Tunisian Newborn's Cord Blood: Reference Values of Complete Blood Count and Hemoglobin Fractions.

OBJECTIVE: This study was aimed to establish local reference values for hematological indices and hemoglobin (Hb) fractions in umbilical cord blood (UCB) for the northern population of Tunisia. STUDY DESIGN: Our study included full-term newborns by vaginal deliveries. Hematological parameters were collected using an automated blood cell counter. The amounts of Hb fractions were measured by capillary electrophoresis of Hb. Statistical analysis was performed using R software. RESULTS: A total of 328 cord blood samples were analyzed. Among them, 154 (male: 44.8%, female: 55.2%) were used to establish reference values. The normal reference values of complete blood count (CBC) and Hb fractions were calculated. Mean neonatal Hb was 14.75 ± 2.26 g/dL. Gestational age affects the expression of CBC values as red blood cell (RBC), Hb, hematocrit (Hct), mean corpuscular volume (MCV), white blood cell (WBC), and the Hb profile. Umbilical blood hemogram parameters and Hb profile are affected by the environment; higher in newborns from urban regions but not affected by gender ratio. CONCLUSION: Reference ranges of normal CBC indices and Hb fractions have been successfully established in Tunisian neonates' UCB. Our data suggest reference values that could be useful for neonatal patients' laboratory results and clinical interpretation. KEY POINTS: · Reference values for CBC and hemoglobin fractions have been established.. · Hematological reference for UCB is useful to identify hemolytic anemia cases early.. · UCB hematological values are influenced by gestational age and probably by environmental factors..

Congenital Large Cutaneous Hemangioma with Arteriovenous and Arterioarterial Malformations: A Novel Association.

BACKGROUND: Congenital cutaneous hemangioma is a benign vascular lesion that is a leading cause of severe hemodynamic compromise in a fetus when it is of significant size and especially in association with arteriovenous malformation. CASE REPORT: A large cutaneous hemangioma involving the right arm of a 32-week-old male fetus was complicated by fetal hypotrophy, hydrops fetalis and neonatal death. Axillary arteriovenous fistulas and bilateral arterial carotid-subclavian anastomosis were demonstrated at autopsy. Microscopically, the main tumor was a mixed capillary-cavernous hemangioma with vascular channels lined by CD31-positive and GLUT1/Ki-67-negative endothelial cells. CONCLUSION: Congenital hemangioma can be associated with vascular malformations, and that associations with other vascular malformations may increase the morbidity/mortality.

Correlation between umbilical resistance index and fetal growth: Pilot study.

AIM: To investigate normal pregnancies to determine whether there is a relationship between umbilical resistance and fetal growth. METHODS: This prospective study was conducted in three academic departments. Third trimester routine prenatal ultrasonography was used to estimate fetal weight and measure umbilical resistance index (RI). After delivery the birthweight was noted, along with the time interval between the ultrasound and the delivery, and then the weekly weight gain was calculated. These data were then used to determine the relationship between fetal growth and umbilical artery RI. RESULTS: Mean patient age was 32 ± 4.8 years; mean RI was 0.62 ± 0.07, and mean weight gain was 186.4 ± 63.9 g/week. Mean percentage weight gain relative to the estimated weight on third trimester ultrasound was 8.86 ± 3.8% per week. There was an inverse linear relationship between umbilical artery RI and fetal growth: percentage of weight gained per week relative to the estimated weight during third trimester ultrasound (%/week) = [31.3 - (36.1 × RI)] × 100. CONCLUSION: In normal pregnancies there seems to be a linear relationship between umbilical RI measured at 31-34 weeks of gestation and average fetal growth in the third trimester. The greater the resistance index, the lower the weight gain.

What are the prognostic factors in the delivery of the second twin?

Objective To evaluate the prognosis of the second twin according to different criteria (presentation, mode of delivery , term, weight, weight difference between twins ,twin to twin delivery time interval, studying the Apgar scores at birth and neonatal morbidity and mortality. Materials and Methods This is a retrospective study of 183 parturients carrying twin pregnancies collected at the department of Obstetrics-Gynecology in Mahmoud Matri Hospital (Ariana) over a period of 9 years ( 1st January 2001 to 31st December, 2009 ) . Results We recorded 357 live births ( 181 J1 and J2 176 ) and 9 stillbirths . The relationship between the order of the twin and the modality of delivery on the one hand, and between the order of twin and type of presentation was considered significant (p < 0.001). We found no significant difference in Apgar score at 1 minute and 5 minutes between the 1st and the 2nd twins. A term ≤ 34 weeks was a poor prognostic factor for the Apgar score at the first and the fifth minute for the 2 twins but no significant difference between the 1st and 2nd twins (  1st min p=0.4623 ; 5th min p = 0.2899 ). Low birth weight ≤ 1500g were significantly more at risk of foetal suffering (p < 0.001). A birth weight discordance of 25% or more was observed 36 cases (19.7 %). The Apgar score was significantly influenced by the birth weight difference only in the first minute (p = 0.043 ). Thereafter, this difference disappears in the 5th minute. The type of presentation and methods of delivery did not influence significantly the second twin morbidity. A time interval between the birth of the first and second twin greater than 15 minutes was a bad prognostic factor for the Apgar score in the 1st min ( p = 0.001) and 5th min ( p = 0.019) . Transfer rate in neonatology and neonatal distress was 31.2 %.The term of birth ( before 34 weeks ), low birth weight ( ≤ 1500 g ) , and twin-to-twin delivery time interval (≥ 15 min) are parameters that influenced significantly the rate of neonatal distress and transfer to pediatric health care unit (p <0.001 , p<0.001, p = 0.004) . We found a significant increase in the transfer to pediatrics when the birth weight difference was larger than 25% ( p = 0.005). However, no significant difference was found concerning the neonatal respiratory distress (p = 0.22). The different modes of delivery and the type of presentation of the second twin did not significantly alter the rate of neonatal respiratory distress (p = 0.28 , p = 0.53) and transfer Pediatrics (p = 0,63, p = 0.38 ). Among the live births, 5 twins had died in labor room : 1st twin in two cases and in 2nd twin in 3 cases and there was no significant correlation between neonatal mortality and the twin's order (p = 0.629 ) . Conclusion A term ≤ 34 weeks, a low birth weight ≤ 1500g and a delay of more than 15 mn were factors that influenced significantly the Apgar score at 1st and 5th minute, and were responsible for more neonatal distress and transfer in pediatrics. A birth weight difference larger than 25% between the two twins influenced the Apgar score at the first minute and was responsible for an increase in the transfer rate.

Ovarian hemangioma: Differential diagnosis of ovarian cancer.

INTRODUCTION AND IMPORTANCE: Ovarian cavernous hemangioma is a rare benign vascular tumor primarily found as either an isolated ovarian mass or as diffuse abdominopelvic hemangiomatosis. Its discovery is often incidental, but symptomatic presentations can occur, including ovarian torsion, can occur without any specification. CASE PRESENTATION: We present the case of a 55-year-old menopausal woman with chronic pelvic pain. Initial diagnostic imaging and tumor markers suggested ovarian malignancy. Subsequent investigations, including ultrasound and MRI, revealed a vascularized adnexal mass with characteristics mimicking malignancy. Surgical exploration through laparoscopy unveiled an 8 cm multicystic solid-cystic lesion with histopathological analysis confirming a 9 cm cavernous hemangioma. CLINICAL DISCUSSION: Histologically, the lesion displayed features consistent with a benign vascular malformation. Literature review indicates variability in presentations and diagnostic challenges in distinguishing these lesions from malignant ovarian tumors. Treatment involved successful cystectomy via laparoscopic surgery, ensuring ovarian preservation so as not to increase the cardiovascular risk due to bilateral annexectomy. CONCLUSION: Ovarian cavernous hemangiomas pose diagnostic challenges due to their rarity and potential mimicry of malignancy. Timely recognition through imaging modalities, especially MRI, and confirmation via histopathological examination remain pivotal. Ovarian-sparing surgical interventions are recommended, particularly for younger patients without suspicious tumor features. Despite their rarity, awareness of these lesions is crucial for accurate diagnosis and appropriate management.

[Delivery in breech presentation: what way should we choose?]. / Présentation de siège: quelle voie d'accouchement choisir?

BACKGROUND: The breech delivery is considered dangerous because of the higher rates of perinatal mortality and morbidity which become attached to it, consequences of obstetric traumas bound to the obstetric operations. What way of delivery is it necessary to privilege? What are the arguments which we have to support our choice? AIM: To assess the maternal and fetal outcome according to the way of delivery. METHODS: In this retrospective study, 194 women with a singleton pregnancy in a breech presentation delivered at term in our maternity unit in Ariana's Hospital from January 2007 to December 2009. RESULTS: Breech presentation was noticed in 2, 59%. The main factors favoring this presentation are: the primipara, the uterine deformations, the pathological ponds, the abnormalities of the amniotic liquid, the fetal weight and the fetal deformations. Vaginal delivery was accepted in 57,7% of women and 75% from them delivered in natural way. The rate of caesarians was 56,7 %. Among these patients, 74, 5 % were indications in a cold caesarian (scar womb, pathological pond, RPM > 12 hours, estimated (esteemed) fetal weight > 3800g). The Apgar's score was superior to seven in 97.6% of cases. There was no significant difference in fetal morbidity, Apgar's score or in the need of transfer in intensive care unit. CONCLUSION: When the acceptance conditions of the vaginal delivery are combined and when the surveillance of the labour is rigorous, it seems that there is no excess of neonatal risk by the natural ways.

[Cervical incompetence: diagnosis, indications and cerclage outcome]. / Incompetence cervicale: diagnostic, indications et devenir du cerclage.

BACKGROUND: Cervical incompetence, a major cause of late abortions and preterm delivery is a diagnosis increasingly easy to establish.Strapping is deemed effective to prevent recurrence of such accidents midwifery. AIM: To evaluate the relevance of the diagnosis of cervical incompetence, check the main indications of banding and study the outcome of rimmed pregnancies. METHODS: A retrospective study about 103 rimmed pregnancies collected in the service of Motherhood Hospital Mahmoud El Matri Ariana to the period of January 2001 until December 2008. RESULTS: The diagnosis of cervical incompetence is suspected in a body of evidence linking ATCD of late abortions or premature births found in respectively 46.2% and 31.1% of our patients in our series, 16.98% are carriers of known uterine defects. 8.49% are classified as high risk front of 3-ATCD of late abortions or preterm delivery and were circled systematically. 2.83% are rimmed after confirmation the incompetent cervix by calibration of the cervix and 55.99% because of clinically short cervix. The strapping has reduced the rate of late abortion which decreased from 46.6% before strapping to 7.6% after. As for preterm delivery, it is reduced from 31.1% before strapping to 18.5% after. This difference is statistically significant. The average term of confinement in our series is 36SA six days. 68 cases were delivered at term. Among patients in whom we have accepted the vaginal delivery, 74.2% had spontaneous labor. One case of rupture of the anterior lip of the cervix was noted. CONCLUSION: The indication of a cervical strapping needs a well established diagnosis involving data from history, clinical examination and possibly endo-vaginal ultrasound to confirm the high-risk of cervical incompetence. The strapping participates significantly to prolong the duration of pregnancy, to lower rates of early major premature and to improve the chance of viability and prognosis of fetuses without serious repercussions on the workflow.

Selective salpingography and tubal catheterization in infertile women.

BACKGROUND: Use of selective salpingography (SS) and fallopian tube catheterization (TC) has revolutionized the diagnosis and treatment of proximal tubal infertility. AIM: To evaluate results of women treated for proximal tubal obstruction by selective salpingography and tubal catherization. METHODS: Selective salpingography was performed in women with proximal bilateral tubal obstructions. Follow-up ranged from 4 to 12 months. RESULTS: twelve patients had been shown to have bilateral proximal obstruction of the fallopian tube. After SS/TC, patency was achieved in 8 cases. Spontaneous conceptions occurred in 4 women. CONCLUSION: SS and TC should be used more widely because it is simple and effective in case of proximal tubal blockage.

[Ovarian drilling for the treatment of infertility with dystrophic ovaries]. / Place du forage ovarien dans le traitement de l'infertilité liée à la dystrophie ovarienne.

BACKGROUND: Dystrophic ovaries represent the main cause of female infertility in Tunisia. AIM: To assess the contribution of ovarian drilling in the treatment of infertility in patients with ovarian dystrophy. METHODS: A retrospective study of 23 patients with dystrophic ovaries that have benefited through their subfertility of laparoscopic ovarian drilling, in the gynecology-obstetrics hospital Mahmoud EL Matri, Ariana, Tunisia. Our study spans a period of 3 years from January 2004 to December 2006. RESULTS: Among the 23 patients who underwent drilling for clomiphene citrate resistance, 9 have been pregnant. The average age of patients having had a pregnancy after ovarian drilling was 29.6 years, the average delay was 7.1mois. Regarding prognostic factors, only infertility's duration lower than 3 years was predictive of a good result. CONCLUSION: Ovarian drilling is an interesting alternative to induction by FSH for patients with dystrophic ovaries.

Maternal and fetal outcomes of large fetus delivery: a comparative study.

AIM: To review the deliveries of macrosomic babies, weighing over than 4000g and their obstetrical and neonatal outcomes. METHODS: Retrospective study involving a total of 209 deliveries at term of macrosomic babies between Marsh 2006 and February 2007 in the Maternity Hospital of Mahmoud ELMATRI, Tunis. The study concerned risk factors, mode of delivery and the incidence of maternal and perinatal complications.We compared data in the study group to a control group of normal weight infants delivered at the same period. RESULTS: Macrosomia occurred in 9.2% of all deliveries. The main risk factors of macrosomia were maternal age over 30 years (p=0,017), multiparty (p<0.001), diabetes mellitus (p=0.012) and prolonged term of delivery (p=0.02). These risk factors were statistically significant compared to control group. Caesarian delivery was achieved in 24.4% in macrosomy group and in 13.7% in control group (p=0,003) the major part occurred during labor. Among vaginal deliveries in macrosomia group, shoulder dystocia was noted in 1,9%, fetal respiratory failure and admission in intensive care unit was noted in 4,8% of the cases and hypoglycemia complicated 15,8% of deliveries. Maternal complications were dominated by post partum hemorrhage documented in 1.2% of the cases and perineal tears noted in 8,2% of vaginal deliveries. CONCLUSION: Vaginal delivery is the most frequent mode of delivery for a fetus weighing in excess of 4 kg and vaginal delivery should be attempted in the absence of contraindications and there is no need for elective systematic caesarian. However, shoulder dystocia remains the main complication of vaginal delivery for macrosomic fetuses and requires experienced obstetricians to manage these deliveries.

First trimester diagnosis of Pallister-Killian syndrome in a fetus with suggestive abnormalities.

BACKGROUND: Pallister-Killian Syndrome is a rare, sporadic chromosomal disorder characterized by a tetrasomy 12p often in mosaic. It is only in 2000 that the first case of PKS was diagnosed in the first trimester further to an increased nuchal translucency. AIM: Report a new case. CASE REPORT: To our knowledge, we present the first case of early prenatal diagnosis of Pallister Killian Syndrome due to the presence of an increased nuchal translucency, a diaphragmatic hernia, a typical facial dysmorphism and a micromelia of a predominantly rhizomelic type . A chorionic cells biopsy showed a normal karyotype. The diagnosis was revealed on cytogenetic analysis of amniotic fluid sampling. CONCLUSION: The main ultrasound indicators of PKS seem to be: Hydramnios, congenital diaphragmatic hernia (CDH) and a micromelia of a rhizomelic type. The Hydrops fetalis, hygroma coli or increased nuchal translucency (INT), fetal overgrowth, ventriculomegaly and presence of a sacral appendix are less common. The amniocentesis with the study of the karyotype on amniotic cells is considered to be the gold standard for the diagnosis of PKS. A good morphological study during the first trimester in search of ultrasound abnormalities highly suggestive of PKS is able to direct the cytogenetic study.

[Unexpected diagnosis of a cystic pelvic mass: benign mesothelioma of the uterus: case report]. / Diagnostic Inattendu devant une masse kystique pelvienne : mésotheliome bénin de l'utérus. A propos d'un cas.

BACKGROUND: Benign mesothelioma is a rare tumour mostly found in the genital tract. CASE: We report the case of 30-years old woman presenting pelvic pain. The ultrasound scan revealed a cystic pelvic mass. Laparoscopic exploration showed a uterine posterior formation. The resection of the dome was performed. Histologic exam and immnunochemistry concluded to a benign cystic mesothelioma. CONCLUSION: The benign mesothelioma of the uterus is usually discovered in histology, differential diagnosis for solid forms can be made with leiomyoma or adenomyoma, whereas the cystic forms can be discussed essentially with the ovarian cysts. The presence of mesothelial immunophenotype in immunochemistry improves diagnosis. Clinical outcome is always favourable without recurrence or malignant transformation.

[Immature teratoma of the ovary and pregnancy]. / Tératome Immature De L'ovaire Et Grossesse.

BACKGROUND: Composing of less than 1% of all ovarian cancers, immature teratoma is a malignancy that mainly affects the young. Immature teratoma of the ovary together with pregnancy is rare. To our knowledge, this association was reported only in twelve cases. AIM: We Report two cases of immature teratoma of the ovary diagnosed during pregnancy and their respective issue. OBSERVATION: 1st case. A 28 years old woman gravida 1 with an immature teratoma of the ovary discovered during delivery by caesarean section. The treatment was conservative including salpingo-oophorectomy, omentectomy, aortic lymph node dissection and appendectomy. This patient had a second pregnancy with a good outcome. She delivered by caesarean section in order to perform radical treatment: hysterectomy and oophorectomy of the remaining ovary. 2nd case. A 22 years old woman gravida 1 with adnexal mass diagnosed during an ultrasonography exam at 15 weeks gestation. A conservative treatment was indicated, including salpingo-oophorectomy, omentectomy, aortic lymph node dissection, appendectomy and biopsy of the remaining ovary. The patient had a normal vaginal delivery. CONCLUSION: Immature teratoma is graded from 1 to 3. The management of this association is discussed, but it takes in consideration the surgical staging, the grade and the secretion of aFP. Conservative treatment without associating chemotherapy can be tempted in tumours with a stade AI and a low grade.

[Prenatal diagnosis and management of fetal megacystis]. / Conduite à tenir devant la découverte anténatale de mégavessie.

BACKGROUND: Prenatal diagnosis of fetal megacystis particularly in the first trimester requires assessement of pronostic and aetiologycal criteria. AIM: Report a new case. CASE: we report a case of severe megacystis in female fetus diagnosed at 23 weeks of gestation. There are no other associated ultrasound findings. Fetal karyotyping was normal (46XX). Termination of pregnancy for medical indications was realised because of progressive enlargement of the fetal bladder. Post-mortem examination shown megacystis-microcolon-intestinal hypoperistalsis syndrome. CONCLUSION: Fetal megacystis is a severe condition when diagnosed early in pregnancy. Ultrasonography follow-up and fetal karyotyping are important to evaluate prognosis.

[Premature rupture membrane at term with unfavourable cervix]. / Rupture prématurée des membranes à terme sur col défavorable.

BACKGROUND: Between expectant attitude in hospital and labour induction, management of and premature rupture membrane at term stay controversial. AIM: The aim of our study was to evaluate the management rupture of the membranes at term with unfavourable cervix. MATERIAL AND METHODS: We conducted a retrospective study. An expectant delay of 24 hours had been followed by induction labour in women with favourable Bishop. Maturation by prostaglandins E2 (PGE2) was performed in case of unfavourable cervix. We administrate one dose each 24 hours (3 doses maxima). Over, labour induction by ocytocine was started. The prescription of antibioprophylaxis is systematic until delivery. RESULTS: We included 137 patients. 51% of patients had a spontaneous labour during the expectant delay. There was no significant difference in neonatal and maternal morbidity in case of expectant management of premature rupture membrane at term. CONCLUSION: Based on our findings and a review of the literature, an expectative of 24 hours is interesting in case if unfavourable conditions. Prostaglandin E2 maturations can be performed in unfavourable cervixes.

Gestational trophoblastic disease in Tunisia.

OBJECTIVE: The aim of our study is to evaluate the frequency of the gestational trophoblastic disease (GTD) in Tunisia, and describe its risk factors and clinical presentations. We also precise therapeutic features used in our country and compare them to those proposed in the literature and finally suggest concrete recommendations. METHODS: We studied retrospectively the cases of GTD proved histologically, occurring during the three years (2000-2001-2002) in the departments of genecology obstetrics of Tunisia and the department of medical oncology of the Salah Azaiz Cancer Institute. RESULTS: The frequency of the GTD in Tunisia is 1 per 918 deliveries. The frequency of the CHM (complete hydatiform mole) is estimated to 68.15% of all the cases of GTD and 1 per 1347 deliveries whereas the frequency of the PHM (partial) is estimated to 30.57% and 1 per 3004 deliveries. The mean gestational age at the moment of the diagnosis is of 11.5 week of amenorrhea (WA) for CHM and 11 WA for the PHM. The metrorrhagia is present in 75% of the CHM and 67% of the PHM. Ultrasonography showed a typical snowstorm aspect in 55%. The mean rate of HCG is 162 x 10(3) UI/l. Vacuum aspiration was performed in all the CHM and in 89.5% of the PHM. One patient followed up for PHM was treated by hysterectomy. 21% of the cases were complicated by trophoblastic retention. Two patients were treated by initial chemotherapy for invasive mole and metastatic mole. 84% of the patients reached complete healing. After treatment of the molar pregnancy, two patients (1.27%) recurred. CONCLUSION: Our results suggest some recommendations: In our practice, all abortion products must be addressed to histopathological examination. The patients must be surveyed during at least one year to detect the occurrence of a GTN. The classification and treatment of the GTN must be codified Modem therapy for gestational trophoblastic diseases (GTDs) has resulted in high cure rates while preserving fertility.

[Polycystic ovary syndrome with infertility]. / Syndrome des ovaires polykystiques avec infertilité.

BACKGROUND: The definition of the polycystic ovary syndrome has been controversial for a long time. Rotterdam consensus established precise criteria since two among three set the definition as follow: anovulation, hyperandrogenism and polycystic ovaries. The aim of this study is to stress on the particularity of ovarian dystrophy and the management of the resulting infertility that represents an important rate of medical counselling of women desiring pregnancy. METHODS: Literature review. RESULTS: Management consists in two parts: treating hyperinsulinism and stimulating ovulation. The "step up low dose" protocol is now taking the place of the classical "step down" protocol. Ovarian drilling have to be considered in case of resistance to Citrate of Clomifene. The hyperstimulation syndrome is the common complication to avoid by a regular following. The "coasting" represents an interesting alternative in case of an explosive response in order to obtain a controlled follicular failure. CONCLUSION: Clinical management of the PCOS have to be organized in regard to patient's age, history ,desire of pregnancy and medical staff experience.

[Predictors of birth outcomes related to women with a previous caesarean section: experience of a Motherhood Center, Bizerte]. / Facteurs prédictifs de l'issue de l'accouchement sur utérus unicicatriciel, expérience du centre de Maternité de Bizerte.

INTRODUCTION: Caesarean section (CS) rates have been significantly increasing in recent decades. For this reason, the obstetrician must frequently decide on the most appropriate mode of delivery for mother and fetus. This study aims to describe vaginal birth after previous cesarean section (VBACs) in our obstetric practice and to identify factors significantly associated with failed VBACs. METHODS: We conducted a population-based study among women with a history of previous cesarean delivery. The study design was retrospective, longitudinal, descriptive and analytical. The case study was conducted over a two years and three months period, from January 1, 2012 to March 31, 2014 during which we collected data from 423 medical records of patients attempting VBACs at the Maternity and Neonatology Center, Bizerte. RESULTS: The rate of attempted VBACs was 47%. The success and the failure rates of these attempts were 82,7% and 17,3% respectively. The main factors for a poor prognosis in patients attempting VBACs were: the absence of a previous vaginal delivery (p = 0.005), a previous indication for cesarean section due to stagnation of dilatation or poor labor progress, (p 0.049 and 0.002 respectively), gestational age at delivery of = 40 weeks (p = 0.046), parity <3 (p = 0,75.10-4), Bishop score <6 at the onset of labor (p = 0,23.10-47), "active labor" duration = 6h (p = 0.002), length of labor> 8 h (p = 0.0031) and the occurrence of abnormal fetal heart rate (FHR) during labor (p = 0144.10 -9). We observed seven cases of uterine rupture (1.7%). There were no cases of maternal mortality. Total maternal morbidity rate was 9,5%. The difference in rates of maternal complications between the two groups (failed and successful attempted vaginal birth after cesarean) was not statistically significant. CONCLUSION: Attempting vaginal birth after cesarean on the basis of good and poor prognostic factors and patient consent, contributes to the reduction in maternal and neonatal morbidity and should lead to the establishment of clear and codified Tunisian guidelines as part of a policy against unjustified iterative caesarean sections.