Clinical Characteristics and Management of Adnexal Torsion.

Adnexal torsion is a gynaecologic surgical emergency. Misdiagnosis or delay may lead to loss of the adnexa and may compromise fertility. Aim: To determine the most relevant findings for the diagnosis of adnexal torsion and the results of laparoscopic surgery. Methodology: A retrospective cohort study of 266 patients who underwent surgical treatment for adnexal torsion in our department from January 1994 to January 2014. Clinical, biological, ultasonographic, therapeutic and histological findings were analysed as well as risk factors and prognosis. Results: The mean age of patients was 33.1 years. Adnexal torsion occurred during pregnancy in 21 patients (7.8%). Abdominal pain was present in 91.7%, vomiting in 63.9% and fever in 19.1% of the cases. Ultrasonographic findings were: ovarian cysts (54.1%), complex mixed echogenicity masses (40.2%) and ovarian enlargement (5.6%). The pain-to-surgery interval varied from 4 hours to 26 hours. At surgery, the mean number of spiral turns was 2. Treatment was carried out by laparotomy in 87 patients (32.7%). The mean size of the adnexa treated by laparotomy was 10.7 cm. Laparoscopic surgery was performed in 137 patients (51.5%). The mean size of the adnexa treated by laparoscopy was 6.9 cm. Laparoscopic treatment was conservative in 77.3% of the cases. Conclusion: Adnexal torsion is a common gynaecologic emergency. Prompt diagnosis of adnexal torsion requires a combination of clinical, biological and sonographic investigation. The prognosis of adnexal torsion was potentially increased by the interval period before surgery. Laparoscopic treatment is the gold standard if possible.

[Medical treatment of endometriosis]

Prerequisites: Pathogenesis and pathophysiology of endometriosis, pharmacodynamics of oral contraceptives, progestagens, antiprogestagens, danazol, GnRh agonist and non-steroidal antiinflammatory

Purpose of review: The aim of this paper is to systematically review the literature evidence of medical treatments for endometriosis and to summarize recently published recommendations

Methods:Literature and recently published recommendations review via bibliographic research using Pubmed/Medline, Google scholar and Cochrane database

Results:Endometriosis is an estrogen-dependent gynecological disease. Medical treatement of endometriosis induce an estrogen deprivation situation. The Oral contraceptives reduce the rate of postoperative endometrioma recurrence and should be considered an essential part of long-term therapeutic strategies.New agents promise a distinct perspective in endometriosis treatment

Conclusions: The effectiveness of medical treatment is well established in the management pelvic pain and infertility associated with endometriosis and constitutes an important alternative or complement to surgery

[Medical treatment of ectopic pregnancy]

The ectopic pregnancy [EP] is a public health problem and its frequency has doubled in most industrialized countries in 20 years. To evaluate the effectiveness of medical treatment of ectopic pregnancy with methotrexate [MTX] intramuscularly [IM]. prospective study supported between October 2006 and December 2010. The selected patients received methotrexate IM [1 mg per kg]. The monitoring was based on: the kinetics of plasma HCG, clinical examination and ultrasound. A second injection was performed if hCG on day 4 was increased by more than 25% or J7> the initial rate. Healing corresponded to obtain a zero rate of HCG in a stable manner. We used the first-line medical treatment in 122 patients. The average age of patients was 31.94 years. A haematosalpinx was found in 87.70% of cases. The initial rate of HCG plasma varied between 40 lU/ml and 4088 IU / ml, with an average of 805.88 m IU / ml. The primary success rate obtained after a single injection of intramuscular MTX was 67%. The high success rate obtained after two injections of MTX was 27%. The overall success rate after 1 or 2 injections of MTX was 82%. 17 patients underwent surgical treatment after a first injection of methotrexate. 5 patients underwent surgery after receiving two doses of methotrexate. The period of normalization of plasma levels of h CG was 24 days on average, with extremes ranging from 4 to 43 days for 67 patients cured after a single injection of MTX. This period was 33 days on average, with extremes ranging from 8 to 62 days for patients healed after two injections of MTX. Medical treatment applied to 38% of ectopic pregnancies diagnosed in our department is effective in 82% of cases if the inclusion criteria are strictly adhered to. Successful treatment is limited by patient compliance and demanding nature of monitoring

[Post-menopausal bleeding. Comparison between ultrasonography, hysteroscopy and histology's results]

Post-menopausal bleeding are frequently found in gynaecological consultations and requires the search of an organic cause. To value the profit and the performances of the transvaginal ultrasonography and the hysteroscopy in the determination of the causes of post-menopausal bleeding. 80 patients presenting abnormal uterine bleeding in post menopause period have been explored in our department with transvaginal ultrasonography and hysteroscopy. The findings have been evaluated on the basis of specimens obtained from either endometrial biopsy, hysterectomy or operative hysteroscopy. We have calculated in our study the sensitivity, the specificity, the positive and negative predictive values of transvaginal ultrasonography and hysteroscopy. The sensitivity, the specificity, the positive and negative values predictive of the transvaginal ultrasonography is respectively 93, 75%, 87, 5%, 83, 3% and 95, 45%. In the other part, hysteroscopy seems more performant in the diagnosis of intrauterine abnormalities with the respective values: 100%, 95, 83%, 94, 11% and 100%. The initial investigation in front of all mennorhagic patients must be the transvaginal ultrasonography but we also need the hysteroscopy because its highly accurate means in the diagnosis of the causes of excessive uterine bleeding in post menopausal period

[Ultrasound diagnosis of ectopic pregnancy: prospective study about 200 cases]

The ectopic pregnancy is responsible for 10% of maternal mortality in the first quarter. Progress in transvaginal ultrasound; have revolutionized the diagnosis of ectopic pregnancy, allowing her diagnosis earlier. To evaluate the contribution of ultrasonography in the diagnosis of ectopic pregnancy. A prospective study about 200 patients hospitalized for ectopic pregnancy between July 2009 and July 2011. All patients underwent a transvaginal ultrasound. The average age was 25.4 years. The study of the endometrium showed an endometrial thickness of 10.1mm in 152 cases. An haematosalpinx was observed in 71% of cases. The average size was 30.5mm. Hemoperitoneum was observed in 64.5% of cases. An ectopic gestational sac with embryo was found in 9 cases [4.5%]. In 51 cases no pathological sonographic signs were noted. The transvaginal ultrasound is the method of choice in the diagnosis of ectopic pregnancy. However the use of BHCG is still necessary

[Correlation between vital signs and hemoperitoneum in ruptured ectopic pregnancy]

Ectopic pregnancy [EP] is a medical-surgical emergency. Rupture of an ectopic pregnancy is a serious complication and may develop severe life-threatening to the patient. To determine correlation between vital signs and hemoperitoneum in ruptured ectopic pregnancy and the association between abnormal vital signs and tubal rupture. Via a retrospective study we have considered a sample of 32 patients of ruptured ectopic pregnancy. All patients were diagnosed at the Gynecology and Obstetrics Unit A at Charles Nicole Hospital, Tunisia. Mean minimum systolic [SBP] 109 mmHg [range 70-150], mean maximum [HR] 81.5 beats/min [range 70-140]. Mean volume of hemoperitoneum 693.75 mL [range 100 -2000 mL].Correlation between vital signs and volume of hemoperitoneum was poor [R 2 = 0.279 for HR, R 2= 0.267 for SBP]. Hypotension was associated with blood loss of at least 1280 ml. Association of tachycardia with hypotension was observed in only 2 cases. Correlation between HR and SBP was not significant and poor [p=0.23, R 2= 0.05] Normal vital signs alone are poor predictors of ruptured ectopic pregnancy and do not correlate well with volumes of hemoperitonieum

[Sublingual misoprostol for cervical ripening before diagnostic hysteroscopy: a randomized and prospective study about 108 cases]

To evaluate the benefits of cervical preparation with 200 mcg of Misoprostol administered 2 hours before diagnostic hysteroscopy. Prospective randomized and double-blind study. A total of 108 patients were randomized into two groups: The first group G1 of 54 patients who received 200 mcg Misoprostol sublingually, two hours before diagnostic hysteroscopy, and a control group of 54 G2 patients without prior preparation. The surgeons were not informed before each act to which group the patient belongs. The parameters analyzed were: the rate of patients requiring dilation to Hegar candle to introduce the hysteroscope, hysteroscopy complications, and the side effects of Misoprostol. In the Misoprostol group, 5 patients required the use of mechanical cervical dilatation [9.2%] against 12 patients [22.2%] in the control group. The average diameter of the larger candle used was 5.3 mm in the Misoprostol group against 4.2 mm in the control group. No significant difference was found between the two groups concerning the rate of complications in both procedures. By comparing the effect of Misoprostol in the group of postmenopausal women, no significant differences were observed regarding the use of cervical dilation or the rate of complications during hysteroscopy. Moreover, no significant difference was observed in patients with a history of vaginal delivery. No significant difference was noted in this study between Misoprostol group and control group, despite less use of cervical dilation and less complications in Misoprostol group

Imperforate hymen A13-cases series

Imperforate hymen is a rare congenital malformation. Patients often remain asymptomatic until puberty and present in early adolescence with cyclic abdominal pain. Early diagnosis and treatment must be performed in order to prevent morbidity. This study was to assess management of this disease. A retrospective study of 13 cases of impe rforate hymen diagnosed in the department of obstetrics and gynecology "A" of Charles Nicolle hospital of Tunis from January 1980 to December 2008. The clinical features and the management are discussed. The mean age was 14 years. All patients were single and had primary amenorrhea. They presented with pelvic pain in 9 cases and bladder urinary retention in 4 cases. Secondary sexual characters were present and normal in all cases. Inspection of the vulva could establish the diagnosis in all cases. Pelvic ultrasounds showed the hematocolpos in all cases. The latter was associated to a hematometria and a Douglas pouch liquid in 2 cases. Hematocolpos was evacuated by hymenectomy under oxytocin. Infusion in all cases. Eight patients were treated by cruciform incisions and five patients were treated by radial incisions of the hymen. The volume of hematocolpos varied from 250 ml to 2000 ml. One patient underwent surgery twice for restenosis of the imperforate hymen. Imperforate hymen is a rare anomaly. Its diagnosis is simple and could be established at birth by a systematic screening. More frequently, the diagnosis must be suspected in front of a primary amenorrhea associated to abdominal pain in order to prevent complications

Ovarian abscess as a complication of assisted reproduction techniques: a case report

AMP makes true great strides these last decades. Logically some complications were noticed even due to ovarian puncture such as hemorrhage, perforation or infection. The aim of this report is to try, through a review of literature, to draw the attention of physicians to a rare entity, ovarian abscess after follicle aspiration for in-vitro fertilization, and to means of prevention. We report a 38-year-old woman who was compolaining from lower abdominal pain located in the left iliac fossa one month after failed IVF trial. The pain was associated with fever and vomiting. The patient's past medical history involves 2 myomectomys [2003-2007]. On admission, her temperature was 38.9°C and her blood pressure was 90/60 mm Hg. Physical examination found nondistended abdomen. Tenderness to deep palpation in the left lower quadrant, without peritoneal signs, was detected. No masses were palpated. Mild tenderness in the left cul-de-sac was found. A full blood count showed a white cell count of 17,500 cells/mm3 with 84.5% polymorph nuclear cells, CRP 173 mg/dl. Pelvic ultrasound shows a left latero uterine mass; right ovary and the uterus are unremarkable; there was no free abdominal fluid. The laparotomy was performed 24 hours later and a left ovarian abscess was found. The treatment was conservative. Antibiotics were associated during 15 days. The clinical evolution was satisfying. The ovarian puncture might be technically difficult, incomplete, and even impossible which exposes to a greater infection risk. An ultrasound evaluation of ovarian accessibility is necessary before starting an IVF attempt, especially in case of overweight or history of abdominal or pelvic surgery, endometriosis tubal abnormalities or myomas. The treatment is based on surgery and antibiotics

[Laparoscopic management of ovarian cysts in postmenopausal women]

To report our experience with laparoscopic treatment of ovarian cysts in postmenopausal women. During the period January 2000 to December 2006, 18 postmenopausal women were admitted for laparoscopy. The indications for the operation were an ovarian cyst that did not meet the criteria of a simple cyst, or was larger than 4 cm. The median age of the patients was 55 [range 43-82]. The mean time since menopause was 6 years [range: 1-30 years]. All laparoscopies were successfully accomplished. No case of malignancy was found. Histological examination revealed 15 serous cysts, one mucinous cyst, one endometroid cyst and one functional cyst. Neither intraoperative nor post-operative complications occurred. There was no surgery-related mortality. Mobilization of all women was carried out within 12 h of the operation. The mean hospitalization stay was 2 days. Laparoscopic management of carefully selected ovarian cysts is an appropriate alternative for exploratory laparotomy even in elderly patients with or without underlying diseases

[Ultrasonographic diagnosis of ectopic pregnancy. a review of 109 cases]

To assess the accuracy of Ultrasonographic diagnosis of ectopic pregnancies. A retrospective study of Ultrasonographic findings of 109 patients operated for ectopic pregnancy between January 1997 and December 1998. Ultrasonography was performed with an Aloka SSD 620 sonographic imager and a 5 MHz endovaginol transducer. All patients had a transvaginal sonography. Of these, 15 had a transobdominal sonogrophy. Ultrasonographic findings of the 109 ectopic pregnancies were on extrauterine gestotionnal sac in 10 cases [9,17%], on adnexel mass clearly separated from uterus and ovary in 87 cases [79,81%], a pelvic fluid in 90 cases [82,56%] and pseudogestationnal sac in 6 cases. Ultrasonographic established the diagnosis of ectopic pregnancy in 89% of cases. Serum B HCG level was needed for diagnosis in 12 cases [11%]. Transvaginal sonography is the method of choice for the evaluation of women with a suspected ectopic pregnancy. However, serum B HCG levels are useful for diagnosis in 11% of cases