Increased plasmatic soluble HLA-G levels in endometrial cancer.

Human Leukocyte Antigen-G (HLA-G) is known as an immune suppressive molecule; it interacts with several immune cells and inhibits their functions. HLA-G molecule is highly represented in pathological conditions including malignant transformation. To the best of our knowledge this is the first study that focuses on the expression of soluble HLA-G (sHLA-G) in endometrial cancer (EC). We aimed at exploring sHLA-G plasma levels and its prognostic value in EC. We examined total sHLA-G expression as well as the sHLA-G1 and HLA-G5 isoforms expression in plasma samples from 40 patients with EC and 45 healthy controls by a specific sandwich ELISA. Immunoprecipitation and Coomassie blue staining were performed to explore the presence of plasmatic sHLA-G monomers and dimers. sHLA-G plasma level was significantly enhanced in patients with EC compared to healthy controls (p = 0.028). Additionally, HLA-G5 molecules were highly represented than sHLA-G1 molecules in EC, at the borderline of significance (p = 0.061). Interestingly, sHLA-G has been shown to be increased in early stages (Stages I and II) as well as in high grade EC (Grade 3) that is associated with rapid spread of the disease (p = 0.057). sHLA-G positive EC plasma were majorly in monomeric form (75%). Clinically, all the HLA-G dimers were detected in early stages and in high grade of EC. Our data strengthen the implication of HLA-G molecules in EC etiology and especially in progression.

Are the Wells Score and the Revised Geneva Score valuable for the diagnosis of pulmonary embolism in pregnancy?

OBJECTIVES: To evaluate and to compare the predictive accuracy of the Wells score and the revised Geneva scores for the diagnosis of pulmonary embolism in the pregnant and postpartum population. STUDY DESIGN: All pregnant or post-partum patients with a suspected PE and for whom a diagnostic imaging testing was performed (VQ scintigraphy or computed tomography pulmonary angiography) over a 3-year period were included in the study. The Wells and Revised Geneva Scores were calculated on the same cohort of patients and dichotomized into low and intermediate/high probability groups. The sensitivities and specificities were calculated. Overall accuracy was determined using receiver operator characteristic curve analysis. RESULTS: A total of 103 patients were included. The overall prevalence of PE was 26.2% (27/103). Using the Wells Score, the prevalence of patients with PE in the low, intermediate and high probability categories was 20.5%, 43.5% and 50% respectively. Using the Revised Geneva Score, the prevalence of patients with PE in the low, intermediate and high probability categories was 17%, 36.2 and 33.3% respectively. In low risk groups of the Wells score and the simplified revised Geneva score the prevalence of PE was not statistically significantly different: respectively: 20.5% and 17.5% (p = 0,232). The agreement on clinical assessment using the Wells score and using the revised Geneva score was weak (κ coefficient = 0.154). In total, 26 (25.2%) patients were classified differently using the 2 scores. There was no significant difference in the overall accuracies of the Wells (0.67, 95% CI 0.54-0.79) and Revised Geneva Scores (0.64, 95% CI 0.52-0.76) as determined by the area under the ROC curves (P = 0.628). The sensitivity, specificity, PPV and NPV of the Wells score and the revised Geneva score were respectively: 40.7%, 81.5%, 44%, 79.4% and 62.9%, 59.2%, 35.4%, 81.8%. CONCLUSION(S): The Wells score and the revised Geneva seems not to be valuable in the pregnant and post partum population. A specific risk score of PE for pregnant and postpartum population is needed to reduce the rate of unnecessary imaging studies, especially in this specific population were the use of radiation and contrast agent is problematic.

Vulvar cancer in Tunisia: Epidemiological and clinicopathological features multicentric study.

OBJECTIVE: To describe for the first time the epidemiologic and clinico-pathologic characteristics of vulvar cancer in Tunisia. DESIGN: Two parts are distinguished in this study: Part1: Multicentric retrospective study about the characteristics of all cancer cases diagnosed during a 17-years period (January 1998-December 2014) in three departments of Gynecology and Obstetrics: one in south Tunisia and two in the capital. Part 2: To determine the Incidence trend of invasive vulvar cancer in North Tunisia 1994-2009, on the basis of North Cancer Registry of Tunisia. RESULTS: A total of 76 cases of vulvar cancer were recorded. The median age at diagnosis was 65.4years and 86.9% of patients were more than 55years old. The symptomatology was dominated by vulvar pruritus in 48.7%. The average size of the tumor was 3.96cm. Stage III was the most frequent (53.7%) followed by stage II (28.3%). Only 10.4% of tumors were at stage I. The most common histologic type of vulvar malignancy was squamous cell carcinoma (SCC) (94.7%). Standardized incidence varied from 1.2/100 000 (1994) to 0.5/100 000 (2009). There was significant decrease of Standardized incidence (APC of -8.8% per year, 95% CI: -5.5%, -9.0%-p<0.001). CONCLUSION: Vulvar cancer in Tunisia is a rare disease, occurs mostly in elderly women, and is diagnosed at advanced stages. Our findings emphasize that a greater effort should be made to facilitate early diagnosis, as treatment in earlier stages is less extensive and potentially curative.

Correlation between umbilical resistance index and fetal growth: Pilot study.

AIM: To investigate normal pregnancies to determine whether there is a relationship between umbilical resistance and fetal growth. METHODS: This prospective study was conducted in three academic departments. Third trimester routine prenatal ultrasonography was used to estimate fetal weight and measure umbilical resistance index (RI). After delivery the birthweight was noted, along with the time interval between the ultrasound and the delivery, and then the weekly weight gain was calculated. These data were then used to determine the relationship between fetal growth and umbilical artery RI. RESULTS: Mean patient age was 32 ± 4.8 years; mean RI was 0.62 ± 0.07, and mean weight gain was 186.4 ± 63.9 g/week. Mean percentage weight gain relative to the estimated weight on third trimester ultrasound was 8.86 ± 3.8% per week. There was an inverse linear relationship between umbilical artery RI and fetal growth: percentage of weight gained per week relative to the estimated weight during third trimester ultrasound (%/week) = [31.3 - (36.1 × RI)] × 100. CONCLUSION: In normal pregnancies there seems to be a linear relationship between umbilical RI measured at 31-34 weeks of gestation and average fetal growth in the third trimester. The greater the resistance index, the lower the weight gain.

[Early postpartum discharge: outcomes and risk factors of readmission]. / Sortie précoce en post-partum: résultats et facteurs de risque de ré hospitalization.

The objective of this study is to evaluate the practice of early postpartum discharge by analyzing maternal readmission rates and identifying readmission risk factors. This is a prospective and analytical study of 1206 patients discharged from hospital on postpartum day 1. For each patient we collected the epidemiological data, the course of pregnancy and childbirth. We identified the causes of readmission and their evolution. Cesarean delivery rate was 42%. Maternal readmission rate was 0.99%. The average length of stay in hospital after readmission was 26 hours. Intestinal transit disorders were the most frequent reason for consultation (50% of cases) followed by fever (25% of cases). The readmission risk factors identified in our study were: cesarean section (p = 0.004), emergency cesarean section (p = 0.016) anemia (P < 0.001) and thrombopenia (p = 0.003). Early postpartum discharge seems a safe option for the mother and their newborn children subject to the ability to clearly communicate health information to the patient and to the compliance with selection criteria.

[Leiomyoma of the bladder causing the destruction of a kidney]. / Léiomyome vésical entraînant la destruction d'un rein.

Leiomyoma of the bladder is a rare benign tumor deemed to have a good prognosis after surgical treatment. This is unfortunately not always true. We report the case of a 33 year-old patient who consulted for lumbar pain on right side. Exploration of patient revealed bladder floor solid tumor with non-functioning right kidney and left urinary tract dilation. Cystoscopy objectified solid tumor of the right perimeatal bladder. Tumor biopsies were performed together with the insertion of a left double J stent. Anatomo-pathologic study showed leiomyoma of the bladder. The patient underwent laparoscopic myomectomy. The postoperative course was uneventful. Pathological effect and sequelae was complete distruction of kidney.

[Neu-Laxova syndrome: Three case reports and a review of the literature]. / Syndrome de Neu-Laxova : rapport de trois cas et revue de la littérature.

INTRODUCTION: The Neu-Laxova syndrome (NLS) is a rare autosomal recessive and early lethal disorder. It is characterized by severe intra-uterine growth retardation, abnormal facial features, ichthyotic skin lesions and severe central nervous system malformations, especially microlissencephaly. Others characteristic features associated with fetal hypokinesia sequence, including arthrogryposis, subcutaneous edema and pulmonary hypoplasia, are frequently reported in NLS. PATIENTS AND METHODS: The clinicopathological characteristics of NLS are described in three cases with striking prenatal diagnostic findings and detailed post-mortem examinations. A review of the literature is undertaken with a focus on molecular basis. RESULTS: We present three new patients with NLS: one stillbirth male and two female newborns, delivered at 29, 35 and 40 weeks of gestational age, respectively. Characteristic ultrasound findings included hydramnios, severe intra-uterine growth restriction, craniofacial and cental nervous system anomalies. The cytogenetic study, performed in one case, was normal. The post-mortem examination revealed characteristic abnormalities in all three cases, that allowed to make a prompt diagnosis of the NLS. Data from these patients suggest that the NLS represents a heterogeneous phenotype. This feature has been highlighted in the literature. CONCLUSION: The SNL is a lethal developmental disorder characterized by phenotypic heterogeneity with striking neurological defects. It is underpinned by genetic heterogeneity. It can be caused by mutations in all three genes involved in de novo L-serine biosynthesis: PHGDH, PSAT1 and PSPH. Hence, the NLS constitutes the most severe end of already known human disease, i.e. serine-deficiency disorder.

Efficacy and safety of pelvic packing after emergency peripartum hysterectomy (EPH) in postpartum hemorrhage (PPH) setting.

OBJECTIVES: To study the safety and effectiveness of pelvic packing in the control of post emergency peripartum hysterectomy (EPH) bleeding in a postpartum hemorrhage (PPH) setting. STUDY DESIGN: From 39 patients with a severe PPH leading to an EPH (January 2010-December 2013), we identified a group of 17 patients requiring a pelvic packing (packing group) and a second group of 22 patients not requiring a pelvic packing (non-packing group). For each group, transfusion requirements were recorded from time of PPH diagnosis to end of the surgical procedure (P1: Period 1) and from that point to the end management in the SICU (P2: Period 2). Laboratory values, transfusion requirements and complications were compared between the 2 groups. Statistical comparisons were performed using Mann-Whitney test, Fisher's exact test and chi-square test. A p-value <0.05 was considered statistically significant. RESULTS: Pelvic packing was successful in the control of bleeding in all the cases. During the second laparotomy for pack removal, none of the patients developed complications such as bowel injuries or necrosis. The 2 groups were similar in term of laboratory values at the end of the surgical procedure and 24h after the end of the surgical procedure. The number of PRBC units required in P1 was higher in the packing group compared to the non-packing group (16.6±5.3 vs 14±5; p=0.04), however the decrease in the amount of PRBCs transfused between P1 and P2 was higher in the packing group (13.3) compared to the non-packing group (9.1) (p<0.01). The incidence of febrile morbidity was higher in the packing group compared to the non-packing group (53% vs 9%; p=0.04); but no significant difference was shown in term of generalized sepsis, as well as renal failure, ARDS, deep vein thrombosis, pulmonary embolism and MOF. CONCLUSION: The pelvic packing is a valuable method with a high success rate in the control of hemorrhage after an EPH in PPH setting with a low rate of complications. It is quite simple and quick to perform, and therefore should be kept in mind by all obstetricians as a lifesaving technique.

[Cœliac disease: a rare cause of recurrent miscarriages]. / La maladie cœliaque: une cause rare de fausses couches à répétition.

Cœliac disease is an autoimmune disorder associated with Gluten intolerance resulting in progressive destruction of the villi of the small intestine. Symptoms are very diverse and can occur at any age. Abortive illness is a rare symptom leading to the detection of cœliac disease. We report the case of a patient with a history of 12 consecutive miscarriages whose etiology was finally related to cœliac disease.

[Macrosomia, shoulder dystocia and elongation of the brachial plexus: what is the role of caesarean section?] / Macrosomie, dystocie des épaules et élongation du plexus brachial: quelle est la place de la césarienne?

The delivery of a macrosomic infant is associated with a higher risk for maternofoetal complications. Shoulder dystocia is the most feared fetal complication, leading sometimes to a disproportionate use of caesarean section. This study aims to evaluate the interest of preventive caesarean section. We conducted a retrospective study of 400 macrosomic births between February 2010 and December 2012. We also identified cases of infants with shoulder dystocia occurred in 2012 as well as their respective birthweight. Macrosomic infants weighed between 4000g and 4500g in 86.25% of cases and between 4500 and 5000 in 12.25% of cases. Vaginal delivery was performed in 68% of cases. Out of 400 macrosomic births, 9 cases with shoulder dystocia were recorded (2.25%). All of these cases occurred during vaginal delivery. The risk for shoulder dystocia invaginal delivery has increased significantly with the increase in birth weight (p <10-4). The risk for elongation of the brachial plexus was 11 per thousand vaginal deliveries of macrosomic infants. This risk was not correlated with birthweight (p = 0.38). The risk for post-traumatic sequelae was 0.71%. Shoulder dystocia affectd macrosoic infants in 58% of cases. Shoulder dystocia is not a complication exclusively associated with macrosomia. Screening for risky deliveries and increasing training of obstetricians on maneuvers in shoulder dystocia seem to be the best way to avoid complications.

[Which surgical strategy to adopt for the management of postpartum haemorrhage and how to improve the effects of hypogastric arteries ligation?] / Quelle stratégie chirurgicale adopter devant une hémorragie du post-partum et comment améliorer les résultats de la ligature des artères hypogastriques?

The objective were to identify the success factors of bilateral hypogastric arteries ligation and to assess its role in surgical treatment of postpartum hemorrhages. We conducted a retrospective study of all the cases of postpartum hemorrhage requiring surgical treatment between January 2008 and December 2011. The study included 88 patients (0,47% of all births). Uterine atony was the most common etiology (64,8 % of patients). Bilateral ligation of the hypogastric arteries was performed in 81.8% of patients. When surgery was the first choice treatment, its success rate was 66%. This rate was variable depending on the etiology of hemorrhage, the presence or the absence of hemostasis disorders and the time between diagnosis and surgical treatment. In case of uterine atony, the association with a second conservative technique, when the first was inadequate, helped stop the bleeding in 98% of cases. Ligation of hypogastric arteries is an effective surgical technique for the treatment of postpartum hemorrhage. Its success rate has increased thanks to early implementation and to the association with other conservative techniques.

[The opening of the internal cervical os predicts cervical ripening better than Bishop's score in nulliparous women at 41 weeks gestation]. / L'ouverture de l'orifice interne du col prédit mieux l'issue de la maturation cervicale que le score de Bishop chez les nullipares à 41 semaines d'aménorrhée.

INTRODUCTION: The objectif was to evaluate ultrasound measurement of the opening of the internal cervical os in the prediction of cervical ripening and to compare it with Bishop's score. METHODS: We conducted a prospective study of 77 nulliparous women admitted to hospital in labor at 41w gestation, with Bishop's Score < 6, over a 10-month period, between July 2012 and April 2013. The measurement of the opening of the internal cervical os was performed using transvaginal ultrasound and Bishop's score was determined by clinical examination. All patients received prostaglandins for cervical ripening. RESULTS: Cervical ripening was successful among 63 patients (81%). Bishop's score and the opening of the internal cervical os were statistically associated with the success or failure of cervical ripening. The success rate of cervical ripening was 100% when the opening of the internal cervical os was equal to or greater than 5 mm (sensitivity: 54%, specificity: 86%). ROC curves showed that the measurement of the internal cervical os was more predictive of cervical ripening than Bishop's score (area under the curve: 0.733 and 0.704 respectively). CONCLUSION: Compared to Bishop's score, echographic measurement of the opening of the internal cervical os is more predictive of the success of cervical ripening in nulliparous women at 41 weeks of pregnancy with an unfavourable cervix.

[Confrontation between ultrasound and fetopathological examination following therapeutic abortion performed in a maternity clinic in Tunisia]. / Confrontation échographique et fœtopathologie après interruption thérapeutique de grossesse dans une maternité Tunisienne de référence.

This study aims to evaluate the value of prenatal ultrasound diagnosis by comparing it with the results of the fetopathological examination in case of therapeutic interruption of pregnancy for fetal indication. We conducted a retrospective descriptive and analytical study carried out over a three-year period from January 2013 to December 2015. It involved 66 fetuses autopsied after therapeutic interruption of pregnancy for fetal indication. Fetopathological examination confirmed ultrasound results in 63 cases (95.4%). In 18 cases (27.2%) there was a full match between the results of the prenatal diagnosis and those of the autopsy. Nine percent of fetal malformations were detected in the first trimester. The majority of malformations (72%) were detected in the second timester. Neurological malformations were the most frequent (60%), dominated by hydrocephalus and anencephaly. This study shows that, in our clinical context, even if ultrasound diagnosis is often non-exhaustive, its signs indicating the need for interruptions of pregnancy are correct. Fetopathological examination is used, in this case, to detect unknown malformations, making it possible to specify the diagnosis and to implement a strategy for subsequent pregnancies.

Antenatal Diagnosis of a Rare Neural Tube Defect: Sincipital Encephalocele.

Context. Fetal sincipital encephalocele is one of the most serious congenital neural tube defects with a high risk of mortality and neonatal morbidity. Prenatal diagnosis of this malformation is important in fetal medicine. Case Report. We report a case of prenatal diagnosis of sincipital encephalocele using ultrasound and MRI imaging. The diagnosis was done at 25 weeks of gestation by identifying an anterior cephalic protrusion through a defect in the skull. Conclusion. Through this case, we discuss the differential diagnosis, management, and prognosis of such lesions.