Regulated Expiratory Methods During Childbirth Process: A Randomized Controlled Trial.

OBJECTIVES: To evaluate the impact of a regulated expiratory method (REM) on the childbirth process. METHODS: This was a randomized trial. Study population included all first-time mothers with a spontaneous onset of labour, at an early stage, and a fetus in cephalic presentation with a normal weight for gestational age. The evaluated intervention was REM based on the use of a specific device. The primary outcome was the cesarean delivery rate. Secondary outcomes included first and second stages of labour times, rates of spontaneous and instrumental vaginal births, and pain scores. Subjective qualitative outcomes related to childbirth experience were evaluated via 2 interviews conducted with the parturient and the midwife responsible for her delivery. Intention-to-treat analysis was employed to compare the 2 groups. RESULTS: The reduction in primary cesarean rates between the 2 groups was not significant (26.7% in control group vs. 18.3% in intervention group; P = 0.274). However, REM allowed for a significant reduction in second stage (P = 0.039) and pushing effort times (P = 0.003). According to midwives, REM had a significant positive impact on parturients' breathing (P < 0.0001) and pushing effort intensity (P = 0.041). It facilitated communication with the parturient (P = 0.002). Moreover, the evaluated method had a significant positive impact on patient's childbirth experience. CONCLUSIONS: Although the reduction in immediate cesarean rates was not significant, REM has the potential to shorten labour duration, improve pain management, and ultimately improve maternal childbirth experience.

Impact of purse-string uterine suture on scar healing after a cesarean delivery: a randomized controlled trial.

BACKGROUND: Uterine closure technique can affect scar healing, potentially resulting in unfavorable gynecologic and life-threatening obstetrical outcomes. Double-layer continuous unlocked suture has been demonstrated to promote optimal residual myometrial thickness. Recently, the purse-string uterine suture technique has emerged as a viable method to enhance the healing of scars. However, the current lack of randomized trials assessing the relevance of this technique warrants further investigation. OBJECTIVE: This study aimed to evaluate the impact of purse-string uterine sutures on scar healing after cesarean delivery when compared with double-layer continuous unlocked suture. STUDY DESIGN: This was a randomized controlled trial; 126 patients with singleton pregnancies undergoing primary cesarean delivery were enrolled in 2 groups. The primary outcome was the mean residual myometrial thickness measured by saline infusion sonography 6 months after surgery by 2 sonographers blinded to uterine closure techniques. Operative time, calculated blood loss, total number of needed threads, and perioperative scar width were used for the perioperative analysis. Healing ratio and cesarean scar defect measurements were used for the 6-month analysis. RESULTS: There was no significant difference in terms of residual myometrial thickness (9.38±2.3 vs 8.4±3.9 mm; P=.187), blood loss (540 [146-982] vs 495 [241-903] mL; P=.815), or operative time (6.2 [5.2-7] vs 6 [5.3-7] minutes; P=.977). Achievement of purse-string uterine suture required significantly fewer threads (1 [1-1] vs 2 [1-2]; P<.001) and fewer hemostatic complementary sutures (1 [1-1] vs 1 [1-2]; P=.013). Scar width was significantly lower with purse-string uterine sutures (50 [40.5-50.5] vs 70 [60-70.5] mm; P<.0001). Purse-string uterine sutures allowed a higher healing ratio (1 [0.9-1] vs 0.84 [0.59-1]; P=.003) and significantly fewer cesarean scar defects (12% vs 35%; P=.018) compared with double-layer continuous unlocked suture. CONCLUSION: Despite resulting in no difference in residual myometrial thickness, purse-string uterine closure seems to be associated with better uterine scar healing on the basis of a higher healing ratio, and a lower rate of cesarean scar defects compared with double-layer continuous unlocked suture.

Pseudoxanthomatous salpingitis: An uncommon lesion of the fallopian tube.

Pseudoxanthomatous salpingitis (PXS) is an uncommon condition characterized by the presence of pigment-laden histiocytes within the lamina propria of the fallopian tube. Less than 30 cases of PXS have been reported in the literature. We herein report a case of PXS associated with an endometriotic cyst.

Rare and severe neural tube defect: Craniorachischisis totalis.

Craniorachischisis totalis is an uncommon and severe form of neural tube defect. It is characterized by anencephaly and spina bifida throughout the vertebral column accompanied by herniation of neural tissue and meninges. Hepatic calcification in the fetus is rare and its clinical significance is not fully established.

Agreement between digital vaginal examination and intrapartum ultrasound for labour monitoring.

Sonographic approach for labour monitoring was introduced in order to improve the shortcomings of digital vaginal examination (DVE). This was a prospective study. We aimed to investigate the agreement between transperineal ultrasound (TPUS) measurements and DVE during first and second stages of labour. Patients in the first stage of labour were included. Cervical length (CL), cervical dilation (CD), cervical position (CP), foetal head descent (FHD) and foetal head rotation (FHR) were assessed by both DVE and TPUS. Agreement between two methods was examined. Eighty-five patients were included. One hundred and eighty-three paired TPUS and DVE assessments were performed. Satisfactory agreement between both methods was obtained regarding CL: systematic bias= -0.05 cm (95%CI, -0.13; 0.03), R = 0.7, p<.0001; CD: systematic bias = 0.07 cm (95%CI, -0.08 to 0.22), R = 0.93, p<.0001 and FHD: systematic bias = 0.83 cm (95%CI, 0.685-0.977), R = 0.55, p<.0001. There was a low correlation for the assessment of CP (kappa = 0.24) and FHR (kappa = 0.06). DVE was inefficient in determining FHR especially during latent phase with failure and error rates of 86% and 36%, respectively. A conceptual sonopartogram covering the hole childbirth process is presented based on reliable ultrasound measurements.Impact StatementWhat is already known on this subject? Digital vaginal examination (DVE) is used worldwide for labour monitoring. However, it is far from perfect. Some investigators have raised concerns about the value of the Bishop score because it is a subjective measure with great intra- and inter-observer variability, affected by a physician's clinical experience. Moreover, this method is intrusive, uncomfortable and may increase the risk of infection. The sonographic approach for labour monitoring was introduced in order to improve the shortcomings of DVE. Multiple studies focussed on the reliability of the sonographic method in assessing each parameter during labour. Hassan et al. were the first to determine whether it is feasible to perform assessment in the first stage of labour based only on US, and to describe a method of recording these observations: the 'sonopartogram'.What do the results of this study add? The outcomes concluded that sonographic approach was at least as accurate as the clinical examination. Moreover, a conceptual sonopartogram covering the hole childbirth process is presented based on reliable ultrasound measurements.What are the implications of these findings for clinical practice and/or further research? Clinical relevance of this sonopartogram should be evaluated in further studies.

Double-layered purse string uterine suture compared with single-layer continuous uterine suture: A randomized Controlled trial.

BACKGROUND: With the aim of preventing cesarean scar defects, we introduced a new technique involving a purse string uterine suture. To date, this uterine suture technique has not been formally evaluated. The objective of the study was to test the hypothesis that compared to single layer continuous uterine suture (SLCUS), a double layered purse string uterine suture (PSUS) significantly reduces cesarean scar defect (CSD) rates, without increasing the perioperative maternal morbidity. METHODS: A prospective randomized study. Primary outcome was the rate of CSD. 100 patients were enrolled in 2 groups according to the uterine suture technique. A hysterosonography was performed by the same senior obstetrician blinded to the uterine suture technique 6 months after surgery .Operative time and calculated blood loss (CBL) were used for the short time analysis. Uterine and CSD measurements were used for the mid time analysis. RESULTS: Despite a longer operative time with PSUS (7.17 ± 2.31 min Vs. 6.31 ± 3.04 min, p = 0.028; p <10‾³); there was no significant difference in terms of CBL (520 ± 58 with PSUS vs. 536 ± 50 ml, p = 0.724). There was a significant decrease in the rate of CSD with PSUS: 6.66% Vs.40% with SLUCS; p<0.001. Moreover, SLUCS was the leading risk factor for CSD: adjusted OR=6; 95% CI [0-1], p<10‾³). CONCLUSION: Compared to single layer continuous suture, double layered purse stringuterine suture significantly reduces cesarean scar defect rates, without increasing the perioperative maternal morbidity.

The extraperitoneal French AmbUlatory cesarean section technique leads to improved pain scores and a faster maternal autonomy compared with the intraperitoneal Misgav Ladach technique: A prospective randomized controlled trial.

OBJECTIVE: To determine whether the French AmbUlatory Cesarean Section (FAUCS) technique reduces postoperative pain and promotes maternal autonomy compared with the Misgav Ladach cesarean section (MLCS) technique in elective conditions. STUDY DESIGN: One hundred pregnant women were randomly, but in a non-blinded manner, assigned to undergo FAUCS or MLCS. The primary outcome was a postoperative mean pain score (PMPS), and secondary outcomes were a combined pain/medication score, time to regain autonomy, surgical duration, calculated blood loss, surgical complications, and neonatal outcome. RESULTS: Women in the FAUCS group experienced less pain than those in the MLCS group (PMPS = 1.87 [1.04-2.41] vs. 2.93 [2.46-3.75], respectively; p < 0.001). Six hours after surgery, the combined pain/medication score for FAUCS patients was 33% lower than that for MLCS patients (p < 0.001). FAUCS patients more rapidly regained autonomy, with 94% reaching autonomy within 12 h vs. 4% of MLCS patients (p < 0.001). There were no differences in maternal surgical or neonatal complications between groups. CONCLUSIONS: Our results indicate that FAUCS can reduce postoperative pain and accelerate recovery, suggesting that this technique might be superior to MLCS and should be more widely used. One potentially key difference between FAUCS and MLCS is that MLCS includes 100 mcg spinal morphine anesthesia in addition to the same anesthesia used by FAUCS. Any interpretation of apparent differences must take the presence/absence of morphine into account.

The autonomous choice of delivery mode: A survey of Tunisian women.

BACKGROUND: The recent overmedication of childbirth process ignores mothers wishes.  In Tunisia, women are not involved in decision-making during childbirth. AIM: To analyze the opinion of a sample of Tunisian women regarding the possibility of making their own informed choices during childbirth and to determine the factors that may influence the requested mode of delivery. METHODS: This was a 5-month descriptive cross-sectional survey. Were included: Tunisian women who were consultants or practitioners at a university obstetrics and gynaecology department in Tunis; female medicine students or members of women dedicated social network groups. The questionnaire was applied during direct interviews or posted online. The main judgment criteria was: participants' opinion regarding access to autonomous choice of delivery mode. Participants were initially enrolled into 2 groups: •    group of women requesting access to autonomous choice. •    group of women who do not request access to autonomous choice.  The participants were then divided into 2 other groups according to the requested mode of delivery: •    Group : Cesarean section •    Group: Vaginal delivery. A multivariate logistic regression was used to identify risk factors that may have influenced the responses. RESULTS: The total number of participants was 197. Access to autonomous choice was requested by 63.45% of the participants. These were mainly: consultants: OR=7.76 95% CI [0.56-106.16] or practitioners: OR=3.93 95% CI [0.01-829.03], with a high level of education OR=1.22 95% CI [0-1174.40], with a past positive birth experience: OR=1.24 95% CI [0.27-5.74]. The women who did not claim access to autonomous choices were mainly: doctors OR=-0.31 95% CI [0-32.58], midwives: OR=-0.08, 95% CI [0-18.12] or even housewives OR=-0.42 95% CI [0-68.88]. The women who preferred to give birth by Caesarean section were mainly: practitioners: OR=2.03 95% CI [0.53-7.81], nulliparous OR=2.51 95% CI [0.243-25.98], pregnant OR= 4.44 95% CI [1.03-19.13], with a history of cesarean delivery: OR=5.68 95% CI [0.64- 50.43] or even a history of negative childbirth experience: OR=1.87 95% CI [0.22-15.85]. CONCLUSION: The request for an Autonomous choice during childbirth most often expresses a certain number of beliefs and fears. Obstetricians should take time to listen and explain, in order to understand the mother's anxieties and enable her to resolve them. Based on the principles of justice, the access to autonomous choices during childbirth process should be universally recognized by legislations and thus fairly respected for all.

Tunisian Women's childbirth experience.

BACKGROUND: The current international context considers birth experiences as a focal point for women's health. However, this subject is rarely discussed in Tunisian literature. AIM: Analyze birth experience of a sample of Tunisian women. METHODS: Transverse descriptive study. All women who gave birth in the study unit during August 2018 were included. A direct interview was conducted during the first postpartum day. The questionnaire used was developed by a multidisciplinary team and included 55 questions, divided into 4 items. We compared the group of women who described their delivery as physically or psychologically traumatic to the group of women who reported a serene birth experience.    A multivariate analysis of variance was used to identify the variables that can influence childbirth experience. RESULTS: During the study period, 170 women were included with a response rate of 81%. Severe anxiety about delivery was reported by 74.5% (n = 127) of women. Delivery was experienced as a trauma in 48.2% (n = 82) of cases. In the group of women who expressed a negative experience, we found a significant association with the use of media and internet as a source of information (p=0.001) and repeated vaginal examinations (p=0.001). Pain significantly impacted women's experience (p = 0.02). Finally, main risk factors of a negative childbirth experience were: uterine revision: OR=7.04 95%CI [0.27-177.68]; Emergency caesarean section: OR=3.04 95%CI [0.94-9.85] and vaginal delivery: OR=2.13 95%CI [0.45-10.14]. CONCLUSION: We can intervene on modifiable factors with the introduction of a specific program preparing women for their childbirth and the improvement of the professional practices. However, the issue will benefit from being discussed and addressed at the national, cultural and societal levels.

French ambulatory cesarean: Mother and newborn safety.

OBJECTIVE: To evaluate mother and newborn child safety after French ambulatory cesarean (FAUCS). METHODS: Prospective comparative cohort study in Tunisia (January-June 2018). Pregnant women indicated for primary or repeat cesarean at term underwent FAUCS or Misgav Ladach cesarean (MLC). Surgical outcomes, overall morbidity, and maternal autonomy during recovery were compared. RESULTS: Among 112 deliveries, 60 were performed by FAUCS and 52 by MLC. FAUCS was feasible in all cases; surgeons achieved a completely extraperitoneal approach in 39 (65.0%) cases. The main difficulty experienced was fetal extraction. Longer operative procedures were recorded in the FAUCS group; however, women in the FAUCS group reported lower pain scores (3 [2-5] vs 4 [3.7-5], P<0.001) and were more likely to decline analgesics (10 [17.0%] vs 0 [0%], P<0.001). They experienced greater autonomy during recovery (median [interquartile range] time to standing, 2 [1.0-2.5] vs 12.8 [8.9-17.9] hours, P<0.001; time to full meal, 4 [3-6[ vs 26.5 [21-31] hours, P<0.001; effective time to hospital discharge, 1 [1, 2] vs 2 [2, 3] days; P<0.001). CONCLUSION: Implementation of the FAUCS technique was safe and successful, and improved maternal condition after cesarean. These short-term results need long-term validation by randomized trials.

Impact of high fidelity simulation on perceptions and professional skills in obstetrics.

BACKGROUND: In our country, the introduction of simulation as a teaching tool for obstetric emergencies is very recent. Several studies are being developed to evaluate its benefit in the continuing education of health professionals. OBJECTIVE: To evaluate the impact of a continuing medical education program based on High fidelity simulation drills (HFS) on professional skills in obstetrics. METHODS: 91 Learners were able to benefit from HFS continuing education program. Mean job tenure was 7.94 years [1-40]. RESULTS: We were able to highlight a positive impact of level 1 with satisfaction rates of more than 90%. 92% of participants said they left with tools applicable in the function framework. Midwives and emergency physicians were the most satisfied. The general evaluation before the beginning of the training had revealed an average score of 7.12/20 [2/20-13/20]. The variance of scores initially obtained was significantly related to the profession of the learner (p <0.0001, R = 0.61). We found significant improvement in post-training scores (p = 0.0001) and a mean difference of +1.46 [-6, +8.66]. These results highlight a level 2 impact of HFS training on learners' knowledge.

Severe gestational hypertriglyceridemia: a rare but serious situation.

The severe hypertriglyceridemia during pregnancy is a rare condition. It is a problem for diagnostic, prognostic and therapeutic. This dyslipidemia benefit from specific and effective treatments, but it is still poorly codified. Dietary is still the essential therapeutic, but fetal extraction should also be considered if the gestational age permits. Post-partum monitoring is required but etiologic thorough is not recommended if the triglycerides rate normalizes. The major complication of hypertriglyceridemia should be actively sought because of important maternal mortality rate.

Diagnosis of fetal occiput position using transperineal ultrasound.

OBJECTIVE: To compare Transperineal (TP) and Transabdominal (TA) ultrasound in the assessment of fetal head position during the second stage of labor. METHOD: A prospective comparative Study including low risk parturients. The assessment of fetal head position was performed for each patient at full dilation. The ultrasound examination was performed by one examiner using TP technique first then TA. A routine digital vaginal examination was performed by a different examiner blinded to ultrasound findings. Considering TA as reference, the three methods were compared. RESULTS: Fifty two patients were enrolled in the study group. Agreement between the clinical examination and TA ultrasound was average with Kappa index = 0.579. Agreement between TA and TP Ultrasound was good with Kappa index = 0.766. TP technique was accurate in the diagnosis of fetal head position (sensitivity =91.3%, specificity=98.38%, PPV=87.5%, NPV=98.91%). TA ultrasound was the most reliable method in case of high presentations. For lower fetal presentations, the TP approach was more relevant. CONCLUSIONS: Assuming that an accurate diagnosis of fetal head position is required before any instrumental delivery where, by definition, fetal presentation is engaged, the TP ultrasound is advised. In a single time this technique provides the necessary information about the station, and the position of the fetal head.

Successful management of acquired uterine arteriovenous malformation.

Uterine arteriovenous malformation (UAVM) is uncommon. They are usually acquired, due to previous intra uterine trauma. We report a case of acquired UAVM in a 28-years-old patient after a medical abortion, diagnosed with ultrasonography and successfully managed with uterine artery embolization.

How to adapt first trimester ultrasound education to Tunisian trainees.

OBJECTIVES: To evaluate the impact of a targeted training program on the quality of NT measures performed by OBST/GYN trainees. METHODS: Prospective study. Step1: each trainee achieved 10 T1US . All were evaluated by 2 experts. Step 2: interactive training session where participants received a detailed feedback report. Step3: each candidate performed again 10 T1US. The results obtained before and after the training session were compared. RESULTS: Step1: Herman score was 4.1 with 38% of unacceptable exams. There was no correlation between the score and the level of the training curriculum. Main difficulty was about obtaining sagittal plane. Step2: self-assigned score before the session overestimated image quality (4.5 Vs. 4.1, p=0.03). At the end of the session, It decreased to 3.1. Step3: a significant improvement of technical settings, mean score (5.4 Vs. 4.1; p <0.001) , percentage of acceptable images (85% Vs. 62%, p = 0.002) and sagittal plane (6.4% Vs. 2.9%; p = 0.003). Only 37% had significantly improved their scores. CONCLUSION: The training program evaluated in this study guides the trainee in his daily self-evaluation. This preliminary study can already open discussion on the education and quality control of the T1US in our country.

Ultrasound monitoring of cervical length in twin Pregnancies.

BACKGROUND: Preterm delivery is the major cause of adverse outcomes in twin pregnancy.  A shortened cervix at 20-24 weeks of amenorrhea is a good predictor of preterm birth in asymptomatic patients. However, there are no recommendations for serial cervical length measurements for these high risk pregnancies. OBJECTIVES: To evaluate the benefits from monthly cervical length monitoring in asymptomatic twin pregnancies. METHODS: This was a prospective study. We compared two groups of twin pregnancies (groupe 1: patients with a monthly and systematic transvaginal ultrasound measurement of the cervical length and groupe2 : patients without monitoring of cervical length) in terms of premature labor screening, mean gestational age at the diagnosis of preterm labor, time saved by tocolysis in case of preterm labor and  mean gestational age at delivery. RESULTS: Ninety nine twin pregnancies were included: 35 patients had a systematic, monthly cervical length (group1) and 64 women had a traditional prenatal care without monitoring of cervical length (group2). A significant relationship between a cervical length measured between 22 and 24 weeks of amenorrhea inferior to 30 mm and preterm labor with a high specificity (100%) and a high positive predictive value (100%). The sensitivity remains average (45%).A significant benefit was demonstrated through this systematic ultrasound measurement of cervical length for the screening of preterm labor (p=0.018), the time saved by tocolysis (p=0.023), as well as the medium gestational age at birth (p=0.046). CONCLUSION: Serial cervical length measurements seems to be a significant predictor of early preterm birth in asymptomatic twin pregnancies.

Comparison of two oxytocin administration protocols in elective cesarean section: 5 iu versus 10 iu.

Background Although Oxytocin is used systematically during caesarean section, no recommendation precise optimal dose for this indication. The bolus administration of 10 IU intravenously after extraction of the newborn, is accompanied by side effects mainly hemodynamic. Objectives To compare two Oxytocin protocols:  05 IU bolus Vs. 10 IU bolus during Cesarean section by studying their respective effectiveness (effects on uterine tone) and adverse effects. Methods A prospective randomized double-blind study including 87 term parturients for undergoing a C-section under loco regional anesthesia. Parturients were randomized into two groups depending on the injected Oxytocine dose : - Group 1 (n = 43): 10 IU + 25 IU IVD in 500 ml of serum / 3h - Group 2 (n = 44): 5 IU IVD + 25 IU in 500 ml serum / 3h. Results The variation of the heart rate and the incidence of low blood pressure were significantly greater for Group 1. No significant differences between the two groups regarding blood loss was noticed per or postoperatively. The type of digestive side effects were more common in the first group. Conclusion Administration of 5 units of Oxytocin during the scheduled C-sections is effective for uterine tone without superimposed bleeding risk, guarantees better hemodynamic stability and less side effects than the 10 units dose.

Contribution of verbal autopsy in the study of cancer mortality among reproductive-age women in Tunisia.

Background In Tunisia, the information system on medical causes of death  is based on the use of standard death certificate model based on international model recommended by the World Organization started in January 2001. However, this system is still burdened with a major death causes of under-registration. Only specific surveys on mortality have FAR generate reliable mortality indicators. Objectives to study the use of verbal autopsy in order to assess cancer mortality among Tunisian women in reproductive age (WRA) . Methods A retrospective   national RAMOS survey (Reproductive Age Mortality Study). This survey was conducted in 2010 and included all deaths of women aged 15-49 years which occurred in 2008 and were due to cancer. Data were collected from civil status records and information gathered from families and from health institution's registers. For all deaths of women aged 15-49 years, the detailed circumstances and the sequence of events leading to death were grouped on a folder called "clinical record of verbal autopsy" .Then; all folders were submitted to the independent expert. Results During the study period, 1729 deaths among women of reproductive age (WRA) were the subject of a verbal autopsy against only 708 recorded by the National death information system (NDIS). Cancer is the leading cause of death among WRA .The specific rate of cancer mortality is 17.83 per 100 000 WRA against only 7.91 per 100 000 WRA estimated by the NDIS. Breast cancer is the leading cause with 35% of all cancers and specific death rate of 6.3 per 100,000 WRA against 2.48 per 100,000 WRA recorded by the NDIS. Conclusion Verbal autopsies Verbal autopsy remains an interesting method for measuring cancer mortality in women of a reproductive age especially in countries with a defective national death information system.

Cancer mortality among reproductive age women in Tunisia.

BACKGROUND: Cause-of-death data are critical to formulating good public health programs. In Tunisia, the mortality surveys of reproductive age women are specifically interested in maternal mortality and we do not have data on deaths from noncommunicable diseases including cancer. AIM: To identify the main cancers causing death among Tunisian women in reproductive age. METHODS: A retrospective   national RAMOS survey (Reproductive Age Mortality Study). This survey was conducted in 2010 and included all deaths of women aged 15-49 years which occurred in 2008 and were due to cancer. Data collection was based on the verbal autopsy method. RESULTS: In Tunisia, cancer is the leading cause of death among reproductive age women, especially breast cancer. The most exposed women are housewives (64.4%), aged 40-49 years (55.3%), living in urban areas (62.2%), belonging to the middle tercile classification of households (45.4%) and reaching a level of basic education (44.2%). CONCLUSION: Cancer should receive priority funding of health care for this population in order to improve its diagnosis and treatment, with a special motion for breast cancer.