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.

[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.

[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.

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.

[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.

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.

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.

[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.

[Uterine rupture: report of 41 cases]. / Ruptures uterines: a propos de 41 cas.

To establish the epidemiological profile, of patients who presented a uterine rupture, as well as the obstetrical follow up, the neonatal outcome and the prognosis factors. A retrospective study of 41 cases of uterine rupture treated in the maternity center of Tunis during a 5-year period. The frequency of uterine rupture was 1.38%@1000 of births. Rupture in scarred uterus was found in 58.5% of the cases against 41.5% in sain uterus. Three risk factors were statistically significant in our series: cesarian section, multiparity and high fetal weight. Uterine rupture is a medico-surgical emergency causing materno-fetal morbidity and mortality.