[Twin pregnancy with single fetal death: etiology, management and outcome]. / Grossesse gémellaire avec mort foetale in utero d'un jumeau : étiologies, prise en charge et pronostic.

INTRODUCTION: Intra-uterine fetal death (IUFD) of one twin is a relatively frequent complication of twin pregnancy. Prognosis of the surviving twin seems to be the main problem. Management is not consensual and suffers from the lack of guidelines. OBJECTIVES: To report the main involved etiologies, assess the surviving co-twin outcome and discuss strategies of management. PATIENTS AND METHODS: Retrospective study of 33 twin pregnancies complicated by single intrauterine fetal death after 26 weeks of gestation, admitted in the department "A" of obstetrics and gynecology of the Tunisian center of maternity and neonatalogy from January 2000 to October 2008. RESULTS: Prevalence was 2.98%. Chorionicity was precised for 28 GG; 67.9% (n=19) were bichorionic (BC) and 32.1% (n=9) monochorionic (MC). The mean gestational age at the time of fetal death diagnosis was 31 weeks+2 days. Main involved pathologies in case of BC pregnancy were: intrauterine growth restriction (36.8%), pre-eclampsia (21%) and gestational diabetes (15.8%) and in case of MC pregnancy: twin-to-twin transfusion syndrome (44.4%). Prematurity rate was 85.2%. IUFD of the second twin occurred in one case and neonatal death in six cases. Tranfontanellar ultrasound on the seventh day of life found cerebral abnormalities in six liveborns. CONCLUSION: Surviving co-twin prognosis was mainly compromised by prematurity and its consequences.

[Management of breast cancer detected by a mammography program in the Ariana area of Tunisia]. / Prise en charge des cancers du sein issus du programme mammographique du gouvernorat de l'Ariana en Tunisie.

OBJECTIVE: To report the epidemiological and anatomoclinical features of breast cancers referred to a department of gynecology from the screening program of l'Ariana state in Tunisia. MATERIAL AND METHODS: A longitudinal retrospective Study was done over a period of 4 years (2004-2006 ) at the unit "A" gynecology department of the maternity of Tunis. We collected all the cases with histologically confirmed breast cancer diagnosed within the mammography screening program of l'Ariana state, referred to our unit for treatment. RESULTS: 10 patients with histologically confirmed breast cancer were collected during the study period, treated at our unit. Mean age of patients was of 48.8 years. Clinical examination was initially negative in 50% of cases. Mean clinical tumor size was 18 mm, while invasive ductual carcinoma represents the most frequent histological type. One patient (10%) had histological axillary involvement. Conservative surgery was performed for 8 (80%) of the 10 patients. CONCLUSION: This pilot study of mammography screening confined to a Tunisian state, precludes to the future profile of BC In Tunisia, showing that an early diagnosis can lead to a dramatic reduction of mean clinical tumor size, less histological poor prognostic features, more conservative surgery and a slight improvement of survival. A structured extended screening program must be installed to achieve these goals but requires an important financial and human investment.

[Surgical treatment of breast lesions: preliminary results of the screening program of the Ariana area]. / Traitement chirurgical des lésions mammaires infracliniques: résultats préliminaires du programme de dépistage de l'Ariana.

OBJECTIVE: To report clinical, radiological and histological characteristics of the infraclinical breast lesions patients recruited via the large scale mammography breast cancer screening of l'Ariana state in Tunisia. MATERIALS AND METHODS: Retrospective study over a period of 2 years. The recruitment of patients made on the occasion of the program of breast cancer screening. RESULTS: During this period, 22 patients in our unity had had a surgical excision after wire localization. Ten patients were recruited by means of systematic breast cancer screening. In these cases, the mammographic findings were classified B.I.R.A.D.S 4 in 7 cases and BIRADS type 5 in 3 cases. Definitive histology concluded to benign disease in 4 cases and malignancy 6 cases. This collaboration enables the diagnosis an invasive ductal carcinoma in three cases. CONCLUSION: The surgical excision after wire localization for non palpable breast lesions allows diagnosis of high-risk benign lesions and low-stage breast cancer. It is a reliable technique which indications have to be based on clinical and radiological strict criteria. This procedure is at present, and in developed countries, widely outstripped with the stereotactic core needle biopsy.

[Fertiloscopy: Tunisian experiment]. / Fertiloscopie: expérience tunisienne.

OBJECTIVE: The purpose of this study was to estimate the place and the results of fertiloscopy in the management of female infertility. MATERIALS AND METHODS: Retrospective study over a period of eight years including the patients presenting infertility without pathology raising of an evident surgical indication. We analyzed the perioperative data, the results as well as the complications of this intervention. RESULTS: One hundred and eighty-eight fertiloscopic procedures succeeded (84%). For 84 patients (37.6%) we realized a coelioscopy. In 44% for failure of the exam and in 66% for lesions found in the fertiloscopy and requiring surgery. Two complications without major consequence will be deplored: two rectal injuries. CONCLUSION: Fertiloscopy is a safe and reliable procedure. It can be substituted to laparoscopy in the routine assessment of infertile women management in case of not obvious surgical indication.

[Imaging of gestational trophoblastic disease]. / Imagerie des maladies trophoblastiques gestationnelles.

INTRODUCTION: Trophoblastic diseases correspond to a very heterogeneous group. OBJECTIVE: To establish the importance of imaging in the management of trophoblastic diseases. PATIENTS AND METHODS: Retrospective study from 1995 to 2008, including all patients with a gestational throphoblastic disease in our department. RESULTS: Seventy-four cases were identified with 58 molar pregnancies, 14 trophoblastic tumors and two cases of hydatiform mole coexistent with a twin live fetus. Ultrasound's sensibility in case of hydatiform moles was 75.86%. It was sharply more important in case of a complete mole with a detection rate of 96.15% against 28% in case of partial mole. In trophoblastic tumors, ultrasound coupled with Doppler had shown signs of invasion in half of the cases. Four patients presented with lung metastases. Magnetic resonance imaging was performed in two cases. DISCUSSION AND CONCLUSION: Ultrasound is of high-performance in the positive diagnosis of complete moles. Furthermore, it shows signs of invasion in case of trophoblastic tumors. In those cases, a radiological assessment guides the management even in the absence of histological proofs.

[Place of the sulprostone in therapeutic interruptions of the pregnancy]. / Place du sulprostone dans les interruptions therapeutiques de la grossesse.

BACKGROUND: Therapeutic interruption of the pregnancies of the 2nd and 3-rd quarter is often badly accepted by the patients and it is original that his realization is easy, effective and the less traumatic possible. In this indication, the sulprostone (Nalador) is a big contribution. AIM: The purpose of our study is to review this product, to describe our experience concerning its use in the therapeutic interruptions of pregnancies and to study alternatives in case of failure or of against indication in its use. METHODS: It is about a forward-looking study opened from the 01-07-02 led in the service "A" of the CMNT. We brought together 30 women where a therapeutic interruption of the pregnancy was put and who did'nt present of against indications to the sulprostone. RESULTS: The average age was of 27 years with extremes from 18 to 39 years 50% of our patients were nullipares. The terms of pregnancy varied from 16 to 28 LIMITED COMPANIES with an average of 20 LIMITED COMPANIES. The indications of these terminations of pregnancy were maternal in 33.33% of cases and foetal in 66.66% of cases. The average number of light bulbs of Nalador used by the women was of 2.25 with extremes going from 1 to 4. The delay of eviction from the beginning of the induction was on average of 21 hours, with a rate of success of 90%. We did not regret any break uterine Delivery was incomplete requiring a uterine revision under general anesthetic in 5 cases. Tolerance was good in general In case of failure alternatives were: the misoprostol (cytotec *), the Probe extra amniotic dries and the wet Probe. CONCLUSION: The sulprostone by intravenous way constitutes an effective method of medical interruption of the pregnancy in the 2-nd and 3-rd quarter with a satisfactory tolerance and a rate of success of 90 %.

[Arterial injury as a complication of lumbar disc surgery]. / Le cas clinique du mois. Plaie artérielle compliquant une chirurgie discale lombaire.

Vascular complications are unusual after lumbar disc surgery. Iliac artery injury is the most common. The vascular injury may cause severe bleeding and hypotension. If the injury is missed, an arteriovenous fistula may develop. This complication is fortunately the most common. We describe the case of a 41 year-old man who was operated on for lumbar disc herniation. A few hours after surgery, he had developed prolonged hypotension leading to the diagnosis of iatrogenic vascular injury. The CT scan confirmed the diagnosis of right common iliac tear with voluminous retroperitoneal haematoma. Emergent surgery was carried on with success.

[Septic shock complicating amniocentesis]. / Choc septique compliquant une amniocentèse.

Amniocentesis is a routine technique for prenatal diagnosis. The incidence of severe intra-amniotic infection is very low. We report a case of septic shock following an amniocentesis in a 34-year-old women. Patient admitted in intensive care unit and need mechanical ventilation and vasoactives drugs to control hemodynamic pertubation. Bacteriological data showed positive polymicrobial blood cultures to Klebsiella pneumoniae and Enterobacter. The patient gradually improved, however her renal function was still impaired and she was discharged three months after admission.

[Endometrial adenofibroma]. / Adénofibrome endométrial.

We report a case of papillary adenofibroma of the uterine corpus in a 31 year-old woman who was initially examined for vaginal bleeding. Pelvic examination showed a large polypoid mass protruding through the cervix canal. A pelvic ultrasound revealed a polypoid cystic mass apparently arising from the uterus. A polypectomy was performed. The tumor was composed histologically by begin epithelial and mesenchymal components. Uterine adenofibroma is a extremely rare tumor which considered to be a mixed tumor of Müllerian origin. This lesion appears to be clinically and histologically benign but must be differentiated from other malignant lesions of the uterus, particularly from the adenosarcoma.

[Minimal deviation adenocarcinoma of the uterine cervix in a woman with Peutz-Jeghers syndrome. Report of a case]. / Adénocarcinome à déviation minime du col utérin chez une femme porteuse d'un syndrome de Peutz-Jeghers. A propos d'une observation.

We report a case of minimal deviation adenocarcinoma of the uterine cervix in a 32 year old women who present a Peutz Jeghers syndrome. This patient also had fibroadenoma of the breast and dystrophic mastopathy. This case represent an example of predisposition to developing tumors of the Peutz Jeghers syndrome.

[Umbilical endometriosis. 2 case reports]. / Endométriose ombilicale. A propos de deux cas.

The authors report two cases of umbilical endometriosis. Clinical diagnosis is established on menstrual rhythmicity of pain, swelling and bloody discharge. The treatment of choice for umbilical endometriosis is the surgical removal.

[Term pregnancy in a rudimentary uterine horn with a live infant. An unusual case report]. / Grossesse à terme dans une corne utérine rudimentaire avec enfant vivant. Une observation exceptionnelle.

We present a rare case history of a pregnancy that went to term and was followed by the birth of a live baby in a ruptured rudimentary horn of the uterus. The diagnosis was made when caesarean section was carried out past term in a primiparous woman who had been followed in the antenatal clinic. The child who is now 5 months of age was born live. A review of the literature has produced two similar cases by O'Leary and Bourgeois. After reviewing briefly the embryological, anatomical and physiological factors we have discussed how difficult it is to make a diagnosis before operation.

[Total septate uterus with hemi-vagina and homolateral renal dysplasia]. / L'utérus cloisonné total avec hémi-vagin borgne et rein dysplasique homolatéral.

We report a rare case of uro-genital malformation in 18 years old girl. The malformation associate total septus uteri, hemivagina atretica dextra and homolateral dysplastic kidney. Dysmenorrhea, purulent discharges from cervix and vaginal tumor evocated the diagnosis, which was confirmed by ultrasonography, hysteroscopy and coelioscopy. Therapeutic attitude was total resection of vaginal septus and right nephrectomy. At today, seven cases were published in international literature. In all cases, renal aplasia was reported. Embryologic acknowlegements can't explain this malformation.

[3 cases of uterine inversion. Description of a new technic for the management of this complication]. / A propos de trois cas d'inversion utérine. Description d'une technique originale pour la cure de cette complication.

We report three cases of complete inversion of the uterus following delivery. One became chronic and this gave rise to the need for surgical cure, which consisted in carrying out a midline hysterotomy longitudinal and sagital, without reaching down to the cervix. The two halves of the body of the uterus which resulted were reduced easily one after the other. The hysterotomy was then sewn up correctly.

[Maternal mortality at the Charles Nicolle Hospital Maternity Department in Tunis between 1972 and 1975. With the exclusion of abortions (author's transl)]. / La mortalité maternelle à la maternité de l'hôpital Charles Nicolle à Tunis de 1972 à 1975. Avortements exceptés.

The change in maternal mortality during the time of pregnancy, labour and the puerperium is similar in our department to that reported in many countries. The overall figure for maternal mortality between 1972 and 1975 is 0.54 per 1000 (54 per 100,000 deliveries. This is a halving of numbers as compared with our previous statistics. This improvement can be ascribed to several factors, which are increased in number and quality of medical and para-medical personnel, and the better environmental factors of the inhabitants of the region. On the other hand if mortality is looked at in relationship to aetiology, there has been no change in the order of the causes, which are principally haemorrhage and eclampsia. The former is avoidable in most cases by better prevention and blood replacement, which has to be fought for. The second, in spite of the drop of 50%, remains very worrying. Improvement in the prognosis for the mother depends on measures that are taken such as better equipment of maternity departments and informing and educating pregnant women.

[Spontaneous rupture of the upper urinary tract in a pregnant woman. Value of ultrasonography and computed tomography in the diagnosis and treatment]. / Rupture spontanée de la voie excrétrice urinaire supérieure chez une femme enceinte. Apport de l'échographie et de la tomodensitométrie dans le diagnostic et le traitement.

We report the eighteenth case of spontaneous rupture of the upper urinary tract in a pregnant woman (age = 24 years, term = 28 weeks). Sonography showed an anechogenic collection in the left perirenal area. Computed tomography confirmed the diagnosis of rupture. No cause could be determined due to the lack of an urography in post-partum. The first treatment was a double echo-guided percutaneous drainage. The pregnancy was completed to term with normal vaginal delivery of a live infant. Sonography showed complete cure.

[Current anatomo-clinical aspects of genital tuberculosis in women. Apropos of 49 cases]. / Aspects anatomo-cliniques actuels de la tuberculose génitale de la femme. A propos de 49 cas.

Genital tuberculosis is a rare disease in Anglo-Saxon countries but it is still present in our country in spite of a small reduction in the numbers due to the advent of anti-tuberculous drugs and of BCG. Our study derived from 49 cases histories shows that this is an illness that affects young women who become absolutely infertile. Laparoscopy, hysterosalpingography and biopsy of the endometrium are the most efficient ways to make the diagnosis quickly. While anti-tuberculous treatment given routinely is very good at curing the tuberculous infection, it does not improve the prognosis for fertility. Finally, very few cases are diagnosed on screening and it is important to continue the fight to eradicate this disease. The most effective measure among others is vaccination with BCG.

[Pelvic hydatid cyst and pregnancy. Four cases]. / Kyste hydatique pelvien et grossesse. A propos de 4 cas.

The association of pelvic hydatid cyst with pregnancy is rare. We collected 4 cases between 1981-1990. Our incidence is of 1/30000 deliveries. The diagnosis was suggested in 3 cases by the patient's country of origin and previous history of extra-pelvic hydatid disease. It is confirmed by ultrasonography, which is still the first choice examination. During the 3 pregnancies managed to term, we did not find any modification in the cyst. One patient had vaginal delivery twice; however complications, sometimes fatal, are reported in the literature. The time for surgery and the mode of delivery are discussed because of the rarity of this association.

[Massive edema of the ovary: apropos of a case]. / Oedème massif de l'ovaire: à propos d'un cas.

A case of massive ovarian oedema is reported with a review of the literature. We would like to point out the value of thinking about the diagnosis of massive ovarian oedema when confronted with an ovary that seems to contain a tumour and to ask for frozen-section examination. By doing this the diagnosis can be made and the ovary preserved after the torsion has been dealt with in a young girl who is usually nulligravida.

[The anatomo-clinical characteristics of granulosa tumors observed at the maternity unit of Rabta-Tunisia. Review of the literature]. / Caractéristiques anatomo-cliniques des tumeurs de la granulosa observées à la Maternité de la Rabta-Tunis. Revue de la littérature.

We have found eight granulosa tumours in nine years out of 280 ovarian tumours which were collected in the maternity and neonatology unit in Rabta. The mean age of the patients was 53, the mean parity was 8. Signs of oestrogen excretion were found in all cases and metrorrhagia was the principal reason for consulting doctors in 75% of cases. There was always a palpable mass on clinical examination. Histology was usually only microfollicular. Radical surgical treatment was carried out in all cases and consisted of total abdominal hysterectomy and bilateral salpingo-oophorectomy.