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

[Prospective study of the relationship between heart rate fetal anomalies, pH umbilical cord at birth and Apgar]

The search for an acute fetal distress during labor remains one of the objectives of obstetrical surveillance. To find a relationship between different aspects of fetal heart rate [FHR] occurring during labor, Apgar score at first minute and the pH blood at birth. A prospective study which involved 170 single-fetal pregnancies to term. In our population, by comparing the APGAR score in the first minute and umbilical pH, it was found that only 25.7% of newborns with Apgar at 1st minute less than 7 had an umbilical arterial pH <7.15. Thus in our study, the Apgar score did not predict umbilical acidosis and the difference was significant [p = 0.02]. In the same population, by comparing the analysis of FCR and umbilical PH, we found that fetal bradycardia was associated with pH umbilical lowest with an average of 7008 and the difference was significant [p = 0.008]. Other types of ERCF were also significantly associated with neonatal acidosis. Recording fetal heart rate is a limited review to assess the exact condition of the fetus. It has a good negative predictive value but there is little specific consideration. Combination with other techniques to better assess the fetal state

[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

[Sexuality and contraception: a prospective study about 85 cases]

Contraception opposing procreation interferes with the primary purpose of sexuality. Few studies have yet been made on the actual interaction between contraception and sexuality. To study contraceptive practices is non medicalized contraception and oral contraception, study aspects of women's sexuality and to study the physiological impact and psychological contraception on women's sexuality. Prospective and analytical study conducted over a period spanning from October 2008 to February 2009. This study was based on a survey, carried out through an oral questionnaire to 85 women in reproductive age, married, with contraceptive-based pill or natural birth control for at least one cycle, having experienced during their personal background a sexuality contraception or at least one contraceptive method other than its current average. Comparison between the group of women using oral contraception and women not using contraception medicalized showed significant differences in outcomes relating to: the average frequency of intercourse / month [p = 0.01], sexual desire [p = 0.01], sexual pleasure [p = 0.03]. The comparison of the different parameters of sexuality among the group of women using intra uterine device and women using oral contraceptives showed no significant differences in the parameters of sexuality. The awareness of the big importance of the interaction between sexuality and contraception, in one way or another, could help us tailor our applications to contraceptive practices of each woman

[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

[Cervical ripening at term. a randomized and prospective study: Misoprotol versus dinoprostone]

To compare the efficacy and safety of cervical ripening at term by vaginal Misoprostol and Dinoprostone. We performed a prospective randomized study on cervical ripening with misoprostol and dinoprostone in the third trimester of pregnancy. 300 patients have been divided into two groups: one consisted by 150 patients who received Misoprostol [Cytotec registered] and the second consisted by 150 patients who received Dinoprostone [Pr‚pidil registered]. Analysis of our results allowed to reveal: a significant decrease in the time of entry into work for the Misoprostol group [9.08 hours versus 12.51 hours, p = 0.007], a significant reduction delivery time [14.48 hours versus 19.30 hours, p = 0.001]. Moreover, the birth rate in the first 24 hours after the first dose was significantly higher in the Misoprostol group [86.7% versus 72.7%, p = 0.003]. The use of oxytocin was significantly reduced with Misoprostol [44% versus 58.7%, p = 0.01]. The mode of delivery was not influenced by membership in one or other of the two groups. Misoprostol seems an interesting molecule for cervical ripening and labor induction

[Ligation of internal iliac arteries for sever hemorrhage in obstetric]

To assess the efficiency of arteries ligation in intractable obstetrical hemorrhage. Prospective study which concerned 53 patients who underwent internal iliac arteries ligation for persistent and severe obstetrical hemorrhage from January 2007 to June 2010. The average age of patients was 29.3 years. The mean parity was 2.2. Main etiology of hemorrhage were: uterine atony [62.2%], abruptio placentae [15.1%]. Coagulation disorders and hypovolemic shock were observed respectively in 20.7% and 37.7%. Blood transfusion was performed in all cases. Internal iliac arteries ligation allowed hemorrhage control in 90.5% of cases. In five cases a hysterectomy was necessary to control bleeding.. No peroperative complication were observed. Internal iliac arteries ligation is a prerequisite treatment of severe postpartum hemorrhage. It is a good alternative to arterial embolization

[Emergency peripartum hysterectomy: indications and prognosis]

Detect the risk factors, indications and maternel morbidity of haemostatic hysterectomy. A retrospective study of 46 women who had haemostatic hysterectomy between 2005 and 2009. The mean age was 33.3 years. The mean parity was 3.5. 35% of patients had a previous cesarean section. The mode of delivery was: vaginal delivery [47.8%], cesarean delivery [52.2%]. The hysterectomy was subtotal in 39 cases [85%]. The indications of haemostatic hysterectomy was: uterine inertia [44%], disseminated intravascular coagulation [26%], placenta accreta [8.7%], Placenta praevia [13%], uterine rupture [8.7%]. Three patients were dead. Five patients had a depression. Six patients had a dyspareunia. Five patients had a decrease of sexual desire. Haemostatic hysterectomy is a multilating surgery giving an irreversible infertility. The development of arterial embolization avoid the appeal to this surgery

[Prospective study about 45 cases of disseminated intravascular coagulation]

Disseminated intravascular coagulation [DIC] in obstetric disorders is a severe complication. To study the frequency and means of diagnosis of DIC and the therapeutic care and maternal morbidity induced. Monocentric, prospective and descriptive study about 45 cases of intravascular coagulation in an obstetrical service collected at the University Hospital of Obstetrics and Gynecology Hedi Chaker of Sfax over a period ranging from June 2007 to June 2010. All the pregnant patients who have given birth beyond 28 weeks and have presented a DIC were selected for this study. The mean age of patients was 31.4 years. The mean parity was 2.6. The main diseases during pregnancy were: severe preeclampsia [22.2%], diabetes [28.8%], intrauterine fetal death [17.7%], previa placenta [8.8%]. The main causes of DIC were: uterine atony [44.4%], abruptio placenta [22.2%], Hellp syndrome [11.1%] and uterine rupture [6, 6%]. The lowest rate of platelets was 21000/mm3. The fibrinogen level was <0.5 g in 40% of cases. Despite reanimation and transfusion with blood products, surgical treatment was necessary in 77.7% of cases. All the patients were transferred in intensive care unit with an average stay of about three days. No maternal death was reported. DIC is a frequent complication of many obstetrical diseases. The treatment is urgent. It requires first to the cause and the shock by massive transfusions of packed red blood cells, fresh frozen plasma, and platelets, associated with antifibrinolytic drugs, if 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

[Genital prolapse in young women: a study of risk factors]

To determine the risk factors for genital prolapse in a group of 33 young women less than 45 years old. We studied 33 young women who had been operated for genital prolapse, whereas the control group consisted of women operated for benign gynaecologic disorders. In the study group the number of pregnancies and deliveries, the babies'weight, the positive family history of prolapse were heavier than in the control group. The women with prolapse had more often chronic pulmonary diseases, asthma, as well as operations for abdominal hernias. The mode of delivery, be it a cesarean section or the use of forceps, and the active second stage of labor had no effect whatever on the occurring of genital prolapse in young women. Our data support the suggestion that multiparity, babies weight and congenital factors are responsible for a higher rate of genital prolapse in young women

[Confrontation ultrasonography-cal25-histology in the managment of ovarian cysts: a prospective study about 77 cases]

To study the correlation between ultrasound, Doppler,measurement of CA 125 and histology in the preoperative diagnosis of ovarian cysts. Prospective and analytical study about 77 patients in whom we analyzed the contribution of ultrasound, the assay of CA125, the couple CA125 ultrasonography and laparoscopy in the diagnosis and management of cysts the ovary. The value of CA125 was considered pathological like the one adopted by our biochemistry laboratory of the CHU Habib Bourguiba, Sfax [> 35 UI / ml]. The mean age was 35.6 years. On the whole, ultrasound has a sensitivity of 71.41% and a specificity of 80%. The positive predictive value was 35.71% and negative predictive value was 96.55%. The sensitivity of CA125 to detect malignant lesions among ovarian cysts was 85.71% and a specificity of 85.93%. The PPV was low [42.85%]. The combination Ultrasound-CA125 had a sensitivity of 85.7%, a specificity of 82.8%, a PPV and NPV respectively 35.3% and 98.1%. The concordance between the macroscopic perlaparoscopic and histological diagnosis of different tumors was 83.3% for functional cysts, 77.7% for serous cysts, and 100% for dermoid cysts, endometriosis and bleeding. The contribution of Doppler ultrasound and tumor markers is essential in the diagnosis of ovarian cysts

[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