Diagnostic and therapeutic challenges of a rare large ovarian strumal carcinoid in pregnancy, about a case report.

INTRODUCTION: Ovarian strumal carcinoid is a rare type of germ cell tumor. It usually affects perimenopausal and postmenopausal women. Very few cases of stromal carcinoid have been reported in the literature in women of childbearing age, particularly during pregnancy. The clinical presentation of the tumor, and in particular its non-specific clinical and radiological appearance and rarity, explain the difficulties in diagnosis and management. PRESENTATION OF CASE: Herein, we describe a rare case of a 36-year-old patient who was followed-up in our outpatient clinic for organic cyst of the ovary. The ultrasound revealed a multilocular regular cystic mass with a modestly thickened wall and fine septations. The MRI indicated a right ovarian cyst with solid tissue. The levels of tumor markers were normal. The patient was lost to follow-up and did not return until six months later. She was admitted in our Department with acute ovarian torsion and underwent emergency surgery at 17 weeks' gestation. A laparoscopic cystectomy of the right ovary was provisionally performed. Pathology revealed an ovarian strumal carcinoid tumor. DISCUSSION: Patients with ovarian stromal carcinoid have an excellent prognosis. Ovarian strumal carcinoid 's primary therapy method is operation. The majority of original ovarian carcinoid tumors progress slowly, and practically all thyroid carcinoid tumors are clinical stage I with a positive prognosis. CONCLUSION: In the absence of standardized treatment, the association of carcinoid strumal tumor with pregnancy, underlines the need for early diagnosis and appropriate multidisciplinary management, taking into account both the maternal and fetal prognosis.

Cornual Pregnancy: Results of a Single-Center Retrospective Experience and Systematic Review on Reproductive Outcomes.

Background and Objectives: Cornual pregnancies (CPs) are rare forms of ectopic pregnancy. When abortion does not occur, it can be a life-threatening condition for the mother and can also impair future fertility. We present our experience in the diagnosis and management of CPs. A systematic review was also conducted to investigate the reproductive outcomes after treatment. Materials and Methods: Between January 2010 and December 2022, we performed a retrospective, cross-sectional, single-center, and descriptive data collection and analysis (ClinicalTrial ID: NCT06165770). The search for suitable articles published in English was carried out using the following databases (PROSPERO ID: CRD42023484909): MEDLINE, EMBASE, Global Health, The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and Cochrane Methodology Register), Health Technology Assessment Database, Web of Science, and search register such as ClinicalTrial. Only studies describing the impact of CP treatment on fertility were selected. Results: Two studies were included in the systematic review. Seventeen patients suffering from CPs were selected. In our series, a pelvic ultrasound allowed for the diagnosis of a cornual localization in 35.30% of cases. Thirteen women (76.47%) underwent immediate surgical management. The laparoscopic approach was the most used (76.92%), with a laparotomic conversion rate of 30%. Four patients (23.52%) received medical treatment with methotrexate. After treatment, two patients managed to achieve pregnancy. Conclusions: CP is a rare form of ectopic pregnancy that can quickly become life-threatening for the mother. Ultrasound does not lead to a precise diagnosis in all cases. In the absence of complications and emergencies, laparoscopy is an approach that could be considered valid. For selected asymptomatic patients, medical treatment may be a valid alternative. The data from the studies included in the systematic review, although demonstrating a superiority of medical treatment in terms of future pregnancies, are heterogeneous and do not allow us to reach a definitive conclusion.

A non-pregnant woman with elevated beta-HCG: A rare case of ovarian seminoma.

INTRODUCTION: Ovarian seminoma is a rare germ cell tumor that typically affects young women. Early diagnosis of malignant tumors, although difficult due to mild symptoms, is crucial for a better prognosis. Here we report the case of a 15-year-old female patient with a large malignant ovarian dysgerminoma to provide a comprehensive overview of the diagnosis and management of this pathology and to help practitioners make an early diagnosis. CASE PRESENTATION: A 15-year-old patient with no significant past medical history presented to the Obstetrics and Gynecology emergency D in Tunisia with subacute abdominal pain, fever, and unexplained weight loss. Diagnostic evaluation revealed a large, solid ovarian mass with elevated CA-125 levels, and the patient subsequently underwent right adnexectomy with peritoneal cytology. Histopathological analysis confirmed the diagnosis of dysgerminoma with peritoneal involvement, resulting in a FIGO IC and TNM T1C classification, and the patient received fertility-sparing polychemotherapy with satisfactory progression. DISCUSSION: Ovarian seminoma mainly affects young women and can be associated with a variety of risk factors. Clinical signs are variable and can be difficult to detect at an early stage. Imaging techniques can help with diagnosis. Tumor markers may be elevated, but histological confirmation is needed. Treatment usually consists of a combination of surgery and chemotherapy, with good long-term survival rates. CONCLUSION: Seminomas are rare tumors and early detection is crucial for a better prognosis. This requires close attention to risk factors and regular gynecological examinations from an early age in patients with these risk factors.

Secondary postpartum hemorrhage due to uterine scar dehiscence, a case report.

INTRODUCTION: Secondary postpartum hemorrhage is rare. The most common cause is retained placenta. Having a uterine scar dehiscence as an etiology is unusual. Complete dehiscence of the uterine scar is even rarer. This rare but serious cause of post-partum haemorrhage can be potentially life threatening due to severe hemorrhage if not managed in adequate time. PRESENTATION OF CASE: We present the case of a 35-year-old patient, gravida 2 para 2. She had undergone two caesarean sections in our department and, after the last one in March 2021, she presented twice to our emergency department with relatively abundant metrorrhagia, but neither the clinical nor the radiological examinations revealed any abnormalities. At 43 days postpartum, she presented to the emergency with severe bleeding per vaginum. The bleeding was profuse, causing hemodynamic instability and severe acute anaemia. An explorative laparotomy was necessary to diagnose the etiology and manage the treatment. Surgical exploration revealed a lateral uterine rupture in the broad ligament and complete dislocation of the caesarean scar. An urgent hysterectomy was performed. DISCUSSION: Partial or complete dehiscence of the hysterorrhoea is a rare cause of secondary postpartum hemorrhage after caesarean section. When hysterorrhaphy dehiscence does occur, the origin of the bleeding is likely to be related to erosion of the vessels at the incision angles. CONCLUSION: The diagnosis of partial or complete dehiscence of the uterine scar may be misleading in the absence of specific clinical or radiological signs. This condition must therefore be considered and suspected in cases of secondary postpartum hemorrhage.

The pentalogy of Cantrell: A rare and challenging prenatal diagnosis.

INTRODUCTION: The sternum, pericardium, diaphragm, abdominal wall, and heart are all affected by the unusual congenital condition known as Cantrell pentalogy. It is a rare congenital disorder that requires multidisciplinary care. Early diagnosis and appropriate management are crucial for improving outcomes in affected individuals. To illustrate the difficulties and complexity of Cantrell pentalogy, we provide two cases. PRESENTATION OF CASE: In case 1, a routine antenatal scan at 12 weeks' gestation revealed thoracoabdominal ectopia cordis in a 29-year-old woman. The pregnancy was terminated medically due to the severity of the anomalies and the poor prognosis. A 32-year-old patient in case 2 had a diaphragmatic hernia, thoracoabdominal ectopia cordis and midline abdominal wall abnormalities. After counselling, a medical termination was chosen. The ultra-sonographic features were confirmed by autopsy results in 2 cases. DISCUSSION: Early diagnosis is feasible in the first trimester if ectopia cordis and omphalocele exist. Additionally, development in ultrasound technology provides us with better visualization and early diagnosis. With patients who have fully developed Cantrell syndrome and those who also have accompanying anomalies, the prognosis is often poor, with short survival and quality of life. CONCLUSIONS: Cantrell pentalogy is a rather uncommon congenital condition. Early detection is possible in the first trimester. The severity of the illness varies greatly, and treatment is determined by the precise abnormalities present. Early diagnosis necessitates adequate initial training as well as ongoing in-service training for sonographers. Early detection and treatment are critical for improving outcomes in affected persons.

Ovarian fibrosarcoma: Diagnostic challenges and treatment options, a case report.

INTRODUCTION: Ovarian fibrosarcoma is a rare cancer. In the literature, there have been very few occurrences of fibrosarcoma with ascites. The presence of ascites complicates the diagnosis further, and is associated with a poor prognosis and has been linked to chemoresistance and metastasis. We present this case of an ovarian fibrosarcoma with ascites to provide a comprehensive overview of the clinical presentation, diagnostic evaluation and management of this pathology, which remains a challenge given the rarity of this entity. PRESENTATION OF CASE: We report the case of a 60-year-old woman who was referred to our unit, because of abdominal bloating, sporadic pelvic pain and abdominal distension. Ultrasound showed a heterogeneous mass over the right adnexa with ascites. Serum tumour markers were within normal limits. During surgery, a total abdominal hysterectomy plus bilateral adnexectomy was performed. The final histopathological findings showed a well-differentiated fibrosarcoma. The patient was followed up regularly and no recurrence was seen 2 years after surgery. DISCUSSION: Ovarian fibrosarcomas are uncommon cancers with no known risk factors. Diagnosis can be difficult, especially in the presence of ascites, and other diagnostic options should be considered. Pathological and immunohistochemistry investigations are required for a clear diagnosis. Early metastases and resistance to adjuvant chemotherapy characterize the prognosis of ovarian fibrosarcoma with ascites. CONCLUSIONS: Ovarian fibrosarcoma with ascites is a rare and challenging ovarian disease, highlighting the need for postoperative pathology to make a clear diagnosis, complete cytoreductive surgery and individual consideration of adjuvant radiochemotherapy should be included in the management.

Fetopathological examination for the fetuses with Down syndrome in Tunisia: Epidemiological study and associated malformations.

BACKGROUND: For Down syndrome (DS), traditional epidemiological studies to determine the prevalence, cause, and clinical significance of the syndrome have been conducted over the last 100 years. In Tunisia, the current work is the first in-depth study in epidemiology of DS from fetopathological data. AIM OF THE STUDY: The aim of this epidemiological study was to determine the impact of some feto-maternal characteristics in occurrence of DS and to search the frequency of associated congenital malformations with this syndrome. METHODS: Our retrospective study was realized for 144 fetuses with DS among 9321 autopsied fetuses in embryo-fetopathological service between 1994 and 2011. RESULTS: In our study, the majority of mothers (72.91%) were 35 years and older, with a statistically significant difference (p<10-6, OR=16.7, CI=8.7-32.4). The abnormalities of extremities (31%) were the most common fetal abnormalities followed by facial (23.51%) and digestive abnormalities (19.63%). CONCLUSION: One of the main conclusions of this research is that the most common risk factor for DS is maternal age. On the other hand, the type and the frequency of associated congenital anomalies with DS are still controversial.

Vulvar cancer in Tunisia: Epidemiological and clinicopathological features multicentric study.

OBJECTIVE: To describe for the first time the epidemiologic and clinico-pathologic characteristics of vulvar cancer in Tunisia. DESIGN: Two parts are distinguished in this study: Part1: Multicentric retrospective study about the characteristics of all cancer cases diagnosed during a 17-years period (January 1998-December 2014) in three departments of Gynecology and Obstetrics: one in south Tunisia and two in the capital. Part 2: To determine the Incidence trend of invasive vulvar cancer in North Tunisia 1994-2009, on the basis of North Cancer Registry of Tunisia. RESULTS: A total of 76 cases of vulvar cancer were recorded. The median age at diagnosis was 65.4years and 86.9% of patients were more than 55years old. The symptomatology was dominated by vulvar pruritus in 48.7%. The average size of the tumor was 3.96cm. Stage III was the most frequent (53.7%) followed by stage II (28.3%). Only 10.4% of tumors were at stage I. The most common histologic type of vulvar malignancy was squamous cell carcinoma (SCC) (94.7%). Standardized incidence varied from 1.2/100 000 (1994) to 0.5/100 000 (2009). There was significant decrease of Standardized incidence (APC of -8.8% per year, 95% CI: -5.5%, -9.0%-p<0.001). CONCLUSION: Vulvar cancer in Tunisia is a rare disease, occurs mostly in elderly women, and is diagnosed at advanced stages. Our findings emphasize that a greater effort should be made to facilitate early diagnosis, as treatment in earlier stages is less extensive and potentially curative.

Spontaneous subserosal venous rupture overlying a uterine leiomyoma in a young woman.

Uterine leiomyomas are very common tumors found in women. Rupture of veins on the surface of uterine leiomyoma is an unusual source of hemoperitoneum. It is an extremely uncommon gynaecological cause of hemoperitoneum. It is a life threatening emergency. We report a case of massive intraperitoneal hemorrhage due to rupture of vessels on the surface of subserous leiomyoma. A differential diagnosis of rupture of leiomyoma'ssurface vessel should be considered, while dealing with a case of hemoperitoneum with pelvic mass.

How to adapt first trimester ultrasound education to Tunisian trainees.

OBJECTIVES: To evaluate the impact of a targeted training program on the quality of NT measures performed by OBST/GYN trainees. METHODS: Prospective study. Step1: each trainee achieved 10 T1US . All were evaluated by 2 experts. Step 2: interactive training session where participants received a detailed feedback report. Step3: each candidate performed again 10 T1US. The results obtained before and after the training session were compared. RESULTS: Step1: Herman score was 4.1 with 38% of unacceptable exams. There was no correlation between the score and the level of the training curriculum. Main difficulty was about obtaining sagittal plane. Step2: self-assigned score before the session overestimated image quality (4.5 Vs. 4.1, p=0.03). At the end of the session, It decreased to 3.1. Step3: a significant improvement of technical settings, mean score (5.4 Vs. 4.1; p <0.001) , percentage of acceptable images (85% Vs. 62%, p = 0.002) and sagittal plane (6.4% Vs. 2.9%; p = 0.003). Only 37% had significantly improved their scores. CONCLUSION: The training program evaluated in this study guides the trainee in his daily self-evaluation. This preliminary study can already open discussion on the education and quality control of the T1US in our country.

[The contribution of ultrasonography in the exploration of postmenopausal metrorrhagias]. / L'apport de l'échographie dans l'exploration des métrorragies post-ménopausiques.

Post-menopausal metrorrhagias represent a frequent reason for consultation in gynecology. Our study aims to evaluate the contribution of pelvic ultrasonography in the exploration of endocavitary lesions in people experiencing this symptom and to compare the results found with those of hysteroscopy and histology. This was an analytic retrospective study of 33 cases referred for evaluation of postmenopausal metrorrhagias at the department of gynecology and obstetrics «A¼ in the Center of Maternity and Neonatology of Tunis in 2012. All patients underwent pelvic ultrasonography and diagnostic hysteroscopy. We analyzed and compare the data obtained with pelvic ultrasonography, hysteroscopy and histological examination. The average age of our patients was 57.78 years and the average age of menopause was 48.36 years. The confrontation between ultrasonographic and histological data showed that ultrasonography has a sensitivity of 80.6%, a specificity of 79.38%, positive predictive value (PPV) of 67.03% and negative predictive value (NPV) of 91.54%. With respect to hysteroscopy these values were 84,44%, 82,72%, 69,93% and 92,65% respectively. Performance level for each exploratory diagnostic tool varied according to the lesion which caused metrorrhagias and generally hysteroscopy was more reliable in the exploration of metrorrhagias than ultrasonography: Youden index 0.67 against 0.59. Our results confirmed data published in the literature that assigns to hysteroscopy a greater reliability compared to pelvic ultrasonography in the diagnosis of endocavitary lesions causing postmenopausal metrorrhagias.

Vitamin D Deficiency is Widespread in Tunisian Pregnant Women and Inversely Associated with the Level of Education.

BACKGROUND: Vitamin D deficiency seems to be common in pregnant women and would be associated with an increased risk of maternal and fetal poor outcomes. This study aimed to determine the prevalence and the main risk factors for vitamin D deficiency in pregnant women living in a sun-rich environment. METHODS: A total of 255 pregnant women living in Tunis City (latitude, 36 degrees N) were randomly selected at 12 - 18 weeks of gestation. Plasma 25-hydroxyvitamin D (25-OHD) was assessed by chemiluminescence immunoassay method. A logistic regression model adjusting for confounding variables was used to identify the independent risk factors for vitamin D deficiency. RESULTS: Plasma 25-OHD concentrations ranged from 4.02 to 78.3 nmol/L [median (IQR), 18.0 (13.6)]. More than 96% of the study population had 25-OHD levels below 50 nmol/L with 82.3% of women having vitamin D deficiency (25-OHD < 30 nmol/L) and 31.4% of women having severe vitamin D deficiency (25-OHD < 15 nmol/L). Daily dietary vitamin D intake [median (IQR), 3.49 (2.92) µg] was clearly lower than the recommended dose. Vitamin D deficiency was more frequent during the low-sunshine season, and in veiled women and those with an average level of education. In multivariate analysis, the independent predictors of vitamin D deficiency were low sunshine season [multi-adjusted OR (95% CI), 2.29 (1.24 - 4.22); p < 0.01], covering clothing [OR (95% CI), 2.54 (1.23 - 5.24); p < 0.05], and average level of education [OR (95% CI), 2.11 (1.09 - 5.91); p < 0.05]. CONCLUSIONS: Tunisian pregnant women, especially those with average/high level of education, are exposed to a high risk of vitamin D deficiency. The main causes of hypovitaminosis D are low sunshine exposure and little dietary vitamin D intake. Public health policies should target the awareness for optimal and safe sun exposure and adequate vitamin D dietary intake. Otherwise, tolerable vitamin D supplementation should be prescribed.

Clinical Assessment of Soluble FMS-Like Tyrosine Kinase-1/Placental Growth Factor Ratio for the Diagnostic and the Prognosis of Preeclampsia in the Second Trimester.

BACKGROUND: Preeclampsia is one of the most common and serious complications of pregnancy. Various reports have demonstrated that disturbances in angiogenic and antiangiogenic factors are implicated in its pathogenesis and have possible relevance in its diagnosis and prognosis. METHODS: In this case-control study, we enrolled 73 patients with 34 preeclamptic cases diagnosed according to clinical criteria and dosing of proteinuria. The cases were matched to controls at the same age and parity. Controls had normal tension and no apparent risk factors for preeclampsia. The dosage of PLGF and sFlt - 1 were performed and correlated to the clinical issue of each group. RESULTS: Our results show a significant decrease in PLGF levels in the cases compared to the control group (average PLGF levels in cases 28.3 pg/mL vs. 664.52 pg/mL in controls); p = 0.0006. sFlt-1 level was significantly higher in cases compared to controls. The average sFtl-1 levels in cases was 5780.72 pg/mL vs. 1886.05 pg/mL in controls; p = 0.0008. The (sFlt-1/PLGF) ratio was significantly higher in cases compared to controls (mean ratio of sFlt-1/PLGF cases is 884.12 pg/mL vs. 12.12 pg/mL in controls); p = 0.0002. Patients who developed a complication had a ratio of sFlt-1/PLGF higher than the rest of patients in the severe preeclampsia group (mean ratio of sFlt-1/PLGF 2727 pg/mL vs. 1207.41 pg/mL). The higher the ratio of sFlt1/PLGF, the shorter the period of fetal extraction was (24 hours to a ratio of 2159.16, 48 hours for a ratio of 811.9, more than 48 hours for a ratio of 184). CONCLUSIONS: PLGF and sFtl-1 could allow discrimination of women with normal pregnancies from those at high risk for developing pregnancy complications. Their ratio may have a value for the diagnosis and prediction of pregnancy outcome.

[Which surgical strategy to adopt for the management of postpartum haemorrhage and how to improve the effects of hypogastric arteries ligation?] / Quelle stratégie chirurgicale adopter devant une hémorragie du post-partum et comment améliorer les résultats de la ligature des artères hypogastriques?

The objective were to identify the success factors of bilateral hypogastric arteries ligation and to assess its role in surgical treatment of postpartum hemorrhages. We conducted a retrospective study of all the cases of postpartum hemorrhage requiring surgical treatment between January 2008 and December 2011. The study included 88 patients (0,47% of all births). Uterine atony was the most common etiology (64,8 % of patients). Bilateral ligation of the hypogastric arteries was performed in 81.8% of patients. When surgery was the first choice treatment, its success rate was 66%. This rate was variable depending on the etiology of hemorrhage, the presence or the absence of hemostasis disorders and the time between diagnosis and surgical treatment. In case of uterine atony, the association with a second conservative technique, when the first was inadequate, helped stop the bleeding in 98% of cases. Ligation of hypogastric arteries is an effective surgical technique for the treatment of postpartum hemorrhage. Its success rate has increased thanks to early implementation and to the association with other conservative techniques.

[Breech presentation: Does the decision of vaginal delivery depend on parity?]. / Présentation du siege : La decision de l'accouchement par voie basse depend-t-elle de la parité ?

BACKGROUND: The breech presentation delivery mode is still controversial. The cesarean section is becoming the current trend especially in case of primiparous. AIM: To compare the maternal and fetal prognosis of the breech presentation delivery according to the parity. METHODS: We conducted a retrospective comparative study covering a two years period. Our data was collected from all patients accepted for vaginal delivery of breech presentation into the entree of the labor room. We compared the primiparous group (G1, n=45) to a second group with parity ≥ 2 (G2, n=56) in terms of maternal and fetal prognosis. RESULTS: The two groups were comparable in term of epidemiological profile and labor evolution. The average age was of 28,2 years in the group G1 vs 30,9 years in the group G2. The average term was 37,4 weeks of amenorrhea, comparable between both groups. We did not note statistically significant difference between both groups regarding duration of work shifts. Indeed, the phase of latency had lasted 4,2 hours in the group G1 vs 3,8 hours in the group G2. The active phase had lasted 3,4 hours in the group G1 vs 2,3 hours in the group G2. 71% of the deliveries of the group primipare and 78 % of multipare had taken place in Vermelin. The appeal to a caesarian during the work was necessary to 5 (11,1 %) primipares against 3 (5,3 %) in the group G2. This difference was not significant (p=0,5). We objectified no statistically significant difference in term of foetal prognosis (Apgar 7 in 1 minute: G1 (n=2) vs G2 (n=2) with p=0.82 or of transfer in neonatal resuscitation: G1 (n=5) vs G2 (n 3) with p= 0.28 between both groups. CONCLUSION: We can conclude that the parity is not a significant variable in the vaginal delivery of the breech presentation.

Ovarian vein thrombosis.

Ovarian vein thrombosis (OVT) is a rare cause of abdominal pain that may mimic a surgical abdomen. It is most often diagnosed during the postpartum period. In this report, we present four cases of postoperative ovarian vein thrombosis. The complications of OVT can be significant, and the diagnosis relies on a careful examination of the radiographic findings. It can occur with lower quadrant abdominal pain, especially in the setting of recent pregnancy, abdominal surgery, pelvic inflammatory disease, or malignancy. Diagnosis can be made with confidence using ultrasound, computed tomography or magnetic resonance imaging. Treatment of ovarian vein thrombosis is particularly important in the post-partum patients, with anticoagulation therapy being the current recommendation.

Desmoid tumors: clinical features and treatment options: a case report and a review of literature.

Desmoid tumors are a rare group of locally aggressive, non malignant tumors of fibroblastic origin that can lead to significant morbidity due to local invasion and may even result in a fatal outcome when located around vital organs. Their clinical presentation, biological behavior and natural history can be quite varied and is incompletely understood at the present time. The optimal therapeutic approach depends on various factors, and a multidisciplinary approach is necessary to achieve local control with acceptable morbidity. Despite progress in the understanding of these tumors and the treatment options, local recurrence remains a major problem.