for correspondence Loı̈c Sentilhes Department of Obstetrics and Gynecology Pavillon Mère-Enfant Rouen University Hospital Charles Nicolle 1, rue de Germont 76031 Rouen-Cedex France E-mail: loicsentilhes@hotmail.com

Advanced pregnancy loss in the rudimentary horn of an undiagnosed unicornuate uterus

A case of advanced pregnancy loss in the rudimentary horn of a unicornuate uterus is presented herein. The unknown uterine malformation and advanced pregnancy resulted in the condition being incorrectly diagnosed on ultrasound. After a failed attempt at dilatation and curettage, a correct diagnosis was made and proper treatment was given during salvage laparotomy performed for arising complications (coagulopathy).

Endometrial Intraepithelial Neoplasia Diagnosed at Endometrial Resection

The literature has no reported cases of isolated endometrial intraepithelial neoplasia found at endometrial resection. If endometrial cancer is occult it might not be detected at diagnostic hysteroscopy or during resection, especially if destructive techniques are used. A 51-year-old woman had history of menorrhagia, with diagnostic hysteroscopy showing benign functional endometrium and diagnosed as dysfunctional uterine bleeding. Endometrial resection was performed and the pathologic examination in one stripe of resected tissue found focal, isolated endometrial intraepithelial neoplasia. This case reinforces the importance of pathologic tissue examination after endometrial ablation. Care must be taken when performing second-generation nonhysteroscopic ablation techniques, as even with direct visualization a premalignant lesion can be missed.