[Tubo-ovarian actinomycosis ruptured in the sigmoid colon]. / Actinomycose tubo-ovarienne pseudotumorale fistulisée au côlon.

Actinomyces is an anaerobic, gram-positive bacteria saprophyte of the oral cavity, lungs, genital and gastro-intestinal tracts. Tubo-ovarian infection is rare. The authors report a case of tubo-ovarian abscess, due to actinomyces ruptured in the sigmoid and diagnosed in a 30-year-old woman using an intra-uterine device for more than 5 years. After salpingo-oophorectomy and partial sigmoid resection, pathology confirmed the diagnosis.

[Voluntary surgical sterilization by laparoscopy in cases of cardiovascular diseases. Prospective study of 19 cases]. / Stérilisation chirurgicale volontaire per-coelioscopique en cas de maladie cardiovasculaire. Etude prospective à propos de 19 cas.

Nineteen women with cardiovascular disease underwent voluntary per-celioscopic sterilisation under local anesthesia at the La Rabta Maternity and Neonatology Centre, Tunis, Tunisia, between 1 July 1988 and 31 March 1989. There were 8 cases of hypertension, 1 of mitral insufficiency and 10 cases of surgically treated valve disease (6 cases of commissurotomy for mitral stenosis and 4 valve replacements). Mean parity of the women was 5 and mean age 35.4. Their educational level was low. Thirteen of them had never used contraception and 4 had had at least 2 therapeutic abortions. Local anesthesia with analgesia was well appreciated since 15 women remained calm and experienced no pain. The procedure involved minimal pneumoperitoneum and Trendelenburg. Recourse to minilaparotomy under general anesthesia was necessary in only one case. The authors stress the importance of counselling patients at the onset and of cooperation with cardiologists and anesthesiologists, and discuss peri-operative treatment protocols (anticoagulants, antibiotics) in particular.

[Induction of labor in fetal death in utero using a Foley catheter and extra-amniotic perfusion of physiologic serum]. / Déclenchement du travail dans les morts foetales in utero par sonde de Foley et perfusion extra-amniotique de sérum physiologique.

Nineteen cases of induction of labour by Foley catheter and extra-amniotic perfusion of normal saline for fetal death in utero occurring more than 24 weeks after the LMP were collected in the La Rabta Maternity and Neonatology Centre, Tunis, during the final 6 months of 1987. The mean age of the women was 27.8 and their mean parity 2.9. Two patients had uterine scars. The mean duration of the pregnancy was 33.3 weeks and initial Bishop score was 4 or less. When the catheter fell out, after 26.4 hours on average, the Bishop score had improved by 4.5 points. Labour occurred spontaneously in 5 cases and required oxytocin stimulation in 5 cases. The interval between induction and fetal expulsion was 44.4 hours. Delivery was followed by routine manual evacuation of the uterus. Two complications were seen: one case of accidental rupture of the membranes and one of rupture of the uterus affecting a scarred uterus. The authors point out certain risk factors concerning rupture of the uterus which should be considered to be contraindications to the method. With the exception of these situations, this method of induction is recommended because of its advantages of efficacy, safety and low cost, in particular in developing countries.

[Voluntary surgical sterilization by laparoscopy in the immediate post partum period. Prospective study in 55 cases]. / Stérilisation chirurgicale volontaire per-coelioscopique dans le post-partum immédiat. Etude prospective à propos de 55 cas.

Fifty five voluntary sterilisations were carried out during the immediate post-partum period via celioscopy and under local anesthesia at the La Rabta maternity and neonatology centre, Tunis, between 1 July 1988 and 31 March 1989. The women had a mean age of 34.6, mean parity of 6 and living children of both sexes. Their socio-economic level was low. They had never used any form of contraception in 50 p. cent of cases and 5 among them had undergone at least one termination of pregnancy. Acceptability of local anesthesia with analgesia was good since 71 p. cent of women remained calm during the procedure and experienced no pain. Among the 16 women who reported pain, this occurred above all when the tubes were grasped (10 cases). There were no notable complications. However, sterilisation was not possible in two cases.

[Pregnancy following female surgical sterilization. A study apropos of 38 cases]. / Grossesses survenues après stérilisation chirurgicale féminine. Etude à propos de 38 cas.

A study of 38 cases of pregnancy that occurred after sterilisation between 1st January 1981 and the 30th September 1987 at the Maternity and Neonatology Department of La Rabta, Tunis. This complication is rare because the overall global figure for failure is 7.1/1000. This is what is found in the literature. When we came to analyse the failures we found there were two groups: 15% of these failures were in women who had been sterilised correctly. This also happens when women have been sterilised with the Yonn ring as with Pomery's ligation technique. In this case when patients become pregnant there is a big chance of their being ectopic (2 tubal pregnancies as against 5 intrauterine pregnancies). 85% of failures were due to technical faults. They particularly happen with laparoscopic sterilisation (85%). They are usually due to lack of experience on the part of the operator. In any case patients do not like it; in fact 73.7% of the patients asked for a termination of the pregnancy and sterilisation was repeated in 87% of the cases.

[Intramural pregnancy: a case report]. / Grossesse intramurale: un cas.

Implantation into the muscle wall is one of the rarer forms of ectopic pregnancy. We report an uncomplicated case which was discovered during therapeutic termination of pregnancy at 10 weeks. We point out how valuable the use of ultrasound during the operation is for making the diagnosis when suction does not provide adequate quantities of products.

[Maternal mortality at the Maternity and Neonatology Center in Rabta of Tunis from 1986 to 1989]. / La mortalité maternelle au Centre de Maternité et de Néonatologie de la Rabta de Tunis de 1986 à 1989.

We studied 29 cases of maternal death occurring over a period of 3 years in the "Centre de Maternité et de Néonatologie de La Rabta-Tunis"; managed by the same staff. 42,028 live births occurred during the study years with 43,220 total births from April 24th 1986 to April 23rd 1989. The maternal mortality rate was 69 per 100,000 live births. A maternal age of under 35, nulliparity and grand multiparity were found, as is well known, to be risk factors. Maternal transfer in obstructed labour from rural maternity units raises the maternal death risk 12 times: 14 deaths out of 29 occurred in transferred patients. Haemorrhage represents a quarter of the causes of death (8 cases) while anaesthetic accidents were responsible for one in six maternal deaths. Some factors were not found such as abruptio placentae, while others such as eclampsia were reduced. We concluded that the maternal mortality rate even though it has been reduced over the last 3 decades it is still high compared with developed countries. We can cut it in half by avoiding maternal transfer in labour.

[The role of culdocentesis in the diagnosis of ectopic pregnancy. Prospective study of 478 cases]. / Place de la culdocentèse dans le diagnostic de la grossesse extra-utérine. Etude prospective à propos de 478 cas.

Four hundred and seventy height Culdocenteses were carried out in cases of possible ectopic pregnancy between the 20th September 1986 and 31st December 1987. Culdocentesis was considered to be positive if 2 cm3 or more of dark non-coagulated blood was removed, and negative if only a yellow liquid or blood stained serum was removed. It was not conclusive if nothing could be aspirated or if the blood was coagulated. Of the 94 cases where culdocentesis was positive, 74 were found to have an ectopic pregnancy. There were 20 false positive cases (due to 5 haemorrhagic ruptures of follicles, 3 refluxes of menstrual blood, 2 with other aetiology, and 10 without known cause). There were 21 cases of ectopic pregnancy in the 293 cases where culdocentesis was non-conclusive. Of the 91 cases where culdocentesis was negative, a second culdocentesis showed an ectopic pregnancy. It was positive 11 days after the first. In our series this diagnostic test was reliable in 77.1% of cases. Laparotomy was carried out in 22.3% of cases and only 18.6% had to have laparoscopy thanks to the use of culdocentesis.

[Wegener's granulomatosis and pregnancy. A case]. / Granulomatose de Wegener et grossesse. Une observation.

Pregnancy concomitant with Wegener's granulomatosis is extremely rare: so far, only four cases have been published. The authors report a fifth case where the disease appeared during the post-partum period, a situation which has already been noted in two of the published cases. Interruption of a subsequent pregnancy was followed by a flare-up of the disease resulting in the patient's death. This suggests that post-partum and post-abortum are probably instrumental in the onset and deterioration of Wegener's granulomatosis. The two patients previously reported who received immunosuppressants combined with corticosteroids had no flare-up after delivery. It seems permissible to prescribe such a therapeutic combination before and after delivery or abortion, especially since the fear of foetal toxicity from these drugs seems to be exaggerated.