[Delivery in breech presentation: what way should we choose?]. / Présentation de siège: quelle voie d'accouchement choisir?

BACKGROUND: 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? AIM: To assess the maternal and fetal outcome according to the way of delivery. METHODS: 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. RESULTS: 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. CONCLUSION: 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.

Selective salpingography and tubal catheterization in infertile women.

BACKGROUND: Use of selective salpingography (SS) and fallopian tube catheterization (TC) has revolutionized the diagnosis and treatment of proximal tubal infertility. AIM: To evaluate results of women treated for proximal tubal obstruction by selective salpingography and tubal catherization. METHODS: Selective salpingography was performed in women with proximal bilateral tubal obstructions. Follow-up ranged from 4 to 12 months. RESULTS: twelve patients had been shown to have bilateral proximal obstruction of the fallopian tube. After SS/TC, patency was achieved in 8 cases. Spontaneous conceptions occurred in 4 women. CONCLUSION: SS and TC should be used more widely because it is simple and effective in case of proximal tubal blockage.

[Cervical incompetence: diagnosis, indications and cerclage outcome]. / Incompetence cervicale: diagnostic, indications et devenir du cerclage.

BACKGROUND: 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. AIM: To evaluate the relevance of the diagnosis of cervical incompetence, check the main indications of banding and study the outcome of rimmed pregnancies. METHODS: 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. RESULTS: 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. CONCLUSION: 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.

[Ovarian drilling for the treatment of infertility with dystrophic ovaries]. / Place du forage ovarien dans le traitement de l'infertilité liée à la dystrophie ovarienne.

BACKGROUND: Dystrophic ovaries represent the main cause of female infertility in Tunisia. AIM: To assess the contribution of ovarian drilling in the treatment of infertility in patients with ovarian dystrophy. METHODS: A retrospective study of 23 patients with dystrophic ovaries that have benefited through their subfertility of laparoscopic ovarian drilling, in the gynecology-obstetrics hospital Mahmoud EL Matri, Ariana, Tunisia. Our study spans a period of 3 years from January 2004 to December 2006. RESULTS: Among the 23 patients who underwent drilling for clomiphene citrate resistance, 9 have been pregnant. The average age of patients having had a pregnancy after ovarian drilling was 29.6 years, the average delay was 7.1mois. Regarding prognostic factors, only infertility's duration lower than 3 years was predictive of a good result. CONCLUSION: Ovarian drilling is an interesting alternative to induction by FSH for patients with dystrophic ovaries.

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

AIM: To review the deliveries of macrosomic babies, weighing over than 4000g and their obstetrical and neonatal outcomes. METHODS: 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. RESULTS: 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. CONCLUSION: 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 deliveries.

[Immature teratoma of the ovary and pregnancy]. / Tératome Immature De L'ovaire Et Grossesse.

BACKGROUND: 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 our knowledge, this association was reported only in twelve cases. AIM: 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 caesarean section in order to perform radical treatment: hysterectomy and oophorectomy of the remaining ovary. 2nd case. A 22 years old woman gravida 1 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 remaining ovary. The patient had a normal vaginal delivery. CONCLUSION: 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 aFP. Conservative treatment without associating chemotherapy can be tempted in tumours with a stade AI and a low grade.

[Obstetric vesicovaginal fistulas, about 131 cases]. / Les Fistules Vésico-Vaginales D'origine Obstétricale. A propos de 131 cas.

BACKGROUND: Vesicovaginal fistulas are the most frequent type of urogenital fistulas. Obstetrical cause remains the dominant etiology. They still represent a public health problem. Aim : to study epidemiological aspects of obstetric vesico-vaginal fistulas and their management. METHODS: a retrospective multicentric study among 19 hospital departments from February 1982 to January 2007. RESULTS: 131 VVF (92% of urogenital fistulas). The vaginal route for surgical repair was used in 2/3 cases. The mean diameter of the fistula was 11.35 mm. In 122 cases (86.5%), the fistula was unique. IVU findings were normal in 83% cases. All patients had normal renal function apart one who had acute renal failure. 177 interventions were performed (1.37 intervention per patient). CONCLUSION: Our findings suggest a regression in obstetrical VVF. However many efforts on institutional, socioeconomic and obstetrical levels have to be done in order to eradicate this pathology that is of major handicap for women regarding socioeconomic, functional and psychological effects.

[Premature rupture membrane at term with unfavourable cervix]. / Rupture prématurée des membranes à terme sur col défavorable.

BACKGROUND: Between expectant attitude in hospital and labour induction, management of and premature rupture membrane at term stay controversial. AIM: The aim of our study was to evaluate the management rupture of the membranes at term with unfavourable cervix. MATERIAL AND METHODS: We conducted a retrospective study. An expectant delay of 24 hours had been followed by induction labour in women with favourable Bishop. Maturation by prostaglandins E2 (PGE2) was performed in case of unfavourable cervix. We administrate one dose each 24 hours (3 doses maxima). Over, labour induction by ocytocine was started. The prescription of antibioprophylaxis is systematic until delivery. RESULTS: We included 137 patients. 51% of patients had a spontaneous labour during the expectant delay. There was no significant difference in neonatal and maternal morbidity in case of expectant management of premature rupture membrane at term. CONCLUSION: Based on our findings and a review of the literature, an expectative of 24 hours is interesting in case if unfavourable conditions. Prostaglandin E2 maturations can be performed in unfavourable cervixes.

[Prenatal diagnosis and management of fetal megacystis]. / Conduite à tenir devant la découverte anténatale de mégavessie.

BACKGROUND: Prenatal diagnosis of fetal megacystis particularly in the first trimester requires assessement of pronostic and aetiologycal criteria. AIM: Report a new case. CASE: we report a case of severe megacystis 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 shown megacystis-microcolon-intestinal hypoperistalsis syndrome. CONCLUSION: Fetal megacystis is a severe condition when diagnosed early in pregnancy. Ultrasonography follow-up and fetal karyotyping are important to evaluate prognosis.

Gestational trophoblastic disease in Tunisia.

OBJECTIVE: The aim of our study is to evaluate the frequency of the gestational trophoblastic disease (GTD) in Tunisia, and describe its risk factors and clinical presentations. We also precise therapeutic features used in our country and compare them to those proposed in the literature and finally suggest concrete recommendations. METHODS: We studied retrospectively the cases of GTD proved histologically, occurring during the three years (2000-2001-2002) in the departments of genecology obstetrics of Tunisia and the department of medical oncology of the Salah Azaiz Cancer Institute. RESULTS: The frequency of the GTD in Tunisia is 1 per 918 deliveries. The frequency of the CHM (complete hydatiform mole) is estimated to 68.15% of all the cases of GTD and 1 per 1347 deliveries whereas the frequency of the PHM (partial) is estimated to 30.57% and 1 per 3004 deliveries. The mean gestational age at the moment of the diagnosis is of 11.5 week of amenorrhea (WA) for CHM and 11 WA for the PHM. The metrorrhagia is present in 75% of the CHM and 67% of the PHM. Ultrasonography showed a typical snowstorm aspect in 55%. The mean rate of HCG is 162 x 10(3) UI/l. Vacuum aspiration was performed in all the CHM and in 89.5% of the PHM. One patient followed up for PHM was treated by hysterectomy. 21% of the cases were complicated by trophoblastic retention. Two patients were treated by initial chemotherapy for invasive mole and metastatic mole. 84% of the patients reached complete healing. After treatment of the molar pregnancy, two patients (1.27%) recurred. CONCLUSION: Our results suggest some recommendations: In our practice, all abortion products must be addressed to histopathological examination. The patients must be surveyed during at least one year to detect the occurrence of a GTN. The classification and treatment of the GTN must be codified Modem therapy for gestational trophoblastic diseases (GTDs) has resulted in high cure rates while preserving fertility.

[Polycystic ovary syndrome with infertility]. / Syndrome des ovaires polykystiques avec infertilité.

BACKGROUND: 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. The aim 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. METHODS: Literature review. RESULTS: Management consists in two parts: treating hyperinsulinism and stimulating ovulation. The "step up low dose" protocol is now taking the place of the classical "step down" protocol. Ovarian drilling have to be considered in case of resistance to Citrate of Clomifene. 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. CONCLUSION: Clinical management of the PCOS have to be organized in regard to patient's age, history ,desire of pregnancy and medical staff experience.

[Prenatal diagnosis of omphalocele: a report of four cases]. / Diagnostic antenatal de l'omphalocele: a propos de quatre cas.

Fetal omphalocele is a congenital midline defect of the ventral abdominal wall with herniation of abdominal contents into the base of ombilical cord. The prenatal diagnosis of omphalocele by real-time sonography is important for intrauterine and neonatal management and prognosis. The prognosis and mortality rate is determined rather by the presence of serious associated anomalies, such as cardiovascular and chromosomal defects, than by the omphalocele itself. MRI should be used to screen for other associated anomalies. In this report we describe four cases of fetal omphalocele diagnosed by sonography. In one case an MR examination was performed for suspected associated nervous anomalies. Prenatal literature is further reviewed to assess the clinical significance of this finding.