Self-administered multi-level pregnancy tests in simplified follow-up of medical abortion in Tunisia.

BACKGROUND: This study was conducted to assess the efficacy and acceptability of using a multi-level pregnancy test (MLPT) combined with telephone follow-up for medical abortion in Tunisia, where the majority of providers are midwives. METHODS: Four hundred and four women with gestational age ≤ 70 days' LMP seeking medical abortion at six study sites were enrolled in this open-label trial. Participants administered a baseline MLPT at the clinic prior to mifepristone administration and were asked to take a second MLPT at home and to call in its results before returning the day of their scheduled follow-up visit 10-14 days later. RESULTS: Almost all women with follow-up (97.1 %, n = 332/342) had successful abortions without the need for surgical intervention. The MLPT worked extremely well among women ≤63 days' LMP in ruling out ongoing pregnancy (negative predictive value (NPV) =100 % (n = 298/298)) and also detecting women with ongoing pregnancies (sensitivity = 100 %; 2/2) as needing follow-up due to non-declining hCG. Among women 64-70 days' LMP, the test also worked well in ruling out ongoing pregnancy (NPV = 96.9 % (n = 31/32) but not as well in terms of sensitivity (50 %), with only one of two ongoing pregnancies detected by MLPT as needing follow-up. Most women (95.1 %) found the MLPT to be very easy or easy to use and would consider using the MLPT again (97.4 %) if needed. CONCLUSIONS: Self-administered pre and post MLPT are very easy for women to use and accurate in assessing medical abortion success up to 63 days' LMP. MLPT use for medical abortion follow-up has the potential to facilitate task sharing services and eliminate the burden of routine in-person follow-up visits for the large majority of women. Additional research is warranted to explore the accuracy of the MLPT in identifying ongoing pregnancy among women with gestational ages > 63 days. TRIAL REGISTRATION: This study was registered on May 13, 2010, on clinicaltrials.gov as NCT01150279 .

[Evaluation of different techniques for vaginoplasty in the treatment of Mayer-Rokitansky-Kuster-Hauser syndrome]. / Evaluation des différentes techniques de vaginoplastie dans le cadre du traitment du syndrome de Mayer-Rokitansky-Küster-Hauser.

BACKGROUND: Rokitansky syndrome is an utero-vaginal aplasia with a frequency of 1 / 5000 female births. To correct this anomaly whose prognosis is mainly functional and psychological numerous surgical techniques have been described. AIMS: To report our experience about 13 patients with Rokitansky syndrome and having benefited from a vaginoplasty between 1993 and 2008 and to evaluate the results of the various anatomical techniques. METHODS: This is a retrospective study of 13 patients who underwent a vaginoplasty in the center of maternity and neonatal units, over a period from December 1993 to April 2008. During this period, two operative techniques were used: the technique of Mac-Indoe and the technique of Davydov. RESULTS: The mean age at the time of surgery was 22 years (15 years-32 years). In 6 patients operated using the technique of Davydov the average depth of neovagina was 6.83 cm, one treatment failure was noted. Among the 7 patients operated using the technique of Mac Indoe the average length of neovagina was 7 cm, 3 treatment failures were noted. It was noted that there was no failure of the anatomical results in patients who have had regular sex after surgery. It was noted that there was failure of the anatomical result in 4 of 9 patients who did not have sexual intercourse after the procedure regardless of the technique used, a failure rate of 44%. CONCLUSION: The choice of technique will be based on the experience of the teams as each technique has similar anatomical and functional results in the literature. Both anatomical and functional, the main factor that determines the success of treatment seems to be the motivation of the patient to have a married life and sexual relationship.

[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.

Fetal sex assignment by first trimester ultrasound: a Tunisian experience.

OBJECTIVE: To assess the feasibility and accuracy of fetal sex identification during the first trimester ultrasound exam. METHODS: A prospective study was carried out on 312 fetuses at 11-14 weeks' gestation. The genital region was examined by transabdominal ultrasound. The angle of the genital tubercle to a horizontal line through the lumbosacral skin was measured. Fetal gender was assigned as male if this angle was > 30 degrees and female when it was < 10 degrees . RESULTS: Sex assignment was feasible in 89.7% and accurate in 85.7% of fetuses. Accuracy was similar in males as in females (87.9% vs 83.3%; NS). However, accuracy increased significantly during the gestational age period in male (Chi-square for trend P = 0.03) but not in female (P = 0.41) fetuses. Compared with singletons, presence of multiple fetuses (n = 12) did not influence feasibility or accuracy (89.2% vs 96% and 85.6% vs 86.4% respectively). In male fetuses, there was a significant increase in the angle of the genital tubercle with increasing crown-rump length(CRL) (r = 0.667; p = 0.025), while in females the angle did not significantly change with increasing gestation. CONCLUSION: Sonographic first trimester sex assignment is highly feasible and accurate.

Extralobar pulmonary sequestration revealed by prenatal hydrothorax.

BACKGROUND: Pulmonary sequestration is a rare congenital pulmonary anomaly that can be diagnosed in utero. AIM: Report a New case. CASE REPORT: In this case report of extralobar pulmonary sequestration, the authors report a case revealed by hydrothorax and describe this disease appearance in different imaging technique (Doppler ultrasonography, magnetic resonance imaging and postnatal multislice CT angiography).

[Early diagnosis and management of cervical ectopic pregnancy]. / Diagnostic precoce et prise en charge des grossesses cervicales.

BACKGROUND: Cervical pregnancy is the rarest of ectopic pregnancy. The classical treatment remains hysterectomy, in particular when diagnosis is made late. The possibilities of more and more premature diagnoses, sometimes before any clinical expression, let suspect the possibility of conservative treatments. We report two cases of medical treatment for early diagnosed cervical pregnancies. AIM: Through a review of the literature, we resume diagnostic criteria and various therapeutic possibilities. CASE REPORTS: The two cases were diagnosed in the first trimester. The treatment consisted in intramuscular administration of methotrexate. The first patient had ultrasound-Guided feticide before the administration of methotrexate. CONCLUSION: Actually, vaginal ultrasound allows early diagnosis of cervical pregnancies, even before the beginning of vaginal bleeding. This advancement allowed conservative treatment. In this situation, current reference is the methotrexate to which can be associated an intracardiac potassium chloride injection in case of embryo positive heart activity.

[Ovarian pregnancy. Report of three cases]. / Grossesse ovarienne, à propos de 3 cas.

BACKGROUND: Ovarian pregnancy is a rare type of ectopic pregnancy. Its diagnosis and management are often difficult. AIM: To highlight specific diagnostic and therapeutic properties of ovarian pregnancy. METHODS: Retrospective Study over a period of 4 years. We observed the patients presenting ovarian pregnancies. Diagnosis was evocated in time of surgery and confirmed by histological data. RESULTS: We observed three patients presenting ovarian pregnancies. All our patients had an abdominal ache. Diagnosis was made by ultrasound scan examination in one case. One patient had a laparotomy as a matter of urgency; the two others had a laparoscopy. All the patients were managed conservatively. The diagnosis of ovarian pregnancies was evocated in time of surgery and confirmed by the histological data. CONCLUSION: the ovary is a rare location for extra-uterine pregnancy. This type of ectopic pregnancy has some clinical properties. The diagnosis is intricate and based on per operatory observations. The management is in spite of medicines improvement, based on surgery.

[First trimester ultrasound: an early screening tool for fetal structural and chromosomal abnormalities]. / Echographie du premier trimestre: un outil de dépistage précoce des malformations foetales et des anomalies chromosomiques.

BACKGROUND: Prenatal diagnosis has been greatly expanded in recent years. Many biological and sonographic criteria participated in the development of fetal medicine. AIM: Analyze the contribution of first trimester ultrasound in prenatal diagnosis of aneuploidy and early fetal malformations, and its impact on the strategy of prevention of disability. METHODS: A prospective longitudinal descriptive study including all women who did a first trimester ultrasound during their pregnancy. We evaluated the detection rate of malformations and chromosomal abnormalities of the morphological embryonary study and nuchal translucency. These tests were then confronted with the results of fetal samples and the outcome of pregnancy. RESULTS: 593 ultrasound examinations were performed. The average age of pregnant women was 32.7 years. The mini-morphological ultrasound study revealed 26 abnormalities (3 major lethal malformations, 5 cystic hygroma and 18 increased nuchal translucency). Chromosomal abnormalities were found in six cases. The first trimester ultrasound has ensured the detection of 2/3 of total aneuploidies of the study. CONCLUSION: The first trimester ultrasound allows early detection of a large number of aneuploidies and fetal malformations.

[Imperforate hymen: Can it be treated without damaging the hymenal structure?]. / Imperforation hyménéale : peut-on la traiter en préservant la virginité ?

UNLABELLED: Imperforate hymen is a rare congenital anomaly, with an incidence of about 1 in 2000 female births. It is generally diagnosed during puberty. Treatment generally consists of a hymenotomy or a hymenectomy. Because the hymen is a symbol of virginity in some communities, its destruction can be source of social problems for some girls. OBJECTIVES: We discuss the diagnostic but especially therapeutic aspects of imperforate hymens and possible surgical techniques, in particular those that preserve the hymen. MATERIAL AND METHODS: We describe the cases of 5 girls treated in our department for imperforate hymen between 2001 and 2007. Two of them required the safeguarding of the normal architecture of their hymen to preserve the appearance of virginity. We analysed diagnostic features and surgical techniques. RESULTS: The average age of our patients was 14.8 years (range: 11 and 17 years). The most frequent reason for consultation was pelvic pain with primary amenorrhea. Inspection of the vulva revealed in all cases a dome-shaped purplish-red hymeneal membrane. Hymeneal incision allowed drainage of old previously blocked menstrual blood. Three patients were treated by radial incisions of the hymen. The parents of 2 patients demanded that their hymens be preserved. Accordingly, one had a simple excision of a central flange of the hymen and the other was treated by a similar technique that also used a Foley catheter . All five patients did well after surgical treatment. The techniques used to preserve the hymen resulted in an apparently intact annular hymen. CONCLUSION: Imperforate hymen is a rare anomaly. Its diagnosis is simple. The traditional technique of radial incisions is a simple procedure that yields good results. The technique using the Foley catheter is an adequate alternative when preservation of the hymen is required.

[Pelvic actinomycosis in Tunisia: five cases]. / Actinomycose pelvienne Expérience tunisienne : à propos de 5 cas.

Actinomycosis is a rare suppurative disease due to Actinomyces species. These Gram-positive, non-acid fast anaerobic filamentous bacteria are normal inhabitants of the human body, tending to reside in the oropharynx and bowel but are occasionally found in the vagina. Pelvic actinomycosis is a rare bacterial disease in women. Clinical manifestations are various and non specific and may be acute or chronic. No consensus exists for treatment. We reviewed files and identified all five cases of pelvic actinomycosis managed at Obstetrics and Gynaecology department "A" at the Maternity Center of Tunis over an eight-year period (1998-2005). The women's average age was 39.2 years. One patient was menopausal and consulted for bleeding. The other four patients were younger and had all been using an intrauterine device (IUD) for contraception. They presented with acute clinical manifestations. Their main symptom was pelvic pain. Three women had fever, and two presented with urinary tract obstruction. All patients had surgery. A pelvic abscess was found in four cases. Laparoscopic management was possible in only one case. Laparotomy was necessary in the other four. Four women had adnexectomies, two with hysterectomy. Digestive complications occurred in three cases. Actinomycosis was diagnosed only after surgery, by the histological examination. This series confirms the difficulties encountered in the management of pelvic actinomycosis. We review the recent literature and describe the diagnostic and therapeutic procedures currently recommended. The relationship between pelvic actinomycosis and IUDs, the most common method of contraception in Tunisia, is clearly established. Clinical diagnosis of pelvic actinomycosis is difficult because the symptoms are non-specific. Laboratory tests can help by showing serious inflammation, however. Imaging findings are also non-specific and may suggest an abscess or an inflammatory or neoplastic process. Interventional radiology, specifically CT- or ultrasound-guided aspiration biopsy can facilitate diagnosis, which in any case requires a histological examination. Treatment of pelvic actinomycosis is not standardized and depends on clinical form. Medical treatment is based on long-term penicillin G. It is always necessary and may be used alone in cases of preoperative diagnosis. Surgery should be offered only in resistant cases and should always be followed by long-term antibiotic treatment. The prognosis of correctly treated pelvic actinomycosis is generally good.

[Prenatal diagnosis of trisomy 21: the Tunisian experience]. / Diagnostic anténatal de la trisomie 21: expérience du service A du centre de maternité de Tunis.

UNLABELLED: Down syndrome (Trisomy 21) is the most common fetal chromosomal abnormality in humans. Its clinical signs are now well known. Methods for prenatal screening have advanced substantially in the past two decades. OBJECTIVE: To describe our experience with prenatal diagnosis of Down syndrome, including the indications, methods and results. MATERIAL AND METHODS: This retrospective study examined cases over a 4-year period. We adopted a sequential screening strategy for patients followed in our department since the beginning of their pregnancies after informed consent. We proposed first trimester ultrasound that measured nuchal translucency thickness and followed it with maternal serum screening. Some patients underwent screening during the second trimester or third trimester ultrasound. To assess the results, we studied the mothers' epidemiological characteristics and analysed the circumstances of prenatal diagnosis of trisomy 21 (T21). RESULTS/DISCUSSION: We identified 22 cases of T21 during the study period, for a total prevalence of 0.98 per thousand. The diagnosis was prenatal in 13 cases, mainly due to ultrasound signs. Of the 14 patients seen prenatally, only 8 were followed from early pregnancy. Five had enlarged nuchal translucency (> 95th percentile). Three had positive second trimester serum screening tests. One patient had amniocentesis planned because of her age (table 1). T21 was diagnosed in the second trimester in two cases and in the third trimester in three. The major morphological abnormalities observed were cardiac. We found an atrioventricular canal defect in four cases, and fetal hydrops in two cases (Table 2). The median gestational age at diagnosis of T21 in this study was 21 weeks. The diagnosis was missed in one patient followed throughout pregnancy in our unit. The median gestational age at termination of pregnancy was 22 weeks. Only one patient chose not to terminate the pregnancy. Her fetus, delivered at term, had no major pathologies. CONCLUSION: The establishment of a screening strategy for trisomy 21 in Tunisia is necessary to reduce handicaps. It should begin by expanding first-trimester ultrasound with nuchal translucency measurement. At the same time, serum marker testing should be offered to all patients. Routine amniocentesis for advanced maternal age should be avoided.

[Eclampsia: epidemiological aspects and management of 28 patients]. / Eclampsie: profil épidémiologique et prise en charge a propos de 28 cas.

AIM: To ascertain the characteristics, clinical features, and maternal fetal outcome in eclampsia in a tertiary referral center (Service A, CMNT). METHODS: 28 case notes were retrieved retrospectively and data was analyzed descriptively. RESULTS: Twenty eight pregnancies complicated by eclampsia were identified. 14.8% of the women were nulliparous and 50% were primiparous. The mean age was 32.5 years. Mean gestational age at the time of seizures was 33.4 weeks' gestation. Twenty-two women had antepartum seizures (78.57%); 8 of the 22 had seizures at home. 6 women had postpartum seizures (21.42%). Headache preceded seizures in 17 cases (60%) hyperreflexia preceded seizures in 16 cases. 50% of women presented with systolic blood pressure (SBP) > 160 mmHg and 42.85% presented with diastolic blood pressure (DBP) > 110 mmHg. One case of maternal mortality are noted. There were 12 perinatal deaths. Three patients had intrauterine fetal deaths. CONCLUSION: Eclampsia increased maternal and perinatal morbidity and mortality. She was not found to be a progression from severe preeclampsia. There is a need to develop new methods to identify this group of patients in an effort to further reduce the prevalence of this dangerous condition.

[Prenatal ultrasound aspects of arthrogryposis multiplex congenita]. / Aspects echographiques de l'arthrogrypose congenitale multiple.

AIM: To analyze the contribution of prenatal ultrasound in the diagnosis of arthrogryposis multiplex congenital according to its type and antenatal expression. METHODS: Retrospective study led between January 1993 and November 2007. We studied the cases of arthrogryposis suspected or diagnosed by antenatal ultrasound while analyzing the circumstances of discovery, the profile of the pregnant women and the abnormal scan findings. RESULTS: 16 observations have been collected. We recovered one multiple pterigium syndrome and five observations of severe fetal akinesia sequences diagnosed in the second trimester. The arthrogryposis was part of different syndromes in other cases. Four distal arthrogryposis had been diagnosed in the second trimester. All cases suspected during the third trimester were associated to an anomaly of the amniotic fluid, mainly to a polyhydramnios. The abnormal scan findings were less specific to this term. CONCLUSION: Arthrogryposis multiplex congenital is rare. It has several morphological aspects. Some ultrasound aspects are specific in the first and second trimesters. The diagnosis is more difficult at the third trimester.

Prenatal diagnosis of ectopia cordis: case report.

UNLABELLED: Ectopia cordis is a rare and impressive malformation presenting as an isolated lesion or as part of the Cantrell's pentology syndrom. It is defined as an anomaly in which the fetal heart lies outside the thoracic cavity. THE AIM of the study is to report the prenatal diagnostic features and management of ectopia cordis. CASE REPORT: We report a prenatal diagnosis case of ectopia cordis using two-dimensional ultrasound at 19 weeks of gestation. Multiple congenital anomalies were found. The most important one was the presence of a ventral thoracoabdominal wall defect with exstrophy of the heart, liver, stomach and intestines. Histopathological examination confirmed the ultrasound findings. Due to severity of the malformations, termination of pregnancy was made.

A double-blind randomized controlled trial of mifepristone or placebo before buccal misoprostol for abortion at 14-21 weeks of pregnancy.

OBJECTIVE: To assess differences in outcomes of misoprostol with or without mifepristone for second-trimester abortion. METHODS: A randomized, double-blind, placebo-controlled trial of buccal misoprostol following placebo or 200mg mifepristone was done in Tunisia among women presenting for abortions at 14-21 weeks of pregnancy between August 2009 and December 2011. Women with a live fetus, a closed cervical os, no cervical bleeding, and no contraindications to study drugs were eligible and underwent randomization (block size 10). Participants returned 24 hours later to receive 400 µg buccal misoprostol every 3 hours until complete fetal and placental expulsion (maximum 10 doses, five per 24-hour period). The primary outcomes were rates of complete uterine evacuation at 48 hours and time to expulsion. RESULTS: A total of 120 women were evenly randomized to treatment. Complete uterine evacuation at 48 hours was recorded in 55 (91.7%) women in the combined group versus 43 (71.7%) in the misoprostol alone group (relative risk 1.28; 95% confidence interval 1.07-1.53). Mean time to complete abortion was 10.4±6.6 hours in the group who received mifepristone versus 20.6±9.7 hours in the misoprostol alone group (P<0.001). Side effects were similar in both groups. CONCLUSION: Adding mifepristone before misoprostol can improve the quality of second-trimester abortion care by making the process faster.

Expanding medical abortion in Tunisia: women's experiences from a multi-site expansion study.

From November 2000 to July 2001, 321 consenting women were enrolled at four sites across the country in an effort to demonstrate that mifepristone medical abortion could safely be used by providers throughout Tunisia. Women who met the study's inclusion criteria were given 200 mg oral mifepristone and offered the choice of taking 400 microg oral misoprostol 2 days later either at home or at the clinic. At follow-up, women were examined to determine completed abortion status and surveyed to gauge their satisfaction with the method. Ninety-six percent of women had a successful abortion using this method. Women expressed a strong preference for home use of misoprostol, indicating that it is more confidential (34%), easier (28%) and requires fewer clinic visits (28%). The high rate of success, demonstrated safety and acceptability of the method in new facilities and with new providers suggests that medical abortion can be safely expanded to new settings with reasonable levels of training and supervision.

The medical abortion experiences of married and unmarried women in Tunis, Tunisia.

CONTEXT: The study explores the social dimensions of abortion in Tunisia and offers evidence supporting the provision of medical abortion to special populations, such as young and unmarried women. METHODS: For this study we recruited 222 women (unmarried: n = 101, married: n = 121) at three clinics in Tunis, Tunisia, from April 1999 to March 2001. All eligible women who consented to participate were administered a simplified regimen of medical abortion consisting of 200 mg oral mifepristone + 400 microg oral misoprostol 2 days later either at home or in the clinic. RESULTS: Our results demonstrate that unmarried women (94.8%) are as likely as married women (94.1%) to have a successful abortion using this regimen. We noted a strong initial preference for home administration of misoprostol among both groups (unmarried: 73.3%, married: 80.2%), which grew even stronger after the procedure. Women indicated that home administration is desirable because transportation to the clinic is expensive (32.7%), home administration is more confidential (26.3%), easier and more convenient (12.8%). Both groups expressed a high degree of satisfaction with the method. CONCLUSIONS: Medical abortion with the option of home administration of misoprostol is safe and feasible for special populations; such as unmarried women in Tunisia.

[Subcapsular liver hematoma, severe complication of pregnancy toxemia. A case report]. / L'hematome sous capsulaire du foie, complication severe de la toxemie gravidique. A propos d'un cas.

Subcapsular liver hematoma is a rare and severe complication of pregnancy. This event is already known to have a poor maternal and foetal prognosis. The authors report a case of spontaneous rupture of subcapsular hematoma of the liver in 40 year old multiparous. Confirmation of diagnosis is obtained by abdominal echotomography or TOM. The surgical treatment of this hematoma joints the traumatic surgery of the liver. In every case foetal extraction by cesarean section constitutes the first therapeutic procedure.

[Sulprostone in the treatment of uterine inertia. Report of 60 cases]. / Place du sulprostone dans la prise en charge des inerties uterines. A propos de 60 cas.

The serious haemorrhages of the delivery still one of the first causes of maternal mortality. We report an analytical study over a period of 18 months and gathering 60 cases of haemorrhage of the delivery by uterine inertia having imposed the recourse to the sulprostone. The average age of the patients was 31 years, the average parity wasv1.9, the rate of childbirth per Caesarean was 65%. The uterine surdistension was the principal etiology of the uterine inertia. The average time of administration of the sulprostone was 10 mn. No complication related to the product was noted. The effectiveness of the treatment was observed in 93.3% of the cases, with 4 cases of failure.