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.

Ultrasound monitoring of cervical length in twin Pregnancies.

BACKGROUND: Preterm delivery is the major cause of adverse outcomes in twin pregnancy.  A shortened cervix at 20-24 weeks of amenorrhea is a good predictor of preterm birth in asymptomatic patients. However, there are no recommendations for serial cervical length measurements for these high risk pregnancies. OBJECTIVES: To evaluate the benefits from monthly cervical length monitoring in asymptomatic twin pregnancies. METHODS: This was a prospective study. We compared two groups of twin pregnancies (groupe 1: patients with a monthly and systematic transvaginal ultrasound measurement of the cervical length and groupe2 : patients without monitoring of cervical length) in terms of premature labor screening, mean gestational age at the diagnosis of preterm labor, time saved by tocolysis in case of preterm labor and  mean gestational age at delivery. RESULTS: Ninety nine twin pregnancies were included: 35 patients had a systematic, monthly cervical length (group1) and 64 women had a traditional prenatal care without monitoring of cervical length (group2). A significant relationship between a cervical length measured between 22 and 24 weeks of amenorrhea inferior to 30 mm and preterm labor with a high specificity (100%) and a high positive predictive value (100%). The sensitivity remains average (45%).A significant benefit was demonstrated through this systematic ultrasound measurement of cervical length for the screening of preterm labor (p=0.018), the time saved by tocolysis (p=0.023), as well as the medium gestational age at birth (p=0.046). CONCLUSION: Serial cervical length measurements seems to be a significant predictor of early preterm birth in asymptomatic twin pregnancies.

Comparison of two oxytocin administration protocols in elective cesarean section: 5 iu versus 10 iu.

Background Although Oxytocin is used systematically during caesarean section, no recommendation precise optimal dose for this indication. The bolus administration of 10 IU intravenously after extraction of the newborn, is accompanied by side effects mainly hemodynamic. Objectives To compare two Oxytocin protocols:  05 IU bolus Vs. 10 IU bolus during Cesarean section by studying their respective effectiveness (effects on uterine tone) and adverse effects. Methods A prospective randomized double-blind study including 87 term parturients for undergoing a C-section under loco regional anesthesia. Parturients were randomized into two groups depending on the injected Oxytocine dose : - Group 1 (n = 43): 10 IU + 25 IU IVD in 500 ml of serum / 3h - Group 2 (n = 44): 5 IU IVD + 25 IU in 500 ml serum / 3h. Results The variation of the heart rate and the incidence of low blood pressure were significantly greater for Group 1. No significant differences between the two groups regarding blood loss was noticed per or postoperatively. The type of digestive side effects were more common in the first group. Conclusion Administration of 5 units of Oxytocin during the scheduled C-sections is effective for uterine tone without superimposed bleeding risk, guarantees better hemodynamic stability and less side effects than the 10 units dose.

Performance of ultrasound fetal weight estimation in twins.

BACKGROUND: Ultrasonography is an essential tool in the management of twin pregnancies. Fetal weight estimation is useful to anticipate neonatal care in case of weight restriction or growth discordance. AIMS: To assess the accuracy of estimated fetal weight (EFW) in twins and to assess the accuracy of sonographic examination to predict birth weight discordance (BWD) and small birth weight (SBW).    Methods : This was  a longitudinal prospective study over a period of one year. We have included 50 twin pregnancies with a first trimester ultrasound calculated term and specified chorionicity. An ultrasound EFW was scheduled for all patients within an interval of 4 days before delivery. We calculated the differences between EFW and BW in terms of absolute difference and percentage error. We studied the correlation and the agreement between EFW and BW. Finally we calculated the sensitivity, the specificity, PPV and NPV of ultrasound in the diagnosis of BWD and SBW. RESULTS: Absolute differences between BWF and BW were similar for the two twins. The relative difference was 7.7% [0-32] for T1 and 8.2% [0-27] for T2. The margin of error was greater than 10% in 38% of the cases for T1 and in 34% of cases for T2. Furthermore, correlation coefficients R1 and R2 for T1 and T2 were close to 1; R 1 =0.87 and  R 2 = 0.89. Linear regression analysis allowed us to calculate the birth weight based on the estimated weight and this according to the following equations: For the first twin BW T1 = 0.846 * EFW 415,57+ T1 For the second twin BW T2 = 65.68 + 0.963 * EFW T2 in 34% of cases for T2. Chorionicity, presentation and gestational age did not affect the estimations. Ultrasonography in the diagnosis of SBW had a sensitivity of 90.32%, a specificity of 76.82%, a (PPV) of 80% and a (VPN) of 87%. The performance of ultrasound in the diagnosis of BWD varied according to the adopted threshold. CONCLUSION: Ultrasound is an effective examination to estimate twins weight. Regarding prenatal diagnosis of birth weight discordance, the relevance of this examination increases with the adopted threshold.

Ultrasound Fetal Weight Estimation: How Accurate Are We Now Under Emergency Conditions?

The primary aim of this study was to evaluate the accuracy of sonographic estimation of fetal weight when performed at due date by first-line sonographers. This was a prospective study including 500 singleton pregnancies. Ultrasound examinations were performed by residents on delivery day. Estimated fetal weights (EFWs) were calculated and compared with the corresponding birth weights. The median absolute difference between EFW and birth weight was 200 g (100-330). This difference was within ±10% in 75.2% of the cases. The median absolute percentage error was 5.53% (2.70%-10.03%). Linear regression analysis revealed a good correlation between EFW and birth weight (r = 0.79, p < 0.0001). According to Bland-Altman analysis, bias was -85.06 g (95% limits of agreement: -663.33 to 494.21). In conclusion, EFWs calculated by residents were as accurate as those calculated by experienced sonographers. Nevertheless, predictive performance remains limited, with a low sensitivity in the diagnosis of macrosomia.

Ultrasound diagnosis of fetal head engagement.

OBJECTIVE: To compare clinical data and transperineal ultrasound results for the diagnosis of fetal head engagement. METHODS: The present prospective longitudinal study enrolled 100 term women attending the Mongi Slim Hospital, La Marsa, Tunisia, between July and September 2012. The clinical assessment of fetal engagement was compared with ultrasound measurements. Ultrasound examination was performed in the delivery room. The probe was placed on the ano-vulvar area. The measure used was the distance between the perineum and external table of fetal skull. RESULTS: The ultrasound measures of the perineum to external table of fetal skull ranged from 13 to 75mm. The measures of the perineum to succedaneum bump ranged from 22 to 68mm. A threshold of 55mm was determined as the perineum to fetal head distance above which a diagnosis of engagement would be reversed. This proposed threshold had a positive predictive value of 98.6%, a sensitivity of 86.7%, and a specificity of 94.1%. CONCLUSION: Transperineal ultrasound is a simple, rapid, and reproducible method for the diagnosis of fetal head engagement. It can be used in the delivery room in addition to clinical examination and when the latter is hampered by a succedaneum bump.

[HELLP syndrome: about 17 cases and literature review]. / Le HELLP syndrome: A propos de 17 cas et revue de la littérature.

BACKGROUND: HELLP syndrome is defined as an association of hemolytic anemia, raised liver enzymes and thrombocytopenia. It is a severe manifestation of pre-eclampsia. AIM: We tried to specify the epidemic factors and the best management of HELLP syndrome Methods: A retrospective study held during 6 years in the department of gynaecology and obstetrics in La Marsa hospital and according to a literature revue. RESULTS: The dominating symptoms included low abdominal pain and vomiting. The syndrome was discovered after 30.5 weeks of amenorrhea on average. Infant extraction was by cesarean section in 11 cases. Maternal morbidity was mainly marked by eclampsia and haemostatic disturbances while neonatal morbidity was attributable to the included prematurity. CONCLUSION: The main management consists essentially in a medical reanimation, in addition to a rapid foetal extraction.

[Indication of metformin in the management of hormonal dysfunction secondary to polycystic ovarian syndrome: prospective comparative study of 63 cases]. / La métformine dans la prise en charge de l'infertilité du sopk hors fiv Etude prospective comparative à propos de 63 cas.

BACKGROUND: Polycystic ovarian syndrome (PCOS) is the most common hormonal dysfunction in women. It's a cause of female infertility by oligoanovulation, clinical and biochemical hyperandrogenism and polycystic ovaries. Weight loss, firstly proposed in overweight or obese patient suffering from PCOS, aims to reduce hyperinsulinism and hyperandrogenism. Recently, Metformin, an insulin sensitizer, has been proposed as an alternative first line treatment for polycystic ovarian syndrome by improving hyperinsulinemia and hyperandrogenism in these women. AIM: The aim of our study, and through a literature review, is to demonstrate if Metformin should be used as a first-line drug for infertile women with this syndrome or as an adjunction to Clomifene Citrate, the longest established treatment already used in this syndrome. METHODS: A prospective comparative study including 63 patients with PCOS has been done during 2 years. Women were randomly allocated to clomifene + Metformin (Metformin group, Metformin took during 8 weeks, 850 mg twice a day, plus Clomifene 100 mg per day during five days) or Clomifene only (100 mg per day during five days). All patients underwent a two- month's diet. RESULTS: The middle age was about 30.63 years and the body mass index (BMI) was about 29.88 kg/ m(2). We noticed a 6.2% weight loss in both groups (a non significant difference in p=0.04). The median of infertility period was about 2.49 years. The ovulation rate in the Metformin group was 53.12% (significant difference for inducing ovulation p=0.02) and 32.25% in Clomifene group (non-significant difference 0.07). There was also a significant difference for ongoing pregnancies (p=0.04). In fact, 11 on 32 patients (34%) achieved a full-term pregnancy in Metformin group versus only 4 ones on 31 patients (12.9%) in Clomifene group. CONCLUSION: Our conclusion is that Metformin is an effective addition to Clomifene Citrate in term of reestablishment of ovulation and full-term pregnancies achievement, excluding ART cycles.

Laparoscopic hemi-hysterectomy in treatment of a didelphic uterus with a hypoplastic cervix and obstructed hemi-vagina.

OBJECTIVE: Maldevelopment of the Müllerian duct system may result in various urogenital anomalies including didelphic uterus with a hypoplastic cervix and obstructed hemi-vagina. CASE REPORT: We report a patient with this anomaly who was treated by laparoscopic hemi-hysterectomy and hysteroscopic resection of hemi-vagina. A 16-year-old patient who had complained of vaginal pus-like discharge on and off for 1 year was diagnosed by MRI to have a double uterus with obstructed right hemi-vagina and ipsilateral renal agenesis. After hysteroscopic identification of hypoplasia of the right uterine cervix, laparoscopic resection of the right uterus and right fallopian tube and hysteroscopic assisted resection of the vaginal septa were performed successfully. CONCLUSION: We think that combined laparoscopy and hysteroscopy may be an effective alternative in the management and diagnosis of Mullerian anomalies.

Efficacy of patient controlled epidural analgesia during labor analgesia--a prospective randomized study using 0.1% bupivacaine with fentanyl 2 mg/ml.

BACKGROUND: Epidural analgesia is the most effective for the control of pain during labor but irregularity of analgesia, toxicity of local anesthetics (LA) and driving block are the major limits of the modalities of maintenance. AIM: The purpose of this work was to assess the effectiveness and adverse effects of adaptations offered with Patient Controlled Epidural Analgesia (PCEA). METHODS: 40 mono-foetal parturients were randomized in two groups: 0.1% bupivacaine continuous drip associated to fentanyl 2 lg/mL (CP-group) or same products administrated in PCEA. Evaluation of analgesia, driving and sensory block allows adapting the outputs of drip. RESULTS: Consumption schedule in LA was of 7.5+/-2 mL/h in the CP-group and 3.5+/-1.5 mL/h in PCEA-group (p < 0.05). Consumption accumulated by LA is reduced by 35 % from the very beginning and 43% a 4-th hour (p<0.05). Incidence of the driving block was of 11 cases in CP-group against 4 in PCEA-group per first hour and of 13 cases against 3 per second hour (p<0.001). 50% of clinical obstetric interventions were brought together in the CP-group against 5 % in the PCEA-group (p=0.013). Incidence of side effects is comparable. CONCLUSION: Besides the perfect analgesia, PCEA offers a psychic independence which explains comfort and maternal satisfaction. Accumulation of LA entails a driving block involved in the change of dynamics of the labor. Incidence of clinical obstetric interventions is the major observation of our study.

[Giant placental chorioangioma]. / Le chorioangiome placentaire geant.

The large placental chorioangioma is a non-trophoblastic vascular tumor of placenta which size is more than 4 cm. It's a rare tumor, the incidence is between 1/3500 and 1/9000 birth. We analyze, on base of our case and from a literature review, the ultrasonography aspects of this tumor: we bring out also the physiological mechanisms of maternal and fetal complications and finally we detail the therapeutic possibilities. Chorioangioma appears in ultrasound scan like a thoroughly limited hypo-echogenic zone The vascular origin of the tumor can be confirmed by color Doppler. A left-right shunt effect results from arterio-venous communications and causes backwardness growth and fetal death in-utero The fetus is exposed to anemia and microangiopathic thrombopenia The maternal complications are: hydramnios, abruption placenta, premature ruptured membrane. Therapeutic possibilities are reduced: In several fetal anemia, blood transfusion can be done. Some techniques for tumor devascularization are be tried by someone.

[Fetal cystic hygroma antenatal diagnosis. Prognosis and management]. / Hygroma kystique retrocervical: diagnostic antenatal, pronostic et conduite a tenir.

Fetal cystic hygroma is a rare congenital malformation. The incidence of this pathology is 1/700 pregnancies. This malformation can be seen at antenatal ultrasonography from the end of the first trimester of pregnancy. The prognosis depends on chromosome analysis, other ultrasound abnormality and the size of the fetal cystic hygroma. Starting from a case diagnosed in the prenatal follow up and from litterature review, the authors discusse the ultrasound diagnosis, prognosis and management of this malformation.

[Postmenopausal uterine bleeding. Analytic study about 65 cases]. / Les métrorragies post-ménopausiques. Etude analytique à propos de 65 cas.

UNLABELLED: Postmenopausal uterine bleeding is frequent in gynecology. This symptom can reveal benign causes as well as cancers. So it's essential to rule out organic pathology. MATERIALS AND METHODS: We propose a retrospective study of 65 postmenopausal women who had uterine bleeding for two years. OBJECTIVES: - To study the relative frequency of different causes of postmenopausal uterine bleeding. - To evaluate the different investigation procedures. RESULTS: In 65 cases of postmenopausal bleeding, we found: - 6 cases of cancer (9.2 %): 4 cases of cancer of uterine corpus and 2 cases of cancer of uterine cervix. - Benign pathology was more frequent (59 cases : 90.8%), essentially represented by endometrial atrophy (37 cases) and hyperplasia (11 cases). - Hysteroscopic aspect in the 4 cases of endometrial cancer: - Polypoid hypertrophy: 2 cases. - Simple hyperplasia: 2 cases. CONCLUSION: Despite the fact that benign pathology is more frequent than malignancy as a cause postmenopausal uterine bleeding, we must always rule out a cancer by oriented biopsy.

[Association fibromyoma and pregnancy. About 23 cases]. / Association fibrome uterin et grossesse. A propos de 23 cas.

UNLABELLED: The coexistence of leiomyoma and pregnancy may lead to complications with unequal gravity. MATERIAL AND METHODS: The authors propose a retrospective study about 23 cases of association of fibromyoma and pregnancy collected over a period of seven years. OBJECTIVES: Study of the effect of fibromyoma on pregnancy and vice-versa. Analysis mode of delivery. RESULTS: Aseptic necrobiosis: 21.7%. Urinary tract compression: 4.3%. Miscarriage: 13%. Threatened premature birth: 26%. Caesarean section: 47.8%. Premature birth: 8.6 %. Neonatal death: nil. CONCLUSION: Maternal morbidity due to this association is important. It is essential that pregnant women be aware of the importance of prenatal consultation during the first trimester of pregnancy.

[Breech presentation: vaginal delivery or planned caesarean section?]. / Presentation de siege: accouchement par voie basse ou cesarienne systematique?

UNLABELLED: Breech delivery is a high risk situation because of its numerous dystocies. The most serious is the last head retention. The authors realized a retrospective study concerning 347 patients who had given birth to a newborn child in breech presentation during a period of 4 years. RESULTS: The vaginal delivery was associated in a significant way to an excess of obstetric traumatisms (5.5%) versus caesarean section (0.5%) and this even after strict selection of vaginal delivery's conditions (P = 0.00453). The rate of the newborn child having Apgar's score < 7 in 5 min was higher in case of vaginal delivery (17.39%) than caesarean section's birth (3.48%). Corrected neonatal mortality is higher in the group of vaginal delivery than caesarean section's group (34% versus 0.49%, P = 0.02553). There is no significant difference of maternal morbidity between caesarean section and vaginal delivery group (P = 4.65). Vaginal delivery is associated to an excess of morbidity and neonatal mortality even after strict selection of the candidates of the vaginal delivery.

[The obstetrical advantages of epidural analgesia in a trial of labor]. / Les avantages obstetricaux de l'analgesie peridurale au cours de l'épreuve de travail.

Two series of labour trial were compared in a forward-looking study. The first series of 24 parturient women (series I) to whom the labour trial took place under peridural analgesy. The second series of 80 parturient women (series II) to whom the labour trial took place without peridural analgesy. The rate of caesarean section is significantly less important in the series I (33.3% versus 58%) P = 0.37. The average duration of the labour trial is significantly prolonged under peridural analgesy but without bared effects for the newborn children. The authors consider that the peridural analgesy is the method that brings ideal conditions for a real test allowing to eliminate dynamic dystocia and maternal restlessness in order to have an accurate cephalo-pelvic confrontation.

[Cervical maturation in post-term pregnancy: prostaglandin E2 versus Foley probe]. / La maturation cervicale dans le dépassement de terme: prostaglandine E2 versus sonde de Foley.

To compare two methods of cervical maturation in frame of labor induction the case of overtaking of term. Study review compare two groups, first group is to form of 51 patients having had one cervical maturation by gel of predipil, second in compound of 63 patients having benefited of one maturation cervical by one probe of Foley. The entrance spontaneous in labor later administration cervical of gel of prostaglandin is of 45% against 8% only in-group of patients having had one maturation by probe of foley. Duration of labor is more short in first group. Probe Foley countered so effective that gel of prostaglandin it appears as one method of cervical maturation of choice in our environment.