Yves Jacquemyn

Female genital mutilation : Knowledge, attitudes and practices of Flemish gynaecologists

Objectiveu2003To assess the knowledge, attitudes and practices with regard to female genital mutilation (FGM) among gynaecologists in Flanders, Belgium. Methodsu2003A questionnaire-based survey was sent to 724 Flemish gynaecologists and trainees. Resultsu2003Three-hundred-and-thirty-four questionnaires were returned. The survey revealed gaps in the knowledge of FGM and the provision of care by Flemish gynaecologists to women who had been mutilated. It also appeared that FGM was not properly addressed in the basic and specialized medical training in Flanders, that little was known about codes of conduct issued by the hospitals when these were not lacking altogether, and that knowledge about legislation concerning FGM was deficient. There was much confusion whether re-infibulation is authorized, and what its legal status is. Some respondents considered cosmetic vaginal surgery as a form of FGM and many were in favour of the medicalization of FGM. Gynaecologists were most commonly confronted with complaints related to sexual problems caused by FGM. Finally, the study also showed that only about a third of the gynaecologists were discouraging women from having their daughters excised. Conclusionu2003There is a need for a thorough discussion among all those concerned of the ethical and legal aspects of re-infibulation, medicalization of FGM and cosmetic vaginal surgery.

Flemish obstetricians' personal preference regarding mode of delivery and attitude towards caesarean section on demand

OBJECTIVESnTo assess Flemish obstetricians preferences about mode of delivery for themselves or their partners and to determine the frequency of caesarean section on demand in Flanders.nnnSTUDY DESIGNnA structured anonymous postal questionnaire was sent to all 672 registered gynaecologist-obstetricians in Flanders.nnnRESULTSnThe response rate was 44%. In the case of an uncomplicated singleton first pregnancy with a cephalic presentation 2% preferred elective caesarean section. There was no difference between male and female obstetricians. Seventy percent said that they would never perform caesarean section on demand. At least 2.6% of all caesarean sections in Flanders seems to be performed on patients demand.nnnCONCLUSIONnThe attitude of Flemish gynaecologist-obstetricians is clearly in favour of vaginal delivery both for themselves, their partners and their patients.

The effect of highly active antiretroviral treatment on viral load and antiretroviral drug levels in breast milk.

Viral load and drug levels were measured in the plasma and breast milk of nine mothers treated with highly active antiretroviral therapy (HAART) and one woman treated only with zidovudine during delivery. In all HAART-treated women after delivery the viral load was less than 400 copies/ml in plasma and breast milk. Compared with the plasma concentration, the breast milk concentration was between 68 and 90% for nevirapine, 6 and 24% for nelfinavir and 90 and 540% for indinavir.

The use of intravenous magnesium in non-preeclamptic pregnant women: fetal/neonatal neuroprotection

PurposeTo review the effect of intravenous magnesium in obstetrics on fetal/neonatal neuroprotection.MethodsA systematic review of published studies.ResultsFive randomized trials and 4 meta-analyses have shown a significant 32xa0% reduction of cerebral palsy when administering magnesium sulfate in case of preterm delivery. The pathophysiologic mechanism is not fully unraveled: modulation of the inflammatory process, both in the mother and the fetus, and downregulation of neuronal stimulation seem to be involved. After long-term high-dose intravenous administration of magnesium, maternal and neonatal adverse effects such as maternal and neonatal hypotonia and osteoporosis and specific fetal/neonatal cerebral lesions have been described. In case of administration for less than 48xa0h at 1xa0g/h and a loading dose of 4xa0g, these toxic amounts are not achieved. American, Canadian and Australian guidelines recommend the use of intravenous magnesium in any threatening delivery at less than 32xa0weeks. The “number needed to treat” to avoid 1 cerebral palsy is between 15 and 35.ConclusionsIntravenous magnesium significantly reduces the risk for cerebral palsy in preterm birth. Open questions remain the optimal dosing schedule, whether or not repeating when delivery has been successfully postponed and a new episode of preterm labor occurs. Some concern has been raised on a too optimistic value for random error which might have led to over-optimistic conclusions in classic meta-analysis. Randomized trials comparing different doses and individual patient data meta-analysis might resolve these issues.

Does practice make perfect? An age-matched study on grand multiparity in Flanders, Belgium

Abstract Aim: To compare the perinatal outcome of grand multi-parous women (giving birth for the fifth to ninth time) and pauciparous (parity 2 to 4) women in the region of Flanders, Belgium. Methods: Population-based, retrospective, age-matched study. Results: 2832 grand multiparous women were compared with 2832 pauciparous women. In univariate analysis grand multiparous women showed more transverse lie, macrosomia, and fetal death and had less frequently epidural analgesia and episiotomy. Logistic regression demonstrated that grand multiparity was a significant factor contributing to fetal death and macrosomia. Conclusion: Grand multiparity is associated with fetal death and macrsomia in the region of Flanders, Belgium.

Methylmalonic acidaemia in pregnancy.

A 27-year-old woman with vitamin B12 responsive form of methylmalonic acidaemia (MMA) was pregnant with her first child. Treatment was unaltered during pregnancy: a low-protein diet and supplements. Her pregnancy was uncomplicated. She had a spontaneous delivery of a healthy girl with no MMA. The postpartum period was uneventful. MMA is a rare autosomal recessive metabolic disorder caused by a deficiency of methylmalonyl coenzyme A mutase or its vitamin B12-dependent cofactor, leading to a toxic accumulation of methylmalonyl acid in plasma and urine. Clinical presentation involves otherwise unexplained deterioration and neurological dysfunction, recurrent vomiting, dehydration, lethargy, respiratory distress and muscular hypotonia. Long-term sequelae are neurological problems, renal failure, pancreatitis and cardiomyopathy. This is the 11th reported case of pregnancy in a woman with MMA.

Complications and patient satisfaction after transobturator anterior and/or posterior tension-free vaginal polypropylene mesh for pelvic organ prolapse

Complications and satisfaction with anterior and/or posterior prolapse repair using a transobturator polypropylene mesh (Prolift®) in a single center prospective cohort was assessed. Among 30 women six mesh erosions were noted, five (17%) after anterior and one (3%) with combined anterior and posterior procedures. The patients’ impression after six months was ‘better’ to ‘much better’ in 25 (84%), no change in four (13%) and one was worse (3%). At six months one patient had suffered re‐appearance of an anterior prolapse and one had relapse of both an anterior and posterior prolapse. Concomitant procedures were not significantly related to risk of erosion, but the erosion group was younger (mean age 58 vs. 67 years, p<0.0001). After polypropylene transobturator mesh for pelvic organ prolapse relapses do occur. Safety may be hampered by a high rate of mesh erosions.

Idiopathic ganulomatous mastitis

Idiopathic granulomatous mastitis (IGM) is a rare chronic benign disease of the breast. Histologically, the disease presents as an inflammatory reaction with non-caseating granulomas considered characteristic for IGM. IGM is often confused with breast cancer or mastitis with abcedations, and is treated with surgery which involves mutilation of the breast. Although no consensus exists on the best treatment modality, the use of low-dose oral and topical steroids has proven efficacy.

Labour should be induced at term: AGAINST: No proof of benefit

GORDON SMITH, PROFESSOR OF OBSTETRICS & GYNAECOLOGY, CAMBRIDGE UNIVERSITY, UK ....................................................................................................................................................................... Delivery of the fetus is one of the few truly disease-modifying therapies available in obstetrics. Management of multiple conditions involves balancing the risk of delivery versus expectant management. Taking the example of early-onset fetal growth restriction, the risk of neonatal death and severe morbidity if the baby is delivered preterm is balanced against the risk of intrauterine fetal death if the baby is not delivered. The declining risk of neonatal complications with advancing gestational age is the rationale for many guidelines recommending delivery thresholds, e.g. delivery at 37 weeks in the small-for-gestational age infant with abnormal middle cerebral artery Doppler (RCOG Guideline No. 31. London: RCOG Press; 2013) and delivery at 38 weeks of gestation in women with diabetes mellitus (NCCWCH. NICE Guideline: Diabetes in pregnancy. London: RCOG Press; 2008).

Pregnancy as a risk factor for undertreatment after bariatric surgery

A pregnant woman presented at the emergency department with severe nausea and vomiting at 20u2005weeks of gestational age; she was known with gastric banding. Advanced imaging studies were avoided of fear to harm the fetus. The patient continued to vomit and at 23u2005weeks intrauterine fetal death was noted. The symptoms did not resolve after delivery and CT scan demonstrated slippage of the gastric band over the pylorus resulting in a high digestive obstruction as the cause of hyperemesis and finally resulting necrosis of the vasa brevia. The gastric band was laparoscopically removed along with the necrotic tissue. Avoidance of radiological and endoscopic investigations of fear to harm the pregnancy resulted in complications and possibly in fetal death.