FIGO opinion paper: Drivers and solutions to the cesarean delivery epidemic with emphasis on the increasing rates in Africa and Southeastern Europe.

Cesarean delivery rates are rapidly increasing in Southeastern Europe (to more than 60%), North Africa (with a rate as high as 72% in Egypt), and in urban areas in Southern Africa (a rate of over 50% in Lagos, Nigeria). Data on the background to these increases are scarce, but likely to include poor birthing facilities in general hospitals, convenience for the doctor, private medicine, fear of litigation, socioeconomic status, shortage of midwives and nurses, and disappearance of vaginal instrumental deliveries. Options to reverse cesarean delivery trends are discussed. In this context there is a need to be better informed about how women are being counseled regarding vaginal or cesarean delivery. The long-term consequences in subsequent pregnancies for mothers and children may well be largely ignored, while these risks are highest in LMICs where higher birth numbers are desired. FIGO has begun discussions with obstetric and gynecologic societies, healthcare bodies, and governments in several countries discussed in this article, to find ways to lower the cesarean delivery rate. The requests came from the countries themselves, which may prove beneficial in helping advance progress.

Cecal volvulus: A rare post-partum complication.

INTRODUCTION AND IMPORTANCE: Cecal volvulus is a rare clinical condition. It is characterized by axial twist of caecum, terminal ileum and the ascendant right colon around their mesenteric pedicles. The main pathophysiologic mechanism is cecal hyper mobility associated to precipitating factor such as colonic tumor, abdominal mass or pregnancy. Cecal volvulus during pregnancy was reported, but it remains exceptional during postpartum period. CLINICAL PRESENTATION: We report a case of cecal volvulus occurring in 37-year-old woman ten days after cesarean section delivery. She presented an acute abdominal pain associated to vomiting and nausea. X ray imaging and abdominal CT showed a large colonic obstruction, the caecum was dilated and located in the left hypochondrium. An open surgery was performed showing twisted bowels involving the caecum, the ileocecal junction and the right colon. There were necrotic areas on the colonic wall. Right hemicolectomy was performed with end to side ileo-colostomy. The evolution was marked by a serious septic shock causing patient's death. CLINICAL DISCUSSION: Cecal volvulus is a rare condition. Its suggested mechanism associates cecal hyper mobility to a precipitating factor. Increased uterine volume may explain cecal volvulus during pregnancy. In post-partum period, it may be explained by rapid uterine size variation. Cecal volvulus diagnosis is challenging. In fact, its symptoms can be confused with post operative ileus after cesarean section delivery. Delayed management leads to worst prognosis. CONCLUSION: Cecal volvulus during post-partum period is a rare condition, it may be serious in case of delayed diagnosis.

Abdominal wall endometriosis: A challenging iatrogenic disease.

INTRODUCTION AND IMPORTANCE: Abdominal wall endometriosis is a rare clinical condition associated with abdominal pain and psychologic disorders. It's pathophysiology remains unclear. Clinical history and imaging findings are necessary for the diagnosis. Its management is challenging, and requires close collaboration between gynaecologists and visceral surgeons specially in complex procedures. The aims of our study are to present risk factors, clinical presentation, imaging findings and management features. It was a retrospective descriptive study including fifteen patients presenting abdominal wall endometriosis. Data about age, medical history, imaging findings, surgical procedures and outcome are reported. CASES PRESENTATION: Fifteen women were included in our study. The most common symptom was cyclic abdominal pain. Twelve of them had history of caesarean section, and three had history of myomectomy. All patients underwent ultrasound and MRI. We performed surgical excision to all cases. One patient needed large excision with abdominoplasty procedure. CLINICAL DISCUSSION: Abdominal wall endometriosis is a rare clinical condition with unclear pathophysiology. It occurs frequently after gynaecologic or obstetric surgery. Most reported complaint was catamenial abdominal pain with abdominal wall mass. Ultrasonography, computed tomography and MRI are useful for diagnosis, specially to eliminate differential diagnoses. Abdominal wall endometriosis management is based on surgery. Excision goals are to remove the mass and to confirm histological diagnosis of parietal endometriosis. CONCLUSION: Parietal endometriosis is a rare and challenging condition with unclear pathophysiology. It requires specific management. This pathology will be encountered more frequently considering the increasing rate of caesarean section.

Oncoplastic breast surgery to treat recurrent granulomatous abscess: A new approach.

INTRODUCTION AND IMPORTANCE: Granulomatous mastitis is a rare chronic and benign inflammatory breast disease with challenging diagnosis and management. No commonly recognized recommendations are established. Despite of medical and surgical approaches, relapse rate remains high. CASE PRESENTATION: A 43-year-old patient with a history of granulomatous mastitis presented recurrent breast abscess associated with skin fistula. She underwent Racquet mammoplasty procedure inspired from oncoplastic techniques. Medical and cosmetic outcomes were satisfactory. CLINICAL DISCUSSION: Granulomatous mastitis is challenging to diagnose and can be confused with inflammatory breast malignancies. It's associated with high relapse rate. Management of granulomatous mastitis is complex. Its treatment varies from medical management based on steroid therapy and immunosuppressants to surgical approach. In case of recurrent breast abscess, surgical techniques inspired from oncoplastic breast surgery, can be used to improve cosmetic outcome. CONCLUSION: Oncoplastic surgical technic may be considered as an efficient procedure to manage recurrent breast granulomatous abscess.

Pelvic actinomycosis: A confusing diagnosis.

INTRODUCTION AND IMPORTANCE: Actinomycosis is a rare chronic and suppurative infection caused by anerobic Gram Positive bacteria: actinomyces. Pelvic location is extremely rare, usually associated with history of IUD contraception and doesn't have specific signs. Pelvic actinomycosis diagnosis may be confused with pelvic gynecologic malignancies or abscess. We present a retrospective and descriptive study of twelve patients with pelvic actinomycosis diagnosed and managed in our department from January 2000 to December 2011. CASES PRESENTATION: The patients' mean age was 47 years. 75% of them had a history of IUD for a mean period of 8,44 years. Pelvic pain was the most common complaint. In four cases, pre-operative clinical presumption was tubo-ovarian abscess. Gynecologic malignancies were suspected in 8 patients. Pelvic actinomycosis management was based on surgery and long-term antibiotic. CLINICAL DISCUSSION: Pelvic actinomycosis is an extremely rare chronic infection, presenting 3% of human actinomycosis. Common clinical presentations include vaginal discharge, tubo-ovarian abscess and pelvic tumors mimicking gynecologic malignancies. It is difficult to diagnose. Association with IUD history was recognized. Management is based on surgery and long-term antibiotic administration. CONCLUSION: Pelvic actinomycosis is an extremely rare chronic infection. This entity is difficult to diagnose. Accurate diagnosis can reduce complications and unnecessary surgeries, and can preserve fertility.

Lotus petal flap for unusual indication: A recto-vaginal fistula with perineal defect after vaginal delivery.

INTRODUCTION AND IMPORTANCE: Three to five percent of vaginal deliveries are complicated by third or fourth degree perineal laceration. Misdiagnosed perineal injuries may be associated with a poor sexual and psychological prognosis. Management of old perineal tears and laceration is challenging with a high failure rate. In such condition, interposition tissue technic or local flap can be a good surgical alternative. Lotus petal Flap, usually indicated in management of large perineal defect in gynecological oncology can be used. CASE PRESENTATION: We report a case of 32-year-old women presenting complex and relapsed perineal fistula after vaginal delivery associated with perineal defect treated by lotus petal flap with a good outcome. DISCUSSION: Perineal defects are commonly encountered after oncologic, traumatic or infectious perineal excisions and described as a challenging situation. In case of perineal defects after obstetrical tears, no validated surgical filler technics are recommended. Inspired from oncologic surgical technics to fill perineal defects, Lotus Flap can be used. Its advantages are to mobilize a satisfactory tissue volume to fill important perineal defect compared to the small bulbocavernous flap with a hidden scar comparing to gracilis muscle flap. This technic is associated with a good sexual and self-imaging outcome. CONCLUSION: Lotus petal flap may be required as a solution to manage perineal defect in case of perineal fistula. This technique provides aesthetic and good results for perineal reconstruction.

Spontaneous acute intussusception in a pregnant woman.

Acute intussusception in adults is rare and particularly so in pregnant women. Its incidence ranges from 0.067% to 0.0015% (Choi et al., 2005 Choi et al. (2005) [1]). The non-specific presenting symptoms may be attributed to the pregnancy itself, making the diagnosis difficult. When it happens, however, it causes considerable morbidity and mortality for the pregnant woman and the fetus. In adults, such intussusceptions are mainly secondary to an intestinal disease and frequently a tumor. We present the case of a 21-year-old pregnant woman who was diagnosed of spontaneous acute intussusception at nine weeks of gestation and therapeutic management.

[How to predict spontaneous resolution of early pregnancies?]. / Comment prédire la résolution spontanée des grossesses jeunes ?

BACKGROUND: Assessment of early pregnancy is indicated in women with suspected abnormalities. It is based on biochemical assessment and on trans vaginal sonography . AIM: To identify clinical, biological and ultrasonographic parameters that are predictive of spontaneous pregnancy resolution. methods: A prospective observational study was performed interesting women with a positive pregnancy test without visualization of the pregnancy on the initial scan. All parameters measured during the initial visit were tested by univariate and multivariate analysis to identify parameters predicting spontaneous resolution of pregnancy. RESULTS: A total of 2675 women were included in the study. In 94 cases (4 %) the location of pregnancy was unknown. Univariate and multivariate analysis showed that four parameters contributed significantly to the predictive power of the logistic model: Absence of pain (p =0,036), endometrial thickness < à 12 mm (p =0,021), initial serum ßhCG level < 1000 UI/l (p =0,015) and progesterone level < 29 nmol/l (p <0,001). CONCLUSION: Women with a high probability of spontaneous resolution of their pregnancies can benefit from a spaced monitoring until the rate of ß-hCG will be negative.

Prediction of ectopic pregnancy in early pregnancy of unknown location.

BACKGROUND: Women having pregnancies of unknown location (PUL) can be defined as those having positive pregnancy test when no pregnancy is visualized on transvaginal ultrasound (TVS). AIM: To identify diagnostic parameters which are predictive of ectopic pregnancies in women with early pregnancies of unknown location. METHODS: We undertook a prospective observational study of pregnant women with suspected early pregnancy complications. Ninety-four patients were classified as having a pregnancy of unknown location (PUL) by transvaginal ultrasound; blood sample was taken on presentation to measure the serum human chorionic gonadotrophin (,-HCG) and progesterone levels. All collected data were tested by univariate analysis and then analyzed in a stepwise procedure to form a logistic model for predicting ectopic pregnancy. RESULTS: A total of 2675 women were referred for suspected early pregnancy complications. In 94 (4%) patients the location of the pregnancy was unknown. Three parameters were found to be statistically significant for predicting ectopic pregnancy:progesterone level, vaginal bleeding associated with pain and the presence of free fluid in the pouch of Douglas. The overall model described by these variables offer a sensitivity of 79 %and a specificity of 59% in the prediction of ectopic pregnancy. CONCLUSION: Logistic regression model can help in the clinical decision-making in women with pregnancy of unknown location.

Primary leiomyosarcoma of broad ligament.

BACKGROUND: Primary broad ligament leiomyosarcoma (LMS) is an extremely rare tumor with few well-documented cases. We are aware of 15 previously reported observations. AIM: Report of a new case. CASE: In this report we report a case of a right pelvic sidewall leiomyosarcoma with involvement of the appendix in a 49-year-old woman. A hysterectomy, bilateral salpingo-oophorectomy, omentectomy and appendicectomy were done, without complications. The patient died five months later. The case illustrates the difficulty of correct diagnosis before intervention. On this occasion, review of the literature confirms that this site remains unusual and the management is difficult.

Primary leiomyosarcoma of the vagina. Case report and literature review.

BACKGROUND: The vast majority of primary vaginal cancers are squamous cell carcinoma. The leiomyosarcoma of the vagina is extremely rare neoplasm. It comprising 2% to 3% of vaginal malignancies. Only 77 cases have been reported up to date in Anglo-Saxon literature . AIM: Report of a new case CASE: We report a case of a patient 43 years old, single and presented a tumor of 7 cm to the detriment of the posterior wall of the vagina. The treatment consisted of a radical colpohysterectomy followed by postoperative radiotherapy. After 40 months, she is still alive without local or distant recurrence. CONCLUSION: This is a rare observation. The surgery is the basic treatment, the poor prognosis of these tumors remains linked especially to the histological grade.