[Sickle cell disease and pregnancy]

Patients with sickle cell disease have abnormal red blood cells. This can cause chronic hemolytic anemia and vaso-occlusion leading to tissue hypoxia and organs dysfunction. Pregnancy in this category of patients is rare with a 1% rate. It has been associated with increased obstetric risks and sickle cell crises. A 30-years-old patient is carrier of major sickle cell disease. In her obstetric history we report two late abortions. The current pregnancy in complicated by hemolyse crisis and foetal hypotrophy. Evolution is marked by in utero foetal death in the 30 weeks of amenorrhoea. Association of sickle cell disease and pregnancy is a purveyor of morbidity and an important foetal [30%] and maternal [la 2%] mortality. These patients often present with multiple visceral lesions, so the pregnancy can be authorized only after a normal pre-conceptionnal check up of their disease. Sickle cell crisis is favoured by pregnancy and complicates it with increase rate of prematurity [35 in 45%]. The disturbance of the materno-foetaux exchanges is responsible of in utero foetal deaths, fetal growth retardationa preeclampsia, placental abruption and miscarriages. The treatment of crisis remains symptomatic. It seems now accepted that systematic transfusion from 26 weeks of amenorrhoea, to obtain a rate of HbS <40% reduces complications and urgency transfusions. The sickle cell disease is a serious illness. Pregnancy of sickle cell patients is possible but must be planned. Management of this Pathology requires collaboration between internist, obstetrician and reanimator

[Delivery of macrosomic]

Management of fetal macrosomia is a situation that obstetricians are often faced. Independently of its etiology, the macrosomian exposed to major complications, dominated during delivery by the risk of shoulder dystocia, which is rare but dramatic situation, requiring the presence of a trained obstetrician ready to cope. We describe results of a retrospective study of 438 cases of confinement of newborn weighing 4000g or more, in our department trough one year period, from 1 January till 31 December 2007. Frequency was of 6.5%, maternal age >30 years old in 59% of cases, mothers average weight was over 80 kg in 56%. A family history of diabetes was found in 18.7%, primiparous was 31% while multiparity was 35%. The diagnosis of macrosomia has been suspected and identified only prior to work in 15.75%. Caesarean section was licited in 30% cases. The complications following vaginal delivery were shoulder dystocia in 22 cases. The neonatal complications were noted in 44 cases, they were represented by: hypoglycemia at birth [7%], 6 cases of acute foetal and one case of neonatal Jaundice. 17 cases were transferred to different pediatrics departments. The main observed maternal complications were represented by: 6 cases of postpartum hemorrhage, cervical tears in 12 cases, 21 vaginal tears and 16 cases of perineal tears, no case of uterine rupture or maternal death has been reported. By an appropriate management during macrosomic vaginal delivery, close monitoring and directed the work with a good command of obstetric maneuvers, we can reduce the risky associated with this delivery and woke it as a mangeable delivery of a non-macrosomic newborn

[Operative hysteroscopy]

It is essential and necessary therapeutic tool in the management of intrauterine pathologies. Indeed, it has facilitated the reach of these lesions and offers many advantages as a minimally invasive technique for either patients or physicians. Retrospective study on a series of 79 cases of operative hysteroscopy performed between January 2004 and December 2006. The mean age of patients was 43.7 years. Gestures made were: polypectomy in 27 cases [34.2%], myomectomy in 17 cases [21.5%], endometrial ablation in 14 cases [17.7%], septum resection in nine patients [11.4%], resection of trophoblastic tissue in two patients [2.5%]. Incidents and accidents during surgery accounted for 2.5%. This technique has now gained an important place in the field of gynecologic endoscopy, endo-uterine resection of intracavitary fibroids and endometrial polyps, the endometrectomy, cure of partition and synechiae are currently codified. Moreover, literature reports a net long-term improvement of clinical signs after hysteroscopic treatment, with improved pregnancy rates and embryo implantation. Hysteroscopy is currently the gold standard as a therapeutic technique for intrauterine lesions. However it has limits and not without complications

[Diagnostic hysteroscopy]

It is an essential and necessary tool in the management of intrauterine pathologies. Indeed, it allows a better diagnosis and better distribution of therapeutics, more precisely targeted. It is a quick, minimally invasive, reproducible and reliable. Retrospective study on a series of 174 cases of diagnostic hysteroscopy performed between January 2004 and December 2006. The mean age was 42,6 years; abnormal uterine bleeding is the main symptom in 110 patients [63%], followed by infertility in 30 patients [17.2%], the abortive disease [7.5%], removal of the intrauterine device [6.9%], and others [5.1%]. Nine patients [5%] had a normal examination; intrauterine abnormalities found were: polyps [31.6%], endometrial hypertrophy [32%], submucous adenomyomas [13.8%], synechiae [12%], endometrial atrophy [9.7%], the intrauterine device [6.9%], uterine septum [6.3%], trophoblast retention [3.5%], intraluminal neoplasms [1.7%], and adenomyosis [1.7%]. The hysteroscopy is accurate, safe, with a low failure rate in the diagnosis of intrauterine abnormalities. It has better sensitivity and specificity compared with sonography and hysterosalpingography. It involves certain risks, but generally remains rare. This examination is currently the gold standard as a diagnostic technique for intracavitary uterine lesions

[Abdominal pain in case of uni-cornuate uterus]

Thinking of the diagnosis of complicated uterine malformation in case of acute abdominal pain. In our case, the patient was holding a unicornuate uterus and was admitted for abdominal pain. The etiological diagnosis was performed during laparotomy leading to hemi-hysterectomy. The unicornuate uterus with rudimentary horn results of a failure of the mullerian ducts. This malformation is discovered during examinations for infertility or after acute complication. The diagnosis is established by imaging [ultrasonography and magnetic resonance imaging] and laparoscopy. Although rare, these malformations should be evocated when patient present abdominal pain and justify the surgical excision of the rudimentary horn to prevent complications [endometriosis, sever dysmenorrhea, rupture of ectopic pregnancy in a rudimentary uterine horn]

[Granular cell tumor of vulva]

Benign tumor whose histogenesis is uncertain, although most of the immunohistochemical and ultrastructural evidences support its neurogenic origin of Schwann cell derivation. It is mostly in the craniocervical region, vulvar involvement is quite rare. A 23 year old woman noted the presence of a 1 cm sized mass on her right labium majus which subsequently increased in size to approximately 3 cm. the mass was totally resected. Her postoperative follow-up was uneventful. Histologic examination of the tumor showed tumor cells with morphologic features consistent with a granular cell tumor. Although benign and slow growing, it has a tendency for recurrence, hence the need for complete surgical excision. Malignant forms, which account for 1-2%, are often fatal with primary and multicentric lesions or metastatic lesions vital organs. While the efficacy of radiotherapy and chemotherapy is unproven. It is a rare entity often benign but may cause, in certain forms, morbidity and mortality. Therefore, clinicians and pathologists should be aware of the clinical and histologic features of these tumors

Breast cancer and pregnancy [about 10 cases]

Breast cancer is the first cancer in Morocco. Its incidence is 60 - 90/ 100 000 woman per year. It represents the most frequently associated cancer with pregnancy. The association of pregnancy and breast cancer represents a particular conflict as regards the foeto-maternal interest. In this un exceptional association, seriousness is related to frequency of advansed forms and the influence of this hormonodependent cancer. In the light of these obseved clinical cases and review of literature, our proposition is to clarify the epidemiological, clinical, prognostic and therapeutic data

Dystocia due to enlarged foetal thoracic parts: a case of non immunised hydrops fetails

The authors exposed the problem of case of a dystocia due to hydrothorax and sub-cutaneous oedema which was complicated by a uterine rupture, diagnosed at 34 weeks amenorrhoea. Authors attempt to analyse the elements at hand to be able to prevent occurance of dystocia