Cornual Pregnancy: Results of a Single-Center Retrospective Experience and Systematic Review on Reproductive Outcomes.

Background and Objectives: Cornual pregnancies (CPs) are rare forms of ectopic pregnancy. When abortion does not occur, it can be a life-threatening condition for the mother and can also impair future fertility. We present our experience in the diagnosis and management of CPs. A systematic review was also conducted to investigate the reproductive outcomes after treatment. Materials and Methods: Between January 2010 and December 2022, we performed a retrospective, cross-sectional, single-center, and descriptive data collection and analysis (ClinicalTrial ID: NCT06165770). The search for suitable articles published in English was carried out using the following databases (PROSPERO ID: CRD42023484909): MEDLINE, EMBASE, Global Health, The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and Cochrane Methodology Register), Health Technology Assessment Database, Web of Science, and search register such as ClinicalTrial. Only studies describing the impact of CP treatment on fertility were selected. Results: Two studies were included in the systematic review. Seventeen patients suffering from CPs were selected. In our series, a pelvic ultrasound allowed for the diagnosis of a cornual localization in 35.30% of cases. Thirteen women (76.47%) underwent immediate surgical management. The laparoscopic approach was the most used (76.92%), with a laparotomic conversion rate of 30%. Four patients (23.52%) received medical treatment with methotrexate. After treatment, two patients managed to achieve pregnancy. Conclusions: CP is a rare form of ectopic pregnancy that can quickly become life-threatening for the mother. Ultrasound does not lead to a precise diagnosis in all cases. In the absence of complications and emergencies, laparoscopy is an approach that could be considered valid. For selected asymptomatic patients, medical treatment may be a valid alternative. The data from the studies included in the systematic review, although demonstrating a superiority of medical treatment in terms of future pregnancies, are heterogeneous and do not allow us to reach a definitive conclusion.

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.

Vitamin D Deficiency is Widespread in Tunisian Pregnant Women and Inversely Associated with the Level of Education.

BACKGROUND: Vitamin D deficiency seems to be common in pregnant women and would be associated with an increased risk of maternal and fetal poor outcomes. This study aimed to determine the prevalence and the main risk factors for vitamin D deficiency in pregnant women living in a sun-rich environment. METHODS: A total of 255 pregnant women living in Tunis City (latitude, 36 degrees N) were randomly selected at 12 - 18 weeks of gestation. Plasma 25-hydroxyvitamin D (25-OHD) was assessed by chemiluminescence immunoassay method. A logistic regression model adjusting for confounding variables was used to identify the independent risk factors for vitamin D deficiency. RESULTS: Plasma 25-OHD concentrations ranged from 4.02 to 78.3 nmol/L [median (IQR), 18.0 (13.6)]. More than 96% of the study population had 25-OHD levels below 50 nmol/L with 82.3% of women having vitamin D deficiency (25-OHD < 30 nmol/L) and 31.4% of women having severe vitamin D deficiency (25-OHD < 15 nmol/L). Daily dietary vitamin D intake [median (IQR), 3.49 (2.92) µg] was clearly lower than the recommended dose. Vitamin D deficiency was more frequent during the low-sunshine season, and in veiled women and those with an average level of education. In multivariate analysis, the independent predictors of vitamin D deficiency were low sunshine season [multi-adjusted OR (95% CI), 2.29 (1.24 - 4.22); p < 0.01], covering clothing [OR (95% CI), 2.54 (1.23 - 5.24); p < 0.05], and average level of education [OR (95% CI), 2.11 (1.09 - 5.91); p < 0.05]. CONCLUSIONS: Tunisian pregnant women, especially those with average/high level of education, are exposed to a high risk of vitamin D deficiency. The main causes of hypovitaminosis D are low sunshine exposure and little dietary vitamin D intake. Public health policies should target the awareness for optimal and safe sun exposure and adequate vitamin D dietary intake. Otherwise, tolerable vitamin D supplementation should be prescribed.

Clinical Assessment of Soluble FMS-Like Tyrosine Kinase-1/Placental Growth Factor Ratio for the Diagnostic and the Prognosis of Preeclampsia in the Second Trimester.

BACKGROUND: Preeclampsia is one of the most common and serious complications of pregnancy. Various reports have demonstrated that disturbances in angiogenic and antiangiogenic factors are implicated in its pathogenesis and have possible relevance in its diagnosis and prognosis. METHODS: In this case-control study, we enrolled 73 patients with 34 preeclamptic cases diagnosed according to clinical criteria and dosing of proteinuria. The cases were matched to controls at the same age and parity. Controls had normal tension and no apparent risk factors for preeclampsia. The dosage of PLGF and sFlt - 1 were performed and correlated to the clinical issue of each group. RESULTS: Our results show a significant decrease in PLGF levels in the cases compared to the control group (average PLGF levels in cases 28.3 pg/mL vs. 664.52 pg/mL in controls); p = 0.0006. sFlt-1 level was significantly higher in cases compared to controls. The average sFtl-1 levels in cases was 5780.72 pg/mL vs. 1886.05 pg/mL in controls; p = 0.0008. The (sFlt-1/PLGF) ratio was significantly higher in cases compared to controls (mean ratio of sFlt-1/PLGF cases is 884.12 pg/mL vs. 12.12 pg/mL in controls); p = 0.0002. Patients who developed a complication had a ratio of sFlt-1/PLGF higher than the rest of patients in the severe preeclampsia group (mean ratio of sFlt-1/PLGF 2727 pg/mL vs. 1207.41 pg/mL). The higher the ratio of sFlt1/PLGF, the shorter the period of fetal extraction was (24 hours to a ratio of 2159.16, 48 hours for a ratio of 811.9, more than 48 hours for a ratio of 184). CONCLUSIONS: PLGF and sFtl-1 could allow discrimination of women with normal pregnancies from those at high risk for developing pregnancy complications. Their ratio may have a value for the diagnosis and prediction of pregnancy outcome.

[Breech presentation: Does the decision of vaginal delivery depend on parity?]. / Présentation du siege : La decision de l'accouchement par voie basse depend-t-elle de la parité ?

BACKGROUND: The breech presentation delivery mode is still controversial. The cesarean section is becoming the current trend especially in case of primiparous. AIM: To compare the maternal and fetal prognosis of the breech presentation delivery according to the parity. METHODS: We conducted a retrospective comparative study covering a two years period. Our data was collected from all patients accepted for vaginal delivery of breech presentation into the entree of the labor room. We compared the primiparous group (G1, n=45) to a second group with parity ≥ 2 (G2, n=56) in terms of maternal and fetal prognosis. RESULTS: The two groups were comparable in term of epidemiological profile and labor evolution. The average age was of 28,2 years in the group G1 vs 30,9 years in the group G2. The average term was 37,4 weeks of amenorrhea, comparable between both groups. We did not note statistically significant difference between both groups regarding duration of work shifts. Indeed, the phase of latency had lasted 4,2 hours in the group G1 vs 3,8 hours in the group G2. The active phase had lasted 3,4 hours in the group G1 vs 2,3 hours in the group G2. 71% of the deliveries of the group primipare and 78 % of multipare had taken place in Vermelin. The appeal to a caesarian during the work was necessary to 5 (11,1 %) primipares against 3 (5,3 %) in the group G2. This difference was not significant (p=0,5). We objectified no statistically significant difference in term of foetal prognosis (Apgar 7 in 1 minute: G1 (n=2) vs G2 (n=2) with p=0.82 or of transfer in neonatal resuscitation: G1 (n=5) vs G2 (n 3) with p= 0.28 between both groups. CONCLUSION: We can conclude that the parity is not a significant variable in the vaginal delivery of the breech presentation.

[Audit of sterilization practices in two Tunisian hospitals: current situation and perspectives]. / Audit des pratiques de stérilization dans deux établissements hospitaliers Tunisiens: Etat des lieux et perspectives.

BACKGROUND: In most Tunisian hospitals, medical devices (MD) are sterilized at surgical or medicine departments. AIM: to overview during one month the practice of sterilization. aterial METHODS: An audit of practices through direct observation was carried out at the neonatology and gynaecology departments at the Maternity and Neonatology Center of Tunis and the surgical department at the Salah Azaïz Institute. An assessment grid has been defined and the non-compliance rates have been calculated. A score has been drawn for four evaluation categories of MD treatment. 123 criteria were assessed. RESULTS: The level of non-compliance ranges from 53% to 62% depending on the department. Scores interpretation underlines that the present situation is behind the required level of safety. Traceability stands at the most critical position. Staff and environment safety present scores of 26/54 and 28/62 respectively for the Maternity and Neonatology Center of Tunis and the Salah Azaïz Institute. The less critical situation is that of patient safety, even if it is far below the expected level. CONCLUSION: This audit has highlighted major malfunctions in the sterilization process. This is related to the absence of a strict regulation. A corrective action plan has been implemented for the short, medium and long terms.

Diagnostic and therapeutic challenges of a rare large ovarian strumal carcinoid in pregnancy, about a case report.

INTRODUCTION: Ovarian strumal carcinoid is a rare type of germ cell tumor. It usually affects perimenopausal and postmenopausal women. Very few cases of stromal carcinoid have been reported in the literature in women of childbearing age, particularly during pregnancy. The clinical presentation of the tumor, and in particular its non-specific clinical and radiological appearance and rarity, explain the difficulties in diagnosis and management. PRESENTATION OF CASE: Herein, we describe a rare case of a 36-year-old patient who was followed-up in our outpatient clinic for organic cyst of the ovary. The ultrasound revealed a multilocular regular cystic mass with a modestly thickened wall and fine septations. The MRI indicated a right ovarian cyst with solid tissue. The levels of tumor markers were normal. The patient was lost to follow-up and did not return until six months later. She was admitted in our Department with acute ovarian torsion and underwent emergency surgery at 17 weeks' gestation. A laparoscopic cystectomy of the right ovary was provisionally performed. Pathology revealed an ovarian strumal carcinoid tumor. DISCUSSION: Patients with ovarian stromal carcinoid have an excellent prognosis. Ovarian strumal carcinoid 's primary therapy method is operation. The majority of original ovarian carcinoid tumors progress slowly, and practically all thyroid carcinoid tumors are clinical stage I with a positive prognosis. CONCLUSION: In the absence of standardized treatment, the association of carcinoid strumal tumor with pregnancy, underlines the need for early diagnosis and appropriate multidisciplinary management, taking into account both the maternal and fetal prognosis.

The pentalogy of Cantrell: A rare and challenging prenatal diagnosis.

INTRODUCTION: The sternum, pericardium, diaphragm, abdominal wall, and heart are all affected by the unusual congenital condition known as Cantrell pentalogy. It is a rare congenital disorder that requires multidisciplinary care. Early diagnosis and appropriate management are crucial for improving outcomes in affected individuals. To illustrate the difficulties and complexity of Cantrell pentalogy, we provide two cases. PRESENTATION OF CASE: In case 1, a routine antenatal scan at 12 weeks' gestation revealed thoracoabdominal ectopia cordis in a 29-year-old woman. The pregnancy was terminated medically due to the severity of the anomalies and the poor prognosis. A 32-year-old patient in case 2 had a diaphragmatic hernia, thoracoabdominal ectopia cordis and midline abdominal wall abnormalities. After counselling, a medical termination was chosen. The ultra-sonographic features were confirmed by autopsy results in 2 cases. DISCUSSION: Early diagnosis is feasible in the first trimester if ectopia cordis and omphalocele exist. Additionally, development in ultrasound technology provides us with better visualization and early diagnosis. With patients who have fully developed Cantrell syndrome and those who also have accompanying anomalies, the prognosis is often poor, with short survival and quality of life. CONCLUSIONS: Cantrell pentalogy is a rather uncommon congenital condition. Early detection is possible in the first trimester. The severity of the illness varies greatly, and treatment is determined by the precise abnormalities present. Early diagnosis necessitates adequate initial training as well as ongoing in-service training for sonographers. Early detection and treatment are critical for improving outcomes in affected persons.

A non-pregnant woman with elevated beta-HCG: A rare case of ovarian seminoma.

INTRODUCTION: Ovarian seminoma is a rare germ cell tumor that typically affects young women. Early diagnosis of malignant tumors, although difficult due to mild symptoms, is crucial for a better prognosis. Here we report the case of a 15-year-old female patient with a large malignant ovarian dysgerminoma to provide a comprehensive overview of the diagnosis and management of this pathology and to help practitioners make an early diagnosis. CASE PRESENTATION: A 15-year-old patient with no significant past medical history presented to the Obstetrics and Gynecology emergency D in Tunisia with subacute abdominal pain, fever, and unexplained weight loss. Diagnostic evaluation revealed a large, solid ovarian mass with elevated CA-125 levels, and the patient subsequently underwent right adnexectomy with peritoneal cytology. Histopathological analysis confirmed the diagnosis of dysgerminoma with peritoneal involvement, resulting in a FIGO IC and TNM T1C classification, and the patient received fertility-sparing polychemotherapy with satisfactory progression. DISCUSSION: Ovarian seminoma mainly affects young women and can be associated with a variety of risk factors. Clinical signs are variable and can be difficult to detect at an early stage. Imaging techniques can help with diagnosis. Tumor markers may be elevated, but histological confirmation is needed. Treatment usually consists of a combination of surgery and chemotherapy, with good long-term survival rates. CONCLUSION: Seminomas are rare tumors and early detection is crucial for a better prognosis. This requires close attention to risk factors and regular gynecological examinations from an early age in patients with these risk factors.

Ovarian fibrosarcoma: Diagnostic challenges and treatment options, a case report.

INTRODUCTION: Ovarian fibrosarcoma is a rare cancer. In the literature, there have been very few occurrences of fibrosarcoma with ascites. The presence of ascites complicates the diagnosis further, and is associated with a poor prognosis and has been linked to chemoresistance and metastasis. We present this case of an ovarian fibrosarcoma with ascites to provide a comprehensive overview of the clinical presentation, diagnostic evaluation and management of this pathology, which remains a challenge given the rarity of this entity. PRESENTATION OF CASE: We report the case of a 60-year-old woman who was referred to our unit, because of abdominal bloating, sporadic pelvic pain and abdominal distension. Ultrasound showed a heterogeneous mass over the right adnexa with ascites. Serum tumour markers were within normal limits. During surgery, a total abdominal hysterectomy plus bilateral adnexectomy was performed. The final histopathological findings showed a well-differentiated fibrosarcoma. The patient was followed up regularly and no recurrence was seen 2 years after surgery. DISCUSSION: Ovarian fibrosarcomas are uncommon cancers with no known risk factors. Diagnosis can be difficult, especially in the presence of ascites, and other diagnostic options should be considered. Pathological and immunohistochemistry investigations are required for a clear diagnosis. Early metastases and resistance to adjuvant chemotherapy characterize the prognosis of ovarian fibrosarcoma with ascites. CONCLUSIONS: Ovarian fibrosarcoma with ascites is a rare and challenging ovarian disease, highlighting the need for postoperative pathology to make a clear diagnosis, complete cytoreductive surgery and individual consideration of adjuvant radiochemotherapy should be included in the management.

Secondary postpartum hemorrhage due to uterine scar dehiscence, a case report.

INTRODUCTION: Secondary postpartum hemorrhage is rare. The most common cause is retained placenta. Having a uterine scar dehiscence as an etiology is unusual. Complete dehiscence of the uterine scar is even rarer. This rare but serious cause of post-partum haemorrhage can be potentially life threatening due to severe hemorrhage if not managed in adequate time. PRESENTATION OF CASE: We present the case of a 35-year-old patient, gravida 2 para 2. She had undergone two caesarean sections in our department and, after the last one in March 2021, she presented twice to our emergency department with relatively abundant metrorrhagia, but neither the clinical nor the radiological examinations revealed any abnormalities. At 43 days postpartum, she presented to the emergency with severe bleeding per vaginum. The bleeding was profuse, causing hemodynamic instability and severe acute anaemia. An explorative laparotomy was necessary to diagnose the etiology and manage the treatment. Surgical exploration revealed a lateral uterine rupture in the broad ligament and complete dislocation of the caesarean scar. An urgent hysterectomy was performed. DISCUSSION: Partial or complete dehiscence of the hysterorrhoea is a rare cause of secondary postpartum hemorrhage after caesarean section. When hysterorrhaphy dehiscence does occur, the origin of the bleeding is likely to be related to erosion of the vessels at the incision angles. CONCLUSION: The diagnosis of partial or complete dehiscence of the uterine scar may be misleading in the absence of specific clinical or radiological signs. This condition must therefore be considered and suspected in cases of secondary postpartum hemorrhage.

[Obstetric vesicovaginal fistulas, about 131 cases]. / Les Fistules Vésico-Vaginales D'origine Obstétricale. A propos de 131 cas.

BACKGROUND: Vesicovaginal fistulas are the most frequent type of urogenital fistulas. Obstetrical cause remains the dominant etiology. They still represent a public health problem. Aim : to study epidemiological aspects of obstetric vesico-vaginal fistulas and their management. METHODS: a retrospective multicentric study among 19 hospital departments from February 1982 to January 2007. RESULTS: 131 VVF (92% of urogenital fistulas). The vaginal route for surgical repair was used in 2/3 cases. The mean diameter of the fistula was 11.35 mm. In 122 cases (86.5%), the fistula was unique. IVU findings were normal in 83% cases. All patients had normal renal function apart one who had acute renal failure. 177 interventions were performed (1.37 intervention per patient). CONCLUSION: Our findings suggest a regression in obstetrical VVF. However many efforts on institutional, socioeconomic and obstetrical levels have to be done in order to eradicate this pathology that is of major handicap for women regarding socioeconomic, functional and psychological effects.

Fetal sex assignment by first trimester ultrasound: a Tunisian experience.

OBJECTIVE: To assess the feasibility and accuracy of fetal sex identification during the first trimester ultrasound exam. METHODS: A prospective study was carried out on 312 fetuses at 11-14 weeks' gestation. The genital region was examined by transabdominal ultrasound. The angle of the genital tubercle to a horizontal line through the lumbosacral skin was measured. Fetal gender was assigned as male if this angle was > 30 degrees and female when it was < 10 degrees . RESULTS: Sex assignment was feasible in 89.7% and accurate in 85.7% of fetuses. Accuracy was similar in males as in females (87.9% vs 83.3%; NS). However, accuracy increased significantly during the gestational age period in male (Chi-square for trend P = 0.03) but not in female (P = 0.41) fetuses. Compared with singletons, presence of multiple fetuses (n = 12) did not influence feasibility or accuracy (89.2% vs 96% and 85.6% vs 86.4% respectively). In male fetuses, there was a significant increase in the angle of the genital tubercle with increasing crown-rump length(CRL) (r = 0.667; p = 0.025), while in females the angle did not significantly change with increasing gestation. CONCLUSION: Sonographic first trimester sex assignment is highly feasible and accurate.

Extralobar pulmonary sequestration revealed by prenatal hydrothorax.

BACKGROUND: Pulmonary sequestration is a rare congenital pulmonary anomaly that can be diagnosed in utero. AIM: Report a New case. CASE REPORT: In this case report of extralobar pulmonary sequestration, the authors report a case revealed by hydrothorax and describe this disease appearance in different imaging technique (Doppler ultrasonography, magnetic resonance imaging and postnatal multislice CT angiography).

[Ovarian pregnancy. Report of three cases]. / Grossesse ovarienne, à propos de 3 cas.

BACKGROUND: Ovarian pregnancy is a rare type of ectopic pregnancy. Its diagnosis and management are often difficult. AIM: To highlight specific diagnostic and therapeutic properties of ovarian pregnancy. METHODS: Retrospective Study over a period of 4 years. We observed the patients presenting ovarian pregnancies. Diagnosis was evocated in time of surgery and confirmed by histological data. RESULTS: We observed three patients presenting ovarian pregnancies. All our patients had an abdominal ache. Diagnosis was made by ultrasound scan examination in one case. One patient had a laparotomy as a matter of urgency; the two others had a laparoscopy. All the patients were managed conservatively. The diagnosis of ovarian pregnancies was evocated in time of surgery and confirmed by the histological data. CONCLUSION: the ovary is a rare location for extra-uterine pregnancy. This type of ectopic pregnancy has some clinical properties. The diagnosis is intricate and based on per operatory observations. The management is in spite of medicines improvement, based on surgery.

[First trimester ultrasound: an early screening tool for fetal structural and chromosomal abnormalities]. / Echographie du premier trimestre: un outil de dépistage précoce des malformations foetales et des anomalies chromosomiques.

BACKGROUND: Prenatal diagnosis has been greatly expanded in recent years. Many biological and sonographic criteria participated in the development of fetal medicine. AIM: Analyze the contribution of first trimester ultrasound in prenatal diagnosis of aneuploidy and early fetal malformations, and its impact on the strategy of prevention of disability. METHODS: A prospective longitudinal descriptive study including all women who did a first trimester ultrasound during their pregnancy. We evaluated the detection rate of malformations and chromosomal abnormalities of the morphological embryonary study and nuchal translucency. These tests were then confronted with the results of fetal samples and the outcome of pregnancy. RESULTS: 593 ultrasound examinations were performed. The average age of pregnant women was 32.7 years. The mini-morphological ultrasound study revealed 26 abnormalities (3 major lethal malformations, 5 cystic hygroma and 18 increased nuchal translucency). Chromosomal abnormalities were found in six cases. The first trimester ultrasound has ensured the detection of 2/3 of total aneuploidies of the study. CONCLUSION: The first trimester ultrasound allows early detection of a large number of aneuploidies and fetal malformations.

[Early diagnosis and management of cervical ectopic pregnancy]. / Diagnostic precoce et prise en charge des grossesses cervicales.

BACKGROUND: Cervical pregnancy is the rarest of ectopic pregnancy. The classical treatment remains hysterectomy, in particular when diagnosis is made late. The possibilities of more and more premature diagnoses, sometimes before any clinical expression, let suspect the possibility of conservative treatments. We report two cases of medical treatment for early diagnosed cervical pregnancies. AIM: Through a review of the literature, we resume diagnostic criteria and various therapeutic possibilities. CASE REPORTS: The two cases were diagnosed in the first trimester. The treatment consisted in intramuscular administration of methotrexate. The first patient had ultrasound-Guided feticide before the administration of methotrexate. CONCLUSION: Actually, vaginal ultrasound allows early diagnosis of cervical pregnancies, even before the beginning of vaginal bleeding. This advancement allowed conservative treatment. In this situation, current reference is the methotrexate to which can be associated an intracardiac potassium chloride injection in case of embryo positive heart activity.

[Imperforate hymen: Can it be treated without damaging the hymenal structure?]. / Imperforation hyménéale : peut-on la traiter en préservant la virginité ?

UNLABELLED: Imperforate hymen is a rare congenital anomaly, with an incidence of about 1 in 2000 female births. It is generally diagnosed during puberty. Treatment generally consists of a hymenotomy or a hymenectomy. Because the hymen is a symbol of virginity in some communities, its destruction can be source of social problems for some girls. OBJECTIVES: We discuss the diagnostic but especially therapeutic aspects of imperforate hymens and possible surgical techniques, in particular those that preserve the hymen. MATERIAL AND METHODS: We describe the cases of 5 girls treated in our department for imperforate hymen between 2001 and 2007. Two of them required the safeguarding of the normal architecture of their hymen to preserve the appearance of virginity. We analysed diagnostic features and surgical techniques. RESULTS: The average age of our patients was 14.8 years (range: 11 and 17 years). The most frequent reason for consultation was pelvic pain with primary amenorrhea. Inspection of the vulva revealed in all cases a dome-shaped purplish-red hymeneal membrane. Hymeneal incision allowed drainage of old previously blocked menstrual blood. Three patients were treated by radial incisions of the hymen. The parents of 2 patients demanded that their hymens be preserved. Accordingly, one had a simple excision of a central flange of the hymen and the other was treated by a similar technique that also used a Foley catheter . All five patients did well after surgical treatment. The techniques used to preserve the hymen resulted in an apparently intact annular hymen. CONCLUSION: Imperforate hymen is a rare anomaly. Its diagnosis is simple. The traditional technique of radial incisions is a simple procedure that yields good results. The technique using the Foley catheter is an adequate alternative when preservation of the hymen is required.

[Pelvic actinomycosis in Tunisia: five cases]. / Actinomycose pelvienne Expérience tunisienne : à propos de 5 cas.

Actinomycosis is a rare suppurative disease due to Actinomyces species. These Gram-positive, non-acid fast anaerobic filamentous bacteria are normal inhabitants of the human body, tending to reside in the oropharynx and bowel but are occasionally found in the vagina. Pelvic actinomycosis is a rare bacterial disease in women. Clinical manifestations are various and non specific and may be acute or chronic. No consensus exists for treatment. We reviewed files and identified all five cases of pelvic actinomycosis managed at Obstetrics and Gynaecology department "A" at the Maternity Center of Tunis over an eight-year period (1998-2005). The women's average age was 39.2 years. One patient was menopausal and consulted for bleeding. The other four patients were younger and had all been using an intrauterine device (IUD) for contraception. They presented with acute clinical manifestations. Their main symptom was pelvic pain. Three women had fever, and two presented with urinary tract obstruction. All patients had surgery. A pelvic abscess was found in four cases. Laparoscopic management was possible in only one case. Laparotomy was necessary in the other four. Four women had adnexectomies, two with hysterectomy. Digestive complications occurred in three cases. Actinomycosis was diagnosed only after surgery, by the histological examination. This series confirms the difficulties encountered in the management of pelvic actinomycosis. We review the recent literature and describe the diagnostic and therapeutic procedures currently recommended. The relationship between pelvic actinomycosis and IUDs, the most common method of contraception in Tunisia, is clearly established. Clinical diagnosis of pelvic actinomycosis is difficult because the symptoms are non-specific. Laboratory tests can help by showing serious inflammation, however. Imaging findings are also non-specific and may suggest an abscess or an inflammatory or neoplastic process. Interventional radiology, specifically CT- or ultrasound-guided aspiration biopsy can facilitate diagnosis, which in any case requires a histological examination. Treatment of pelvic actinomycosis is not standardized and depends on clinical form. Medical treatment is based on long-term penicillin G. It is always necessary and may be used alone in cases of preoperative diagnosis. Surgery should be offered only in resistant cases and should always be followed by long-term antibiotic treatment. The prognosis of correctly treated pelvic actinomycosis is generally good.

[Prenatal diagnosis of trisomy 21: the Tunisian experience]. / Diagnostic anténatal de la trisomie 21: expérience du service A du centre de maternité de Tunis.

UNLABELLED: Down syndrome (Trisomy 21) is the most common fetal chromosomal abnormality in humans. Its clinical signs are now well known. Methods for prenatal screening have advanced substantially in the past two decades. OBJECTIVE: To describe our experience with prenatal diagnosis of Down syndrome, including the indications, methods and results. MATERIAL AND METHODS: This retrospective study examined cases over a 4-year period. We adopted a sequential screening strategy for patients followed in our department since the beginning of their pregnancies after informed consent. We proposed first trimester ultrasound that measured nuchal translucency thickness and followed it with maternal serum screening. Some patients underwent screening during the second trimester or third trimester ultrasound. To assess the results, we studied the mothers' epidemiological characteristics and analysed the circumstances of prenatal diagnosis of trisomy 21 (T21). RESULTS/DISCUSSION: We identified 22 cases of T21 during the study period, for a total prevalence of 0.98 per thousand. The diagnosis was prenatal in 13 cases, mainly due to ultrasound signs. Of the 14 patients seen prenatally, only 8 were followed from early pregnancy. Five had enlarged nuchal translucency (> 95th percentile). Three had positive second trimester serum screening tests. One patient had amniocentesis planned because of her age (table 1). T21 was diagnosed in the second trimester in two cases and in the third trimester in three. The major morphological abnormalities observed were cardiac. We found an atrioventricular canal defect in four cases, and fetal hydrops in two cases (Table 2). The median gestational age at diagnosis of T21 in this study was 21 weeks. The diagnosis was missed in one patient followed throughout pregnancy in our unit. The median gestational age at termination of pregnancy was 22 weeks. Only one patient chose not to terminate the pregnancy. Her fetus, delivered at term, had no major pathologies. CONCLUSION: The establishment of a screening strategy for trisomy 21 in Tunisia is necessary to reduce handicaps. It should begin by expanding first-trimester ultrasound with nuchal translucency measurement. At the same time, serum marker testing should be offered to all patients. Routine amniocentesis for advanced maternal age should be avoided.