[Social determinants of contraceptive use in Tunisia]. / Les déterminants sociaux de l'utilisation des méthodes contraceptives en Tunisie.

BACKGROUND: In Tunisia, the "Revolution" of January 2011 highlighted significant regional disparities and social inequalities in access to health care, including reproductive health services. The purpose of this study was to analyze the social determinants of the use of contraception in Tunisia. METHODS: A cross-sectional national study conducted in 2012; on a sample of 15 to 49-year married women (n=4374) drawn by a two levels random sampling. Prevalence of contraception and its association factors were assessed. Logistic regression was used to evaluate the variation of contraception prevalence with area of residence, age, level of education, number of children and household income. RESULTS: The prevalence of contraception was 66.4 %. Eighty-two percent of women used a modern contraceptive method. The use of contraceptive methods was significantly dependent on the age (P<0.001), area of residence (P=0.008), education (P<0.001). The prevalence of contraception was higher in North West (OR=1.1 [0.81-1.5]; P<0.001), among multiparous women (OR=4.49 [3.57-5.66]; P<0.001), among the youngest women (OR=1.4 [0.9-2,19]; P<0.001) and among those with higher levels of education (OR=1.62 [1.19-2.21]; P=0.008). CONCLUSION: Tunisia, precursor Arab country in family planning, is recording a slowdown in the use of contraception in comparison with other countries of North Africa. Social determinants, such as, age, living conditions, area of residence and level of education are indicators to consider when targeting interventions.

[Accuracy of ultrasound estimated fetal weight performed by residents at delivery day]. / Performance de l'estimation échographique du poids fœtal réalisée par les internes de spécialité le jour de l'accouchement.

UNLABELLED: Ultrasound fetal weight estimation (EFW) has become a routine practice in obstetrics with a major impact on obstetrical management. OBJECTIVES: To evaluate the accuracy of sonographic fetal weight estimations performed by residents in obstetrics at the delivery day and to search parameters influencing this exam. METHODS: A prospective study performed in 299 patients at 37 weeks of gestation or more, during their delivery day. Ultrasound fetal weight estimations were performed by residents and compared to birth weights (BW). The estimated fetal weight (EFW) was calculated using the formula of Hadlock: Log10 EPF=1,335+0.0316 BIP+0,0457 PA+0,1623 LF-0,0034 PA LF. RESULTS: Mean absolute difference between EFW and BW was 200g [100-450]. Mean absolute percentage error was 5.71 % [2.7-11.37]. The proportion of the EFW within 10 % of BW was 69.6 %. There was a good correlation between EFW and BW (R=0.79). Obesity and fetal macrosomia had negatively influenced ultrasound performance. For the diagnosis of macrosomia, ultrasound has a sensibility of 38 % and a specificity of 99.59 %. CONCLUSION: Ultrasound fetal weight estimations performed by residents in the delivery room were as accurate as those performed by experimented sonographers. Thus, the predictive performance remains limited with a low sensitivity in the diagnosis of macrosomia.

[Diagnosis of fetal engagement by transperineal sonography: a preliminary Tunisian study]. / Diagnostic de l'engagement fœtal par l'échographie transpérinéale: étude préliminaire tunisienne.

INTRODUCTION: The assessment of fetal head engagement by digital examination is highly subjective even though this method remains the gold standard. Ultrasound could be a new way to specify the fetal head engagement with objective and reproductible measurements. OBJECTIVE: To compare the clinical data and the transperineal ultrasound results for the diagnosis of fetal head engagement. PATIENTS AND METHODS: We conducted a prospective longitudinal study on a series of 70 patients and compared the clinical assessment of fetal engagement to the ultrasound measurements. Ultrasound examination was performed in the delivery room. The probe was placed on the ano-vulvar area. The measure used was: distance perineum-external table of fetal head bone. RESULTS: The ultrasound measures of the distance [perineum-external table of fetal head bone] went from 13 to 75 mm; and the measures of the distance [perineum-succedaneum bump] went from 22 to 68 mm. We tried to retain a value threshold of the distance [perineum-external table of fetal head bone] above which the diagnosis of engagement would be countered. The threshold so proposed is of 55 mm with a positive predictive value in 98%, a sensibility in 87% and specificity in 93%. DISCUSSION AND CONCLUSION: Transperineal ultrasound is a simple and easy method to define fetal head engagement by measuring the distance between perineum and fetal head. This new tool can be very useful in the delivery room when clinical examination is inconclusive hampered, for example, by the presence of a succedaneum bump.

[Hypogastric artery ligation for post-partum hemorrhage]. / Ligature bilatérale des artères hypogastriques dans la prise en charge des hémorragies du post-partum.

UNLABELLED: Post-partum hemorrhage is the leading cause of maternal mortality in Tunisia as in many other countries. In case of failure of medical measures, bilateral ligation of hypogastric arteries (BLHA) represents an interesting alternative to the hemostatic hysterectomy to preserve patients fertility. OBJECTIVE: Report our BLHA experience in the post-partum hemorrhage management. PATIENTS AND METHODS: Retrospective study conducted between January 2001 and December 2008. We collected all the patients who had undergone a BLHA in case of post-partum haemorrhage. RESULTS: Fifty-seven BLHA were carried out during the study period. The success rate was 82.45%. The procedure failed in 10 patients. Most cases were uterine atony and placenta accreta. We reported one complication: a case of perioperative ligation of the primitive iliac artery. Surgical management was successful. Magnetic resonance imaging performed on average two months after surgery had shown a complete repermeabilization in seven cases among eight. CONCLUSION: BLHA is an interesting and effective option in the management of severe post-partum hemorrhage. Technique learning is recommended especially in case of non availability of uterine artery embolization.

[Evolution of maternal mortality in a level 3 Tunisian maternity from 1998 to 2007]. / Evolution de la mortalité maternelle dans une maternité tunisienne de niveau 3 entre 1998 et 2007.

INTRODUCTION: The action plan for the maternal mortality is generally based on research studies' results carried out within hospital structure. OBJECTIVES: Determination and follow-up of the evolution of maternal mortality from 1998 to 2007 in a level 3 Tunisian maternity and identification of its main causes. PATIENTS AND METHODS: It is a retrospective study carried out between January 1998 and December 2007. In our service, since 1984, maternal deaths are systematically recorded. Information about deaths are collected from the following sources: childbirth folder, folder of hospitalization in reanimation, after the autopsy, through information collected beside the family, or by the National System of Maternal Death Surveillance, only since 1999. RESULTS: Thirty-one mother deaths were colligated during the study. The average age of patients was around 33 years. The global maternal mortality rate during the study was about 56 deaths for 100,000 live births. The trend was characterized by a net decrease to this rate to 2003, and stagnation after that or even an increase in 2007. Deaths were due, in 81% of cases, to a direct obstetric reason. Hemorrhage was the principal etiology, which was implicated in 35.48% of the total cases. Complications of preeclampsia were incriminated in 19.35% of the total number of cases. In this set, transfer rate was about 48.38%. CONCLUSION: The evolution over the years shows a net regression of maternal mortality. However, the trend was characterized by a recent stagnation. However most of cases were avoidable. Much progress has to be carried out in the cases of peripartum hemorrhages and preeclampsia, since they represent the main death causes.

[Management of breast cancer detected by a mammography program in the Ariana area of Tunisia]. / Prise en charge des cancers du sein issus du programme mammographique du gouvernorat de l'Ariana en Tunisie.

OBJECTIVE: To report the epidemiological and anatomoclinical features of breast cancers referred to a department of gynecology from the screening program of l'Ariana state in Tunisia. MATERIAL AND METHODS: A longitudinal retrospective Study was done over a period of 4 years (2004-2006 ) at the unit "A" gynecology department of the maternity of Tunis. We collected all the cases with histologically confirmed breast cancer diagnosed within the mammography screening program of l'Ariana state, referred to our unit for treatment. RESULTS: 10 patients with histologically confirmed breast cancer were collected during the study period, treated at our unit. Mean age of patients was of 48.8 years. Clinical examination was initially negative in 50% of cases. Mean clinical tumor size was 18 mm, while invasive ductual carcinoma represents the most frequent histological type. One patient (10%) had histological axillary involvement. Conservative surgery was performed for 8 (80%) of the 10 patients. CONCLUSION: This pilot study of mammography screening confined to a Tunisian state, precludes to the future profile of BC In Tunisia, showing that an early diagnosis can lead to a dramatic reduction of mean clinical tumor size, less histological poor prognostic features, more conservative surgery and a slight improvement of survival. A structured extended screening program must be installed to achieve these goals but requires an important financial and human investment.

[Surgical treatment of breast lesions: preliminary results of the screening program of the Ariana area]. / Traitement chirurgical des lésions mammaires infracliniques: résultats préliminaires du programme de dépistage de l'Ariana.

OBJECTIVE: To report clinical, radiological and histological characteristics of the infraclinical breast lesions patients recruited via the large scale mammography breast cancer screening of l'Ariana state in Tunisia. MATERIALS AND METHODS: Retrospective study over a period of 2 years. The recruitment of patients made on the occasion of the program of breast cancer screening. RESULTS: During this period, 22 patients in our unity had had a surgical excision after wire localization. Ten patients were recruited by means of systematic breast cancer screening. In these cases, the mammographic findings were classified B.I.R.A.D.S 4 in 7 cases and BIRADS type 5 in 3 cases. Definitive histology concluded to benign disease in 4 cases and malignancy 6 cases. This collaboration enables the diagnosis an invasive ductal carcinoma in three cases. CONCLUSION: The surgical excision after wire localization for non palpable breast lesions allows diagnosis of high-risk benign lesions and low-stage breast cancer. It is a reliable technique which indications have to be based on clinical and radiological strict criteria. This procedure is at present, and in developed countries, widely outstripped with the stereotactic core needle biopsy.

[Imaging of gestational trophoblastic disease]. / Imagerie des maladies trophoblastiques gestationnelles.

INTRODUCTION: Trophoblastic diseases correspond to a very heterogeneous group. OBJECTIVE: To establish the importance of imaging in the management of trophoblastic diseases. PATIENTS AND METHODS: Retrospective study from 1995 to 2008, including all patients with a gestational throphoblastic disease in our department. RESULTS: Seventy-four cases were identified with 58 molar pregnancies, 14 trophoblastic tumors and two cases of hydatiform mole coexistent with a twin live fetus. Ultrasound's sensibility in case of hydatiform moles was 75.86%. It was sharply more important in case of a complete mole with a detection rate of 96.15% against 28% in case of partial mole. In trophoblastic tumors, ultrasound coupled with Doppler had shown signs of invasion in half of the cases. Four patients presented with lung metastases. Magnetic resonance imaging was performed in two cases. DISCUSSION AND CONCLUSION: Ultrasound is of high-performance in the positive diagnosis of complete moles. Furthermore, it shows signs of invasion in case of trophoblastic tumors. In those cases, a radiological assessment guides the management even in the absence of histological proofs.

[Fertiloscopy: Tunisian experiment]. / Fertiloscopie: expérience tunisienne.

OBJECTIVE: The purpose of this study was to estimate the place and the results of fertiloscopy in the management of female infertility. MATERIALS AND METHODS: Retrospective study over a period of eight years including the patients presenting infertility without pathology raising of an evident surgical indication. We analyzed the perioperative data, the results as well as the complications of this intervention. RESULTS: One hundred and eighty-eight fertiloscopic procedures succeeded (84%). For 84 patients (37.6%) we realized a coelioscopy. In 44% for failure of the exam and in 66% for lesions found in the fertiloscopy and requiring surgery. Two complications without major consequence will be deplored: two rectal injuries. CONCLUSION: Fertiloscopy is a safe and reliable procedure. It can be substituted to laparoscopy in the routine assessment of infertile women management in case of not obvious surgical indication.