Phylogeny and Classification of Human Papillomavirus (HPV)16 and HPV18 Variants Based on E6 and L1 genes in Tunisian Women with Cervical Lesions

Background: High-risk human papillomavirus (HPV) types are the main etiological factors for cervical cancer. HPV16 and HPV18 are generally the most common forms associated with development of high-grade cervical lesions. This study was undertaken to identify intratypic variants of HPV16 and HPV18 among women with cervical lesions in Tunisia. Materials and Methods: DNA was extracted from cervical samples collected from 49 women. using a PureLinkTM Genomic DNA mini Kit (Invitrogen). E6 and L1 open reading frames (ORF) were amplified by PCR and viral DNA amplicons were subjected to automated sequencing using Big Dye Terminators technology (Applied Biosystems). The obtained sequences were analyzed using an appropriate software program to allow phylogenetic trees to be generated. Results: HPV16 and HPV18 were detected in 15 and 5 cases, respectively. HPV16 E6 sequences clustered with the European German lineage (A2) whereas one isolate diverged differently in the L1 region and clustered with the African sub-lineage (B1). HPV 18 E6 sequences clustered with the European sub-lineage (A1) but L1 sequences clustered as a new clade which diverged from A1-A5. Conclusions: Our results suggest that the distribution of HPV16 and HPV18 sequences in women with cervical lesions in Tunisia is mainly related to European epidemiological conditions and point to the presence of recombinant HPV forms.

Incidence and risk factors of postpartum anal incontinence: a prospective study of 503 cases.

BACKGROUND: Background: Anal incontinence is a devastating functional postpartum complication. it can cause deep deterioration in the quality of life. AIM: To assess the incidence of postpartum anal incontinence (PPAI) and the major risk factors predisposing for it in the short and middle terms. METHODS: This prospective observational study was conducted in the department of Obstetrics and Gynecology B in the Maternity and Neonatology Center of Tunis between March 1st and july 31st, 2009. RESULTS: Five hundred and three women were included. PPAI was 4.2% on the fourth day postpartum and 4% between weeks 6 and 8 postpartum. Predisposing factors to 4th day PPAI were forceps delivery (p<0.001), prolonged second stage of labor> 5hours (p=0.047), expulsion phase > 20mn (p<0.001), uterine revision (P=0.001) and first degree perineal lacerations (p<0.001). Between 6 and 8 weeks postpartum, identified risk factors were Shoulder dystocia (p<0.001), anu-vulvar distance < 2cm, perineal scars and transverse abdominal diameter >105mm (p<0.001). CONCLUSION: Preventive measures must be implemented in patients with PPAI risk factors.

[Laparoscopic management of ovarian masses during pregnancy]. / Prise en charge coelioscopique des masses ovariennes au cours de la grossesse.

BACKGROUND: The diagnosis of an adnexal mass associated with pregnancy is increasingly common with the routine use of ultrasound during prenatal care. AIM: To assess the feasibility, advantages and limiting factors of laparoscopy in the management of ovarian masses during pregnancy. METHODS: Rretrospective study of a series of 34 pregnant women operated by laparoscopy for adnexal masses during a period of 14 years. RESULTS: The mean age of patients was 29 years. Fifty percent of patients were nulliparous. In 62% of cases, patients were asymptomatic. Laparoscopy was performed at a mean gestational age of 15 weeks. Open laparoscopy was performed in 58.8% of cases. Intraperitoneal cystectomy was performed in 28 cases (72%). In two cases (5 %), it was a borderline ovarian tumor requiring further surgery outside of pregnancy. Fetal loss was noted at a term of 16 weeks. CONCLUSION: Laparoscopic management of adnexal masses during pregnancy appears to be safe and reproducible procedure with few maternal and fetal complications.

[Iron status in pregnant women and its changes during preeclampsia]. / Statut du fer chez la femme enceinte et ses variations au cours de la prééclampsie.

BACKGROUND: Micronutrients or trace elements are minerals essential for growth and development of the body human. AIMS: To analyze changes in normal pregnancy and during preeclampsia, serum iron and its main proteins: ferritin and soluble transferrin receptors. METHODS: This is a prospective study of case- control study of 56 pregnant women and 30 non-pregnant women selected as controls. Pregnant women received a quarterly dosing paramètres. The same assays were performed once in controls. RESULTS: The comparative assay of various parameters in normal pregnancy and in control women showed a significant decrease in serum iron from 1 to the third quarter, a slight decline in reserves ferritin in 1st and 2nd quarter increases and becomes significant in the third quarter and an increase of soluble receptors trasferrine during pregnancy, which becomes significant in the third quarter. We noted a disturbance of these parameters in preeclampsia. CONCLUSION: Iron is essential for fetal development. His involvement in several maternal- fetal complications is not to dismantle .

The value of sonohysterography in the diagnosis of tubal patency among infertile patients.

BACKGROUND: Tubal pathology is one of the main causes of infertility. In the routine fertility work-up, our ability to evaluate tubal function is limited to tubal patency and peritubal adhesions. AIMS: To assess the value of sonohysteroography (SHG) in evaluation of tubal patency in infertile patients and to compare its results with hysterosalpingography and laparoscopy. methods: In this prospective study, 40 consecutive women were underwent three methods of exploration of tubal patency: hysterosalpingography, sonohysteroography and laparoscopy with dye test, within a period of 6 months. RESULTS: The Mean age of our patients was 32 ± 5 years. Of the 40 women who were recruited, 30 had primary and 10 had secondary infertility. Altogether 80 tubes were exanimated by these 3 methods. Sonosalpingography showed patency in 51(63.7%) tubes, hysterosalpingography in 47 (58.7%) tubes, and laparoscopy in 52 (65%) tubes. Sonosalpingography and laparoscopy agreed in 70 out of 80 tubes (concordance, 87.5%). As regards the appearance of the right and left tubes, the results of sonohysterography agreed with laparoscopy in 75% and 87.5%, respectively, while HSG agreed with laparoscopy in 64% and 54% respectively. CONCLUSION: SHG is useful in the assessment of tubal patency and its implication in the fertility workup as a simple and fast procedure can minimize costes and abus of sophisticated techniques.

[How to predict spontaneous resolution of early pregnancies?]. / Comment prédire la résolution spontanée des grossesses jeunes ?

BACKGROUND: Assessment of early pregnancy is indicated in women with suspected abnormalities. It is based on biochemical assessment and on trans vaginal sonography . AIM: To identify clinical, biological and ultrasonographic parameters that are predictive of spontaneous pregnancy resolution. methods: A prospective observational study was performed interesting women with a positive pregnancy test without visualization of the pregnancy on the initial scan. All parameters measured during the initial visit were tested by univariate and multivariate analysis to identify parameters predicting spontaneous resolution of pregnancy. RESULTS: A total of 2675 women were included in the study. In 94 cases (4 %) the location of pregnancy was unknown. Univariate and multivariate analysis showed that four parameters contributed significantly to the predictive power of the logistic model: Absence of pain (p =0,036), endometrial thickness < à 12 mm (p =0,021), initial serum ßhCG level < 1000 UI/l (p =0,015) and progesterone level < 29 nmol/l (p <0,001). CONCLUSION: Women with a high probability of spontaneous resolution of their pregnancies can benefit from a spaced monitoring until the rate of ß-hCG will be negative.

Does the mode of delivery affect neonatal morbidity and mortality in very low-birth-weight infants ?

BACKGROUND: Despite the great advances made in neonatal intensive care, one of the greatest challenges in perinatology today, remains the management of very low-birth-weight infants (VLWB). AIM: To evaluate the impact of the mode of delivery on very lowbirth- weight infants' survival and their outcome. METHODS: We performed a retrospective comparative study in the department "B" of gynecology-obstetrics in collaboration with the neonatology department of the same centre during a 12-month period. The study population included mothers giving birth to infants weighing between 500 and 1500 grams, at gestational age > 26 weeks and an Apgar score > 3 at one minute. All included cases were classified according to the way of delivery: vaginal delivery ( Group A) giving birth to neonates of group 1 and cesarean section ( group B) giving birth to neonates in group 2 . RESULTS: The study involved 69 women giving birth to 82 very lowbirth- weight infants. Both groups of parturients were homogeneous and similar in age, parity, prenatal care and gestational age. No statistically significant difference was noticed in terms of morbidity and mortality in the very low-birth-weight infants of the two groups. A higher rate of cesarean sections was noticed in breech presentations (74%). CONCLUSION: Systematic cesarean section does not guarantee better outcome for very low-birth-weight infants.

Prediction of ectopic pregnancy in early pregnancy of unknown location.

BACKGROUND: Women having pregnancies of unknown location (PUL) can be defined as those having positive pregnancy test when no pregnancy is visualized on transvaginal ultrasound (TVS). AIM: To identify diagnostic parameters which are predictive of ectopic pregnancies in women with early pregnancies of unknown location. METHODS: We undertook a prospective observational study of pregnant women with suspected early pregnancy complications. Ninety-four patients were classified as having a pregnancy of unknown location (PUL) by transvaginal ultrasound; blood sample was taken on presentation to measure the serum human chorionic gonadotrophin (,-HCG) and progesterone levels. All collected data were tested by univariate analysis and then analyzed in a stepwise procedure to form a logistic model for predicting ectopic pregnancy. RESULTS: A total of 2675 women were referred for suspected early pregnancy complications. In 94 (4%) patients the location of the pregnancy was unknown. Three parameters were found to be statistically significant for predicting ectopic pregnancy:progesterone level, vaginal bleeding associated with pain and the presence of free fluid in the pouch of Douglas. The overall model described by these variables offer a sensitivity of 79 %and a specificity of 59% in the prediction of ectopic pregnancy. CONCLUSION: Logistic regression model can help in the clinical decision-making in women with pregnancy of unknown location.

[Pregnancy of unknown location]. / Les grossesses jeunes de localisation indéterminée

BACKGROUND: A pregnancy of unknown location is a descriptive term that can be defined after performing trans vaginal ultrasound. This situation includes patients with a positive pregnancy test but with no evidence of intra or extra uterine pregnancy on transvaginal sonography. AIM: To discuss different aspects of management of women with pregnancy of unknown location. METHODS: Review of the literature. RESULTS: Serum human chorionic gonadotrophin levels, progesterone levels and mathematical models are helpful in the prediction of final outcome of pregnancy: intra uterine pregnancy, ectopic pregnancy, spontaneous resolution or persistent pregnancy of unknown location. Active expectant management of asymptomatic women with a pregnancy of unknown location has been shown to be safe. CONCLUSION: Surgical intervention (diagnostic laparoscopy and uterine curettage) to diagnose the location of the pregnancy should be restrictive.

[Prospective study of the contribution of hydrosonography in the exploration of the uterine cavity]. / Etude prospective de l'apport de l'hydrosonographie dans l'exploration de la cavité utérine.

BACKGROUND: Recent developments in ultrasound have led to a new exploration technique: hydrosonography. AIM: To evaluate diagnostic performance of hysterosonography in the assessment of the uterine cavity, by comparing it with standard transvaginal ultrasound and particularly with diagnostic hysteroscopy. METHODS: This is a prospective study over a period of nine months from 1st January to 30 September 2009. Transvaginal ultrasound was performed for all patients followed by hydrosonography then by diagnostic hysteroscopy. RESULTS: Sixty-two patients underwent three examinations. The mean age of our patients was 42.2 years. Bleeding disorders of the menstrual cycle were the most common reasons for seeking. Referring to the pathological examination, hysteroscopy is the most accurate technique in the diagnosis of endometrial hyperplasia and intracavitary masses, followed by hydrosonography then by transvaginal ultrasound. The concordance between hydrosonography and hysteroscopy in the diagnosis of submucosal fibroids and hyperplasia of the endometrium is very good (K> 0.8). CONCLUSION: The hysterosonography seems a relevant exam, allowing a complete assessment of the uterine cavity.

[Safety of Magnesium sulfate in severe preeclampsia]. / Sulfate de Magnésium au cours de la Préeclampsie Sévère : Innocuité d'utilisation ?

BACKGROUND: Several observational studies and randomized trials have described the use of various regimens of magnesium sulfate to prevent or reduce the rate of seizures and complications in women with severe preeclampsia. AIM: To assess the validity of a service protocol in the management of severe pre-eclampsia all specifying the benefits, complications and side effects of magnesium sulfate . METHODS: We have performed a retrospective descriptive study over two years (2009-2010) concerning 150 patients affected with severe preeclampsia in the department "B" of gynecology and obstetrics of the "Rabta" at the Centre of Maternity and Neonatology of Tunis (third level maternity). The protocol consisted in the administration of 3 grammes of magnesium sulfate followed by intravenous dose of 1 g/hour associated with an anti-hypertensive treatment. RESULTS: One hundred and forty patients (93%) had 2 or more criteria of severity associated. Seventy-eight (52 %) patients with severe preeclampsia have profited an anti-hypertensive treatment based on nicardipine associated with magnesium sulfate without notable secondary effects. In two cases (1.3 %) an eclampsia was noted with magnesium sulfate, 27.4 % of severe preeclampsia was noted at a term within 34 week of amenorrhea. Only one case of surdosage was noted in post partum. CONCLUSION: The use of magnesium sulfate in practice does not appear to increase the risk of complications or major side effects in the mother and fetus.

[Hysteroscopic myomectomy]. / Myomectomies perhystéroscopique.

BACKGROUND: Hysteroscopic resection of submucous myomas is a safe alternative to conventional surgery. AIM: To evaluate the anatomical and functional results of endoscopic resection of submucous myomas and to present the principle complications of this technique. METHODS: This is a retrospective study performed in the department "B" of gynecology and obstetrics in maternity center of Tunis "La Rabta". It analyzes a series of 105 hysteroscopic resections of intracavitary fibroids during a period of 8 years from January 2003 to December 2010. RESULTS: The mean age of our patients was 41 years and 5 months. The most frequently reason for consultation was the disorder of the menstrual cycle type of menometrorrhagia (47.6%), menorrhagia (22.8%) and postmenopausal bleeding (11.4%). Preoperative assessment of the fibroid was based on transvaginal ultrasound in all cases associated with diagnostic hysteroscopy in 51.4% of cases and with hydrosonography in 28.6% cases. The mean size of the fibroid was 3.08 cm. Type 0 myomas represented 42.8% of cases. The most frequent emplacement of the myoma was the anterior surface of the uterus (44.7%). After surgery, the resection was considered as complete in 88 patients (83.8%), partial in 17 patients (16.2%) requiring a second operation. The functional result was good with disappearance of bleeding symptoms in 90% of cases after a mean follow up of 17 months. CONCLUSION: Hysteroscopic resection of sub mucosal fibroids is a technique that respects the uterine cavity with satisfactory functional results and low morbidity.