[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.

[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.

[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.

[Uterine sarcomas: clinical and therapeutic aspects (10 cases)]. / Sarcomes utérins: aspects cliniques et thérapeutiques. A propos de 10 cas.

PURPOSE: Uterine sarcomas are rare tumours characterized by clinical and histopathological diversity and poor prognosis. We analyzed diagnostic, prognostic and therapeutic difficulties encountered with these tumors by insisting on the importance of early diagnosis. PATIENTS AND METHODS: From 1997 to 2004 ten patients with uterine sarcoma who underwent surgery in the obstetrics and gynecology unit at the Tunis maternity center were included in this retrospective study. The tumors were classified at the time of diagnosis using the FIGO staging system. The histological diagnosis was based on the WHO classification. RESULTS: There were 5 cases of leiomyosarcoma, 2 cases of carcinosarcoma, 2 cases of endometrial stromal sarcoma and 1 adenosarcoma. There were four cases of stage I, two cases of stage II, two cases of stage III and two of stage IV tumors. The diagnosis of uterine sarcoma was strongly suspected and proved before the initial operation in 20% of cases and during this operation in 60% of cases. Diagnosis was only established at the histological exam in two cases. Total hysterectomy with bilateral salpingo-oophorectomy was performed in 90% of patients. Radiation therapy was performed in four. Chemotherapy was delivered in two patients. After an average of four years five patients were in remission, three had died and two were lost to follow-up. CONCLUSION: Early preoperative or intra-operative diagnosis is essential while awaiting for more effective chemotherapy protocols or therapeutic strategies.

[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.

[Maternal mortality at the Maternity and Neonatology Center in Rabta of Tunis from 1986 to 1989]. / La mortalité maternelle au Centre de Maternité et de Néonatologie de la Rabta de Tunis de 1986 à 1989.

We studied 29 cases of maternal death occurring over a period of 3 years in the "Centre de Maternité et de Néonatologie de La Rabta-Tunis"; managed by the same staff. 42,028 live births occurred during the study years with 43,220 total births from April 24th 1986 to April 23rd 1989. The maternal mortality rate was 69 per 100,000 live births. A maternal age of under 35, nulliparity and grand multiparity were found, as is well known, to be risk factors. Maternal transfer in obstructed labour from rural maternity units raises the maternal death risk 12 times: 14 deaths out of 29 occurred in transferred patients. Haemorrhage represents a quarter of the causes of death (8 cases) while anaesthetic accidents were responsible for one in six maternal deaths. Some factors were not found such as abruptio placentae, while others such as eclampsia were reduced. We concluded that the maternal mortality rate even though it has been reduced over the last 3 decades it is still high compared with developed countries. We can cut it in half by avoiding maternal transfer in labour.

[A triple association: renal malacoplakia, bilateral vulvar hypertrophy, upper limb algodystrophy]. / Triple association: malacoplakie rénale, hypertrophie vulvaire bilatérale, algodystrophie des membres supérieurs.

The authors report a case of malakoplakia of the left renal parenchyma, an uncommon site for an inflammatory disease first described in the bladder by Michaelis and Guttmann in 1902 and Von Hansmann in 1903. This case was observed in a 24-year-old girl with no urological history, presenting with bilateral vulval hypertrophy and reflex sympathetic dystrophy of the upper limbs, in whom malakoplakia of the left kidney was discovered incidentally. Intravenous urography showed two large kidneys with a stretched appearance of the renal pelvis. Pathological examination of the partial nephrectomy specimen revealed the diagnosis of malakoplakia, an inflammatory diseases of the renal parenchyma. The pathogenesis has been only partially elucidated, but probably involves a disorder of macrophage function.

[Measurement of the obstetrical pelvis by tomodensitometry (110 cases)]. / Mensurations du bassin obstetrical par tomodensitometrie (à propos de 110 cas).

We had studied in one year 110 cases of scano-pelvimetry, the clinical examination had not found a shrink pound in 41%, revealed by the sceno-pelvimetry. This method is more precisely than the classic pelvimetry, but more expansive. The simultaneous study of echography and pelvimetry had contributed to a better obstetrical decision.

[Screening for carential anemia in pregnant women: prospective study. Report of 200 cases]. / Depistage de l'anemie carentielle chez la femme enceinte: etude prospective. A propos de 200 cas.

To report the frequency and intensity of anemia in a population of pregnant tunisian women. Our retrospective study concern 200 patients collected from january to july 1999 in a population of pregnancies. Mean age was 30.1 years and 68.5% of patients consult in the third trimester with a 33.5% rate of multiparity. The frequency of anemia is 37.5%. Anemia was ferriprive in 97.3% and hypochromic in 24% of cases. Mean ferritinemia is 4.19 ng/ml after 24 weeks of amenorrhea with a marqued decrease in case of multiparity and pregnancy evolution. Mean transferrinemia is significantly low in anemic (3.98 g/dl) versus non anemic (3.60 g/dl) patients (< 0.05). The comparison of anemia with parity, the delay between two pregnancies and term of pregnancy showed a higher risk with multiparity, short delay between two pregnancies and advanced term. The frequency of anemia in tunisian pregnant women is relatively high, prevention is based on iron supplementation and hygienodietetic advices.

[Fetal pathology study of 88 cases of letal spina bifida]. / Etude foeto-pathologique de 88 cas de spina bifida létaux.

Lethal spina bifida continue to be frequent in Tunisia; we report 88 cases of letal spina bifida: 1.05 per thousand births. This pathology was more frequent with women. The up letal spina bifida situated is predominant with female and the dow spina bifida situated is frequent with male. We have noted an association with anencephalia (46 cases) and hydrocephaly (21 cases). Prevention is based on obstetric health care and hygiene dietetic advices to avoid alimentary deficit.

[Diagnosis of holoprosencephalia. Report of 17 cases]. / Diagnostic de l'holoprosencephalie. A propos de 17 cas.

OBJECTIVE: To establish the epidemiologic profile of holoprosencephalia and determine benefits of ultrasound and foetopathologic examination to the diagnostic. METHODS AN MATERIAL: [corrected] Retrospective study about 17 cases of holoprosencephalia observed in CMNT between Janaury 1992 and September 2000. RESULTS: Ultrasound diagnosis was made in 13 cases (75%). Ultrasound criteria were; absence of median structure of the brain and unique ventricule. The prognosis was always bad. Foetopathologic examination revealed 7 cases of lobar holoproencephalia and 10 of semi lobar. Fascial dysmorphia were noted in 82% of cases. CONCLUSION: The foetopathology and genetic counselling looking for fascial, dysmorphia in family's members gives a good evaluation of recurrences.

[Hypogastric artery ligation for post-partum hemorrhage]. / Ligature bilatérale des artères hypogastriques dans la prise en charge des hémorragies du post-partum.

UNLABELLED: Post-partum hemorrhage is the leading cause of maternal mortality in Tunisia as in many other countries. In case of failure of medical measures, bilateral ligation of hypogastric arteries (BLHA) represents an interesting alternative to the hemostatic hysterectomy to preserve patients fertility. OBJECTIVE: Report our BLHA experience in the post-partum hemorrhage management. PATIENTS AND METHODS: Retrospective study conducted between January 2001 and December 2008. We collected all the patients who had undergone a BLHA in case of post-partum haemorrhage. RESULTS: Fifty-seven BLHA were carried out during the study period. The success rate was 82.45%. The procedure failed in 10 patients. Most cases were uterine atony and placenta accreta. We reported one complication: a case of perioperative ligation of the primitive iliac artery. Surgical management was successful. Magnetic resonance imaging performed on average two months after surgery had shown a complete repermeabilization in seven cases among eight. CONCLUSION: BLHA is an interesting and effective option in the management of severe post-partum hemorrhage. Technique learning is recommended especially in case of non availability of uterine artery embolization.