A case of cutaneous endometriosis developed on an abdominal scar.

BACKGROUND: Endometriosis is characterized by the presence of an ectopic endometrial tissue. It affects between 1% and 5% of women in reproductive age. Its main clinical symptoms are dysmenorrhoea and infertility. Among women having had abdominal surgery for any gynecological reason, the prevalence of endometriosis is between 15% and 50%. CASE REPORT: We report the case of a 15 year-old patient who underwent surgery twice : once for appendicitis two years before and once for acute salpingitis and tubo-ovarian abscesses one year before. Laparotomy was performed by Pfannenstiel incision. The post operative course was uneventful. The patient reported the gradual emergence of two bluish nodes on the abdominal scar. These nodules became painful and turgid during the menstrual period. She also reported the issue of blood from the abdominal scar during menstruation. The abdominal examination, performed during the menstrual period, showed a scar of good quality and two regular shiny and bluish cutaneous nodules measuring 1 cm in size. These elements were firm and painless. An endometriosis node on the scar of laparotomy was suspected. Surgery was performed in order to remove both nodules. At surgery the depth of nodules reached the top of the abdominal fascia of the major rights. The content of these nodules was chocolate brown. The histo-pathological examination confirmed that these nodules contained ectopic endometrial tissue. CONCLUSION: The etiopathogeny of endometriosis is still a subject of debate. This case illustrates the possibility of occurrence of endometriosis on abdominal scars after laparotomy: an unusual location.

Ovarian abscess as a complication of assisted reproduction techniques: a case report.

BACKGROUND: AMP makes true great strides these last decades. Logically some complications were noticed even due to ovarian puncture such as hemorrhage, perforation or infection. The aim of this report is to try, through a review of literature, to draw the attention of physicians to a rare entity, ovarian abscess after follicle aspiration for in-vitro fertilization, and to means of prevention. CASE REPORT: We report a 38-year-old woman who was plainting from lower abdominal pain located in the left iliac fossa one month after failed IVF trial. The pain was associated with fever and vomiting. The patient's past medical history involves 2 myomectomys (2003-2007). On admission, her temperature was 38.9 degrees C and her blood pressure was 90/60 mm Hg. Physical examination found nondistended abdomen. Tenderness to deep palpation in the left lower quadrant, without peritoneal signs, was detected. No masses were palpated. Mild tenderness in the left cul-de-sac was found. A full blood count showed a white cell count of 17,500 cells/mm3 with 84.5% polymorph nuclear cells, CRP 173 mg/dl. Pelvic ultrasound shows a left latero uterine mass; right ovary and the uterus are unremarkable; there was no free abdominal fluid. The laparotomy was performed 24 hours later and a left ovarian abscess was found. The treatment was conservative. Antibiotics were associated during 15 days. The clinical evolution was satisfying. CONCLUSION: The ovarian puncture might be technically difficult, incomplete, and even impossible which exposes to a greater infection risk. An ultrasound evaluation of ovarian accessibility is necessary before starting an IVF attempt, especially in case of overweight or history of abdominal or pelvic surgery, endometriosis, tubal abnormalities or myomas. The treatment is based on surgery and antibiotics.

[Imperforate hymen: a series of 13 cases]. / Imperforation hyménéale: A propos de 13 cas.

BACKGROUND: Imperforate hymen is a rare congenital malformation. Patients often remain asymptomatic until puberty and present in early adolescence with cyclic abdominal pain. Early diagnosis and treatment must be performed in order to prevent morbidity. THE AIM of this study was to asses management of this disease. METHODS: A retrospective study of 13 cases of imporforate hymen diagnosed in the department of obstetrics and gynecology "A" of Charles Nicolle hospital of Tunis from January 1980 to December 2008. The clinical features and the management are discussed. RESULTS: The mean age was 14 years. All patients were single and had primary amenorrhea. They presented with pelvic pain in 9 cases and bladder urinary retention in 4 cases. Secondary sexual characters were present and normal in all cases. Inspection of the vulva could establish the diagnosis in all cases. Pelvic ultrasounds showed the hematocolpos in all cases. The latter was associated to a hematometria and a Douglas pouch liquid in 2 cases. Hematocolpos was evacuated by hymeneotomy under oxytocin infusion in all cases. Eight patients were treated by cruciform incisions and five patients were treated by radial incisions of the hymen. The volume of hematocolpos varied from 250 ml to 2000 ml. One patient underwent surgery twice for restenosis of the imperforate hymen. CONCLUSION: Imperforate hymen is a rare anomaly. Its diagnosis is simple and could be established at birth by a systematic screening. More frequently, the diagnosis must be suspected in front of a primary amenorrhea associated to abdominal pain in order to prevent complications.

Incidence, clinical analysis, and management of ovarian fibromas and fibrothecomas.

OBJECTIVE: The objective of the study was to identify the incidence, diagnosis, and therapeutic and histological particularities of ovarian fibromas and fibrothecomas. STUDY DESIGN: This was a retrospective study of 24 patients who underwent surgical treatment for ovarian fibromas and fibrothecomas between January 1994 and December 2006. Clinical, ultrasonographic, tumor marker, therapeutic, and histologic data were analyzed. RESULTS: The mean age of patients was 49 years. Thirteen patients were menopausal. Ultrasonographic findings were ovarian echogenic tumor in 6 cases, hypoechogenic tumor in 12 cases, mixed tumor in 6 cases, and anechogenic tumor in 1 case. Cancer antigen-125 level measured in 21 cases was abnormal in 3 cases. Twenty-one patients underwent laparotomy. Three patients underwent laparoscopy; however, 1 was converted to laparotomy because of a suspected tumor. Histological findings were 16 fibromas and 9 fibrothecomas. CONCLUSION: Ovarian fibromas and fibrothecomas are uncommon, accounting for 3.3% of ovarian tumors. These lesions often occur in perimenopausal and menopausal patients. Clinical, ultrasonographic, and tumor marker data remain the best preoperative approach currently available for ovarian tumors. However, the diagnosis remains histological.

[Benign ovarian tumors during pregnancy. A review of 26 cases]. / Tumeurs de l'ovaire au cours de la grossesse: a propos de 26 cas.

OBJECTIVE: To identify the particularities of ovarian tumors during pregnancy. METHODS: A retrospective study of 26 patients who underwent surgical treatment for ovarian tumors during pregnancy between January 1993 and December 2005. Clinical, ultrasonographic, therapeutic and histological data were analysed. RESULTS: The mean age of patients was 26.5 years. The circumstances under which the ovarian tumors were discovered consisted of adnexal torsion in 57% of cases, chronic pelvic pain in 15% of cases and at routine ultrasonographic scan in 26% of cases. 20 patients underwent cystectomy by laparotomy and 4 patients underwent laparoscopic cystectomy. 3 patients underwent adnexectomy. One abortion occurs 2 days after an adnexectomy. 17 deliveries occur at term. Histological findings were functional cyst in 4 cases, serous cyst in 11 cases, mucinous cyst in 2 cases and dermoid cyst in 7 cases. CONCLUSION: Ovarian tumors during pregnancy are rare. They are usually serous, functional and dermoid cysts. Laparoscopic ovarian cystectomy offers significant advantages with respect to laparotomy for the pregnant patient.

[Accuracy of frozen section diagnosis: an analysis of 1695 consecutive cases]. / Fiabilite de l'examen extemporane: analyse de 1695 examens consecutifs.

BACKGROUND: The intraoperative frozen section is a well established procedure for rapid diagnosis that helps in making therapeutic decisions. AIM: Assessment of the accuracy of frozen section diagnosis and analysis of the causes of its discordance. METHODS: A retrospective review of 1695 surgical specimens performed in 1207 patients between January 2002 and April 2005. Frozen section results were compared with the final diagnoses in paraffin sections. RESULTS: The frozen section diagnosis was benign in 84.2%, malignant in 10.2% and borderline in 0.4% of all cases. The frozen section result was deffered to permanent section in 5.2%. The sensitivity, specificity, positive and negative predictive values were 84.6%, 99.8%, 98.2% and 97.8% respectively. Overall diagnostic agreement was 97.5% (Kappa=0.88). Frozen section diagnosis was incorrect in 2.5% of cases. Most of the discrepancies were false negative cases frequently due to sampling errors and misinterpretation. False positive cases were always related with misinterpretation. CONCLUSION: The frozen section evaluation is highly accurate and reliable. However, the surgeon and the pathologist must be aware of its limitations.

[Diagnostic value of immunohistochemistry in ovarian sex cord-stromal tumors]. / Apport de l'immunohistochimie dans le diagnostic des tumeurs stromales de l'ovaire.

BACKGROUND: The ovarian tumors' diagnosis is based on biological and radiologic tests but only the histological examination associated to an immunohistochemical study allow best diagnosis. AIM: The purposes of this study is to examine inhibin and other markers immunoreactivity to ovarian sex cord-stromal tumors and their histological mimics and to discuss its value in the differential diagnosis. METHODS: We report a retrospective study of 31 cases of ovarian sex cord-stromal tumors and review the clinical, pathologic and immunohistochimical features of these tumors. RESULTS: The average age of our patients was 51,3 years with an average size of 8,4cm. Immunostaining for inhibin was positive in 66% of granulosa cell tumor, in 50% of Sertoli-Leydig cell tumor and in 54% of thecoma-fibroma group. Inhibin immunoreactivity was more important than with cytokeratin and epithelial membrane antigen, but less marked than with CD99, vimentin, smooth muscle actin, desmin and S-100 protein. CONCLUSION: The results of this study show that although it is not complete specificity, inhibin, contrarily to the other markers, can be used to help in the distinction between ovarian sex cord-stromal neoplasms and the other primary and metastatic tumors.

Fetal intracranial haemorrhage and periventricular leukomalacia after second-trimester intrauterine fetal death in monochorionic twins.

BACKGROUND: Intrauterine fetal death of one twin in a monochorionic pregnancy may be associated with adverse neurologic sequelae in the surviving co-twin. OBJECTIVE: The aim of this report is to try, through a review of literature, to predict the risk of cerebral impairment in the survivor co-twin and to assess the feasability of neurosonography and magnetic resonance imaging in the prenatal diagnosis of brain damage. CASE REPORT: We report a case of monochorionic twins complicated by a fetal death at approximately 23 weeks' gestation with pathologically confirmed leukomalacia in the surviving twin. A detailed sonographic evaluation of the intracranial anatomy of the surviving twin was performed. Fetal magnetic resonance imaging was offered as well. The patient opted for termination. Evacuation was performed at 24 weeks, and pathologic evaluation revealed severe cerebral infarction with haemorrhage. CONCLUSION: However difficult, a multidisciplinary prenatal counselling should be performed in order to study the prognosis and to try to prevent cerebral palsy in the surviving co-twin.

Spontaneous ovarian hyper stimulation syndrome and deep vein thrombosis in a non pregnant woman: case report.

AIM: To assess aetiological factors and complications in a patient with severe ovarian hyperstimulation syndrome (OHSS) and internal jugular vein thrombosis. CASE: A 27-year-old non pregnant woman with bilateral ovarian masses who had underwent laparotomy for suspicion of malignant tumor. The pathological examination disclosed malignancy and the diagnosis of OHSS were confirmed. The postoperative evolution was complicated by internal jugular, subclavian vein thrombosis and pulmonary embolism. All biological parameters were negative. The evolution was good. CONCLUSION: The incidence of thromboembolism in women with OHSS is low and the typical finding is deep venous thrombosis in the neck area. Preventive measure of OHSS is very important, and the patients must be treated timely and correctly once OHSS occurs.

Laparoscopic management of ovarian cysts in postmenopausal women.

AIM: To report our experience with laparoscopic treatment of ovarian cysts in postmenopausal women. METHODS: During the period January 2000 to December 2006, 18 postmenopausal women were admitted for laparoscopy. The indications for the operation were an ovarian cyst that did not meet the criteria of a simple cyst, or was larger than 4 cm RESULTS: The median age of the patients was 55 (range 43-82). The mean time since menopause was 6 years (range: 1-30 years). All laparoscopies were successfully accomplished. No case of malignancy was found. Histological examination revealed 15 serous cysts, one mucinous cyst, one endometroid cyst and one functional cyst. Neither intraoperative nor post-operative complications occurred. There was no surgery-related mortality. Mobilization of all women was carried out within 12 h of the operation. The mean hospitalization stay was 2 days. CONCLUSIONS: Laparoscopic management of carefully selected ovarian cysts is an appropriate alternative for exploratory laparotomy even in elderly patients with or without underlying diseases.

[Management of dermoid ovarian cysts. Report of 58 cases]. / Prise en charge des kystes dermoides de l'ovaire. A propos de 58 cas.

OBJECTIVE: To assess diagnosis and therapeutic problems of der mo id cysts.' METHODS: A retrospective study of 58 patients having undergone surgery for dermoid cyst between 1991 and 1999. Clinical, ultrasonographic and therapeutic data were analysed. RESULTS: Dermoid cyst accounts for 21.8% of all ovarian tumours. The mean age of patients was 34.75 years (17-73 years). 48 patients (82.7%) presented symptoms. In 10 cases (17.3%), the cysts were discovered during gynaecological and or ultrasonographic examination. The pre-operative diagnosis was precised with the help of ultrasonography in 52 cases, with standard abdominal X-ray in 19 cases and with computed tornography scan in 4 cases. Laparotornic and laparoscopic treatment were performed in respectively 51 and 7 cases. One case of granulornatous peritonitis after laparoscopic surgery was observed. Histological findings were 64 dermoid cysts and 2 serous cysts. Dermoid cysts were bilateral in 6 cases (10.34%) and associated with contro-laterally serous cyst in 2 cases. CONCLUSION: Dermoid cysts are tumors encountered mainly in young patients. After a careful pre-operative assessment, the laparoscopic approach is very interesting. However, a laparotomy should be considered in case of suspected malignancy.

[Struma ovarii. Report of a malignant and a benign case]. / Struma ovarii. A propos d'un cas malin et un cas benin.

Struma ovarii is a rare type of ovarian teratoma, composed entirely or in part of thyroid tissue. Malignant Struma ovarii were exceptional. We report one benign and one malignant cases of Struma ovarii. We insist upon their rarety and the difficulty of preoperatory diagnosis. Prognosis is good after surgery.