[What are the prognostic factors in the delivery of the second twin?]

Objective: To evaluate the prognosis of the second twin according to different criteria [presentation, mode of delivery, term, weight, weight difference between twins ,twin to twin delivery time interval, studying the Apgar scores at birth and neonatal morbidity and mortality

Materials and Methods: This is a retrospective study of 183 parturients carrying twin pregnancies collected at the department of Obstetrics-Gynecology in Mahmoud Matri Hospital [Ariana] over a period of 9 years [1st January 2001 to 31st December, 2009]

Results: We recorded 357 live births [181 J1 and J2 176] and 9 stillbirths. The relationship between the order of the twin and the modality of delivery on the one hand, and between the order of twin and type of presentation was considered significant [p < 0.001]. We found no significant difference in Apgar score at 1 minute and 5 minutes between the 1st and the 2nd twins. A term = 34 weeks was a poor prognostic factor for the Apgar score at the first and the fifth minute for the 2 twins but no significant difference between the 1st and 2nd twins [1st min p=0.4623; 5th min p = 0.2899]. Low birth weight = 1500g were significantly more at risk of foetal suffering [p < 0.001]. A birth weight discordance of 25% or more was observed 36 cases [19.7 %]. The Apgar score was significantly influenced by the birth weight difference only in the first minute [p = 0.043]. Thereafter, this difference disappears in the 5th minute. The type of presentation and methods of delivery did not influence significantly the second twin morbidity. A time interval between the birth of the first and second twin greater than 15 minutes was a bad prognostic factor for the Apgar score in the 1st min [p = 0.001] and 5th min [p = 0.019]. Transfer rate in neonatology and neonatal distress was 31.2 %.The term of birth [ before 34 weeks], low birth weight [= 1500 g], and twin-to-twin delivery time interval [ >/= 15 min] are parameters that influenced significantly the rate of neonatal distress and transfer to pediatric health care unit [p <0.001, p<0.001, p = 0.004]. We found a significant increase in the transfer to pediatrics when the birth weight difference was larger than 25% [p = 0.005]. However, no significant difference was found concerning the neonatal respiratory distress [p = 0.22]. The different modes of delivery and the type of presentation of the second twin did not significantly alter the rate of neonatal respiratory distress [p = 0.28, p = 0.53] and transfer Pediatrics [p = 0,63, p = 0.38 ]. Among the live births, 5 twins had died in labor room: 1st twin in two cases and in 2nd twin in 3 cases and there was no significant correlation between neonatal mortality and the twin's order [p = 0.629]

Conclusion: A term = 34 weeks, a low birth weight = 1500g and a delay of more than 15 mn were factors that influenced significantly the Apgar score at 1st and 5th minute, and were responsible for more neonatal distress and transfer in pediatrics. A birth weight difference larger than 25% between the two twins influenced the Apgar score at the first minute and was responsible for an increase in the transfer rate

[Management of ovarian endometriomas: intraperitoneal cystectomy versus fenestration and coagulation]

Ovarian endometriomas is a common condition among women of reproductive age and represents a major cost in terms of public health. Despite these implications for public health, it remains difficult to arrive at a consensus on the optimal surgical treatment. To study the clinical and paraclinical characteristics of this pathology and to compare two major surgical techniques: the intraperitoneal cystectomy and fenestration -coagulation in terms of recurrence and prognosis for future fertility. A retrospective study of 31 patients who underwent surgical treatment for ovarian endometrioma histologically proved. The study period covers 10 years from January 2000 to December 2009. Laparoscopy was performed in 27 patients. The endometrioma was located to the left side in 64% of cases. The main strategy performed is intraperitoneal cystectomy in 18 patients [58.8%]. In second place we find the fenestration-coagulation. The mean duration of postoperative follow-up is 10.3 months. The recurrence of the cyst and the persistence of pain symptoms were significantly less frequent in the group of patients who underwent intraperitoneal cystectomy. The laparoscopic surgery remains the first line approach in terms of ovarian endometrioma.Cystectomy offers performance equal or superior to the fenestration-coagulation technique, and exposes to fewer recurrences. For these reasons, it should be recommended. The fenestration-coagulation is possible in case the cystectomy is difficult or incomplete

[Delivery in breech presentation: what way should we choose?]

The breech delivery is considered dangerous because of the higher rates of perinatal mortality and morbidity which become attached to it, consequences of obstetric traumas bound to the obstetric operations. What way of delivery is it necessary to privilege? What are the arguments which we have to support our choice? To assess the maternal and fetal outcome according to the way of delivery. In this retrospective study, 194 women with a singleton pregnancy in a breech presentation delivered at term in our maternity unit in Ariana's Hospital from January 2007 to December 2009. Breech presentation was noticed in 2, 59%. The main factors favoring this presentation are: the primipara, the uterine deformations, the pathological ponds, the abnormalities of the amniotic liquid, the fetal weight and the fetal deformations. Vaginal delivery was accepted in 57,7% of women and 75% from them delivered in natural way. The rate of caesarians was 56,7 %. Among these patients, 74, 5 % were indications in a cold caesarian [scar womb, pathological pond, RPM > 12 hours, estimated [esteemed] fetal weight > 3800g]. The Apgar's score was superior to seven in 97.6% of cases. There was no significant difference in fetal morbidity, Apgar's score or in the need of transfer in intensive care unit. When the acceptance conditions of the vaginal delivery are combined and when the surveillance of the labour is rigorous, it seems that there is no excess of neonatal risk by the natural ways

[Cervical incompetence: diagnosis ; indications and strapping outcome]

Cervical incompetence, a major cause of late abortions and preterm delivery is a diagnosis increasingly easy to establish.Strapping is deemed effective to prevent recurrence of such accidents midwifery. To evaluate the relevance of the diagnosis of cervical incompetence, check the main indications of banding and study the outcome of rimmed pregnancies. A retrospective study about 103 rimmed pregnancies collected in the service of Motherhood Hospital Mahmoud El Matri Ariana to the period of January 2001 until December 2008. The diagnosis of cervical incompetence is suspected in a body of evidence linking ATCD of late abortions or premature births found in respectively 46.2% and 31.1% of our patients in our series, 16.98% are carriers of known uterine defects. 8.49% are classified as high risk front of 3-ATCD of late abortions or preterm delivery and were circled systematically. 2.83% are rimmed after confirmation the incompetent cervix by calibration of the cervix and 55.99% because of clinically short cervix. The strapping has reduced the rate of late abortion which decreased from 46.6% before strapping to 7.6% after. As for preterm delivery, it is reduced from 31.1% before strapping to 18.5% after. This difference is statistically significant. The average term of confinement in our series is 36SA six days. 68 cases were delivered at term. Among patients in whom we have accepted the vaginal delivery, 74.2% had spontaneous labor. One case of rupture of the anterior lip of the cervix was noted. The indication of a cervical strapping needs a well established diagnosis involving data from history, clinical examination and possibly endo-vaginal ultrasound to confirm the high-risk of cervical incompetence. The strapping participates significantly to prolong the duration of pregnancy, to lower rates of early major premature and to improve the chance of viability and prognosis of fetuses without serious repercussions on the workflow

Maternal and fetal outcomes of large fetus delivery: a comparative study

To review the deliveries of macrosomic babies, weighing over than 4000g and their obstetrical and neonatal outcomes. Retrospective study involving a total of 209 deliveries at term of macrosomic babies between Marsh 2006 and February 2007 in the Maternity Hospital of Mahmoud ELMATRI, Tunis. The study concerned risk factors, mode of delivery and the incidence of maternal and perinatal complications.We compared data in the study group to a control group of normal weight infants delivered at the same period. Macrosomia occurred in 9.2% of all deliveries. The main risk factors of macrosomia were maternal age over 30 years [p=0,017], multiparty [p<0.001], diabetes mellitus [p=0.012] and prolonged term of delivery [p=0.02]. These risk factors were statistically significant compared to control group. Caesarian delivery was achieved in 24.4% in macrosomy group and in 13.7% in control group [p=0,003] the major part occurred during labor. Among vaginal deliveries in macrosomia group, shoulder dystocia was noted in 1,9%, fetal respiratory failure and admission in intensive care unit was noted in 4,8% of the cases and hypoglycemia complicated 15,8% of deliveries. Maternal complications were dominated by post partum hemorrhage documented in 1.2% of the cases and perineal tears noted in 8,2% of vaginal deliveries.Vaginal delivery is the most frequent mode of delivery for a fetus weighing in excess of 4 kg and vaginal delivery should be attempted in the absence of contraindications and there is no need for elective systematic caesarian. However, shoulder dystocia remains the main complication of vaginal delivery for macrosomic fetuses and requires experienced obstetricians to manage these deliveriesbetter, other tests are requiring: magnetic resonance imaging and Tc-Squid biosusceptometers

[Unexpected diagnosis of a cystic pelvic mass: benign mesothelioma of the uterus: case report]

Benign mesothelioma is a rare tumour mostly found in the genital tract. We report the case of 30- years old woman presenting pelvic pain. The ultrasound scan revealed a cystic pelvic mass. Laparoscopic exploration showed a uterine posterior formation. The resection of the dome was performed. Histologic exam and immunochemistry concluded to a benign cystic mesothelioma. The benign mesothemioma of the uterus is usually discovered in histology, differential diagnosis of the uterus is usually discovered in histology, differential diagnosis for solid forms can be made with leiomyoma or adenomyoma, whereas the cystic forms can be discussed essentially with the ovarian cysts. The presence of mesothelial immunophenotype in immunochemistry improves diagnosis. Clinical outcome is always favourable without recurrence or malignant transformation

First trimester diagnosis of Pallister-Killian syndrome in a fetus with suggestive abnormalities

Pallister-Killian Syndrome is a rare, sporadic chromosomal disorder characterized by a tetrasomy 12p often in mosaic. It is only in 2000 that the first case of PKS was diagnosed in the first trimester further to an increased nuchal translucency. Report a new case. To our knowledge, we present the first case of early prenatal diagnosis of Pallister Killian Syndrome due to the presence of an increased nuchal translucency, a diaphragmatic hernia, a typical facial dysmorphism and a micromelia of a predominantly rhizomelic type. A chorionic cells biopsy showed a normal karyotype. The diagnosis was revealed on cytogenetic analysis of amniotic fluid sampling. The main ultrasound indicators of PKS seem to be: Hydramnios, congenital diaphragmatic hernia [CDH] and a micromelia of a rhizomelic type. The hydrops fetalis, hygroma coli or increased nuchal translucency [INT], fetal overgrowth, ventriculomegaly and presence of a sacral appendix are less common. The amniocentesis with the study of the karyotype on amniotic cells is considered to be the gold standard for the diagnosis of PKS. A good morphological study during the first trimester in search of ultrasound abnormalities highly suggestive of PKS is able to direct the cytogenetic study

[Immature t eratoma of the ovary and pregnancy]

Composing of less than 1%of all ovarian cancers, immature teratoma is a malignancy that mainly affects the young. Immature teratoma of the ovary together with pregnancy is rare. To nor knowledge, this association was reported only in twelve cases. We Report two cases of immature teratoma of the ovary diagnosed during pregnancy and their respective issue. Observation 1st case. A 28 years old woman gravida 1 with an immature teratoma of the ovary discovered during delivery by caesarean section. The treatment was conservative including salpingo-oophorectomy, omentectomy. aortic lymph node dissection and appendectomy. This patient had a second pregnancy with a good outcome. She delivered by cacsarean section in order to perform radical treatment: hysterectomy and oophorectomy of the remaining ovary. 2nd case. A 22 years old woman gravida I with adnexal mass diagnosed during an ultrasonography exam at 15 weeks gestation. A conservative treatment was indicated, including salpingo oophorectomy, omentectomy, aortic lymph node dissection, appendectomy and biopsy of the resnaining ovary. The patient bad a normal vaginal delivery. Immature teratoma is graded from 1 to 3. The management of this association is discussed, but it takes in consideration the surgical staging, the grade and the secretion of alpha FP. Conservative treatment without associating chemotherapy can be tempted in tumours with a stade Al and a low grade

[Prenatal diagnosis and management of fetal megacystis]

Prenatal diagnosis of fetal megacystis particularly in the first trimester requires assessement of pronostic and aetiotogycal criteria. Report anew case we report a case of severe megscystis in female fetus diagnosed at 23 weeks of gestation. There are no other associated ultrasound findings. Fetal karyotyping was normal [46XX]. Termination of pregnancy for medical indications was realised because of progressive enlargement of the fetal bladder. Post-mortem examination showis megacystismicrocolon-in testinal hypoperistalsis syndrome. Fetal megacystis is a severe condition when diagnosed early in pregnancy. Ultrasonography follow-up and fetal karyotyping are important to evaluate prognosis

[Polycystic ovary syndrome with infertility]

The definition of the polycystic ovary syndrome has been controversial for a long time. Rotterdam consensus established precise criteria since two among three set the definition as follow: anovulation, hyperandrogenism and polycystic ovaries. of this study is to stress on the particularity of ovarian dystrophy and the management of the resulting infertility that represents an important rate of medical counselling of women desiring pregnancy. Literature review. Management consists in two parts: treating hyperinsulinism and stimulating ovulation. The "step up low done" protocole is now taking the place of the classical "step down" protocole. Ovarian drilling have to be considered in case of resistance to Citarate of Clomifen. The hyperstimulation syndrome is the common complication to avoid by a regular following. The "coasting" represents an interesting alternative in case of an explosive response in order to obtain a controlled follicular failure. Clinical management of the PCOS have to be organized in regard to patient's age, history, desire of pregnancy and medical staff experience