Kaouther Dimassi

Ultrasound Fetal Weight Estimation: How Accurate Are We Now Under Emergency Conditions?

The primary aim of this study was to evaluate the accuracy of sonographic estimation of fetal weight when performed at due date by first-line sonographers. This was a prospective study including 500 singleton pregnancies. Ultrasound examinations were performed by residents on delivery day. Estimated fetal weights (EFWs) were calculated and compared with the corresponding birth weights. The median absolute difference between EFW and birth weight was 200 g (100-330). This difference was within ±10% in 75.2% of the cases. The median absolute percentage error was 5.53% (2.70%-10.03%). Linear regression analysis revealed a good correlation between EFW and birth weight (r = 0.79, p < 0.0001). According to Bland-Altman analysis, bias was -85.06 g (95% limits of agreement: -663.33 to 494.21). In conclusion, EFWs calculated by residents were as accurate as those calculated by experienced sonographers. Nevertheless, predictive performance remains limited, with a low sensitivity in the diagnosis of macrosomia.

Ultrasound diagnosis of fetal head engagement

To compare clinical data and transperineal ultrasound results for the diagnosis of fetal head engagement.

Article originalDiagnostic de l’engagement fœtal par l’échographie transpérinéale : étude préliminaire tunisienneDiagnosis of fetal engagement by transperineal sonography: A preliminary Tunisian study

INTRODUCTION The assessment of fetal head engagement by digital examination is highly subjective even though this method remains the gold standard. Ultrasound could be a new way to specify the fetal head engagement with objective and reproductible measurements. OBJECTIVE To compare the clinical data and the transperineal ultrasound results for the diagnosis of fetal head engagement. PATIENTS AND METHODS We conducted a prospective longitudinal study on a series of 70 patients and compared the clinical assessment of fetal engagement to the ultrasound measurements. Ultrasound examination was performed in the delivery room. The probe was placed on the ano-vulvar area. The measure used was: distance perineum-external table of fetal head bone. RESULTS The ultrasound measures of the distance [perineum-external table of fetal head bone] went from 13 to 75 mm; and the measures of the distance [perineum-succedaneum bump] went from 22 to 68 mm. We tried to retain a value threshold of the distance [perineum-external table of fetal head bone] above which the diagnosis of engagement would be countered. The threshold so proposed is of 55 mm with a positive predictive value in 98%, a sensibility in 87% and specificity in 93%. DISCUSSION AND CONCLUSION Transperineal ultrasound is a simple and easy method to define fetal head engagement by measuring the distance between perineum and fetal head. This new tool can be very useful in the delivery room when clinical examination is inconclusive hampered, for example, by the presence of a succedaneum bump.

Use of transperineal sonography during preterm labor.

The gold standard for cervical length (CL) assessment is transvaginal ultrasound scan (TVUS). Transperineal ultrasound scan (TPUS) is an alternative route to CL measurement, which may be more acceptable to women. The primary outcome of this study was to investigate the reliability of TPUS performed by obstetrical team on duty in case of preterm labour (PL) and to compare transperineal to transvaginal CL measurements as a reference. Secondary, we aimed to assess the predictive value of transperineal CL measurement for preterm delivery (PD). Correlation, agreement and patient’s preference were assessed. Cut-off points predictive of PD were calculated using receiver-operating characteristic (ROC) curves. Sixty patients admitted with PL were included. Median CL measurements with TPUS and TVUS were 25.3 mm and 27.3 mm, respectively. Correlation was significant (R = 0.95; p  < 0.0001; [95% CI = (−0.032–0.170)]. The cut-off point was 25 mm for TPUS and 22.8 mm for TVUS. In case of PL, CL measurement with TPUS seems reliable and can be performed by the obstetric duty team.

Knowledge and uptake of genital cancer screening methods among Tunisian women

Genital cancers are amajor public health problem in Tunisia. There is limited research exploring Tunisian women’s understanding of these diseases. The aim of the present study was to assess the knowledge and uptake of genital cancer screening methods among a population of Tunisian women to investigate associations with socioeconomic status. A national cross-sectional survey of 4590 women aged 35–70 years was conducted between April and September, 2005. The protocol was approved by the Committee of the Tunisian National Council of Statistics. All participants gave informed consent. Questions on knowledge anduptake of genital cancer screeningmethodswere asked during an interview with each participant. Statistical calculations were performed using SPSS version 13.0 (SPSS Inc, Chicago, IL, USA). P b 0.05 was considered statistically significant. Overall, awareness among the participants that cancer could be located in the breasts or cervix was 69.1% (n = 3027) and there was a contrast in this awareness between urban and rural regions (78.1% vs 57.2%; P b 0.001). Among the women who were aware that cancer could be located in the genital organs, 46.9% (n = 1580) declared that they did not know any of the symptoms associatedwith genital cancers, whereas 32.5% (n = 1092) knew of more than one symptom. Only 26.3% (n= 1207) knew of one or more screening methods for genital cancers. The best known screening method was the Pap smear (41.6%; n = 463) followed by self-breast examination (40.0%; n = 445). Mammography was the least known (18.2%; n = 203). A higher level of education was associated with an increased knowledge of screeningmethods: 52.6% of womenwith a higher level of education knew of the Pap smear compared with 4.1% of women with no formal schooling (P b 0.001). In Hong Kong, level of education had no influence on knowledge of mammography and housewives were more likely to have heard of it than nonhousewives [1]. These findings suggest the importance of media as a source of information [2]. In the present study, only 22.4% (n = 971) of women declared that they had received at least one clinical breast examination. There was a significant difference according to area (27% [n = 667] urban vs 16.3% [n = 304] rural; P b 0.001); age (30.9% [n = 512 aged 34–44 years vs 11.3% [n = 138] aged N54 years; P b 0.001); and economic level (high 39.9% [n = 371] vs low 13% [n = 213]; P b 0.001) (Table 1). Almost 50% (n=2138) of women did not practice self-breast examination. The percentage who did perform self-examination was higher among urban women than rural women (56.7% [n = 1415] vs 38.6% [n = 723]) and among women aged 34–44 years compared with those aged 45–54 years or older than 54 years (59.4% [n = 991], 51.7% [n= 762], and 31.4% [n= 385]), P b 0.001). The highest percentage performing self-breast examination was observed in the most developed (according to socioeconomic indicators) region (69.8%; n = 409); and among the highest economic level group compared with the lowest (68.8% [n = 665] vs 35% [n = 578] P b 0.001). Only 8.6% (n = 368) of women declared that they had received at least one mammography screening. Similar low percentages have been observed [3] and factors that have been shown to influence the uptake of mammography are economic level and lack of health insurance [4]. In the present study, younger, more educated women from the highest economic level and those living in the coastal region have better access to mammography. Only 17% (n= 708) of women declared that they had undergone at least one Pap test. There was a significant difference according to area (21.6% [n = 515] urban vs 10.8% n = 193] rural; P b 0.001); age (21.4% [n = 344] aged 34–44 years vs 9% [n = 105] aged N54 years; P b 0.001); region (34.3% [n = 198] in most developed vs 10.3% [n = 65] in least developed); and economic level (32.7% [n = 305 highest vs 8.3% [n = 129] lowest). Assessment of women’s knowledge about screening methods is needed to understand their subsequent practices. Knowledge and uptake of genital cancer screening methods are still very low despite the implementation of a national program. The results of the present study elucidate several factors relevant for consideration in the national prevention and control program for genital cancers in Tunisia, and highlight inequity in access to screening.

A broad ligament pregnancy successfully managed by laparoscopy

A 32-year-old woman, gravida 2, para 1, was referred for pelvic pain and amenorrhoea of 5weeks. The patient’s obstetric history revealed one full-term, spontaneous and normal vaginal delivery. She had no past medical history or prior surgery. There was neither vaginal bleeding nor pelvic tenderness. Serum quantitative beta hCG levels were 26784 IU/ml. A subsequent ultrasound displayed an empty uterine cavity and an endometrial thickness of 11mm. An ectopic gestational sac and a live extrauterine embryo with a crow-rump length of 12mm were seen beside and right to the uterus. The most likely diagnosis was an ectopic pregnancy. The patient was taken for surgery with a laparoscopic approach. Intraoperatively, the gestational sac was found in the right broad ligament (Figure 1(A)). The uterus, fallopian tube and ovary were normal. Hence, the diagnosis of a broad ligament pregnancy was made. The broad ligament was opened, the sac was excised and products of conception extruded. The patient had an uneventful postoperative course. On histological examination, chorionic villi displayed irregularity in size and shape. A partial hydatiform mole was initially suspected (Figure 1(B)). The patient was closely followed-up with serial monitoring serum beta hCG level. She had a favourable outcome and serum hCG level was <15 IU/ml at day 28.

Transperineal ultrasonography for measuring cervical length during preterm labor.

The established gold-standard technique for measuring cervical length is transvaginal ultrasonography (TVUS). Transperineal ultrasonography (TPUS) is an alternative approach that could be preferred by patients. The objectives of the present studywere to investigate the reliability of TPUS in comparisonwith TVUS during preterm labor, and to compare patient satisfaction with both methods. A prospective comparative study enrolled patients presenting at the LaMarsa University Hospital experiencing preterm labor. Patients were eligible if they had a singleton pregnancy with a surviving fetus in a cephalic presentation, and if the duration of pregnancy was longer than 24weeks of amenorrhea. The protocol was approved by the Committee of La Marsa University Hospital and all participants provided informed verbal consent to participate. TPUS measurements of cervical length were performed by one of three residents. The probe was placed sagittally on the perineum, close to the labia majora, and without intrusion into the vagina. Following this, the probewas rotated until a clear image of the complete cervical canal was obtained. If necessary, the patients hips could be raised and supported. Following TPUS examination, TVUS measurement of cervical length was performed by a senior sonographer (Fig. 1). The senior sonographer was blinded to the TPUS measurements. Following examination, all patients were interviewed and asked which method of cervix evaluation they preferred. Statistical analysis was performed using XLSTAT version 2014.4.09 (Addinsoft, NewYork,NY, USA) and P b 0.05was considered statistically significant. The Pearson correlation coefficient was used to assess the correlation between the two techniques and Bland–Altman plots were used to study the agreement [1] between measurements made with TPUS and TVUS. The study enrolled 60 patients. TPUS assessment failed to obtain a clear image of the cervix in one case owing to bowel shadowing related to fecal impaction. In the literature, TPUS-failure rates have been report to reach 30%, with most studies attributing failure to a lack of operator experience [2–4]. By contrast, in the present study, the residents performing TPUS had no previous experience of the technique and received only a 1-h hands-on training course, suggesting that, in the present study, TPUS was easy to learn and accessible. High TPUS-failure rates could be due to pubic symphysis shadowing and the elevation of a patients hips can improve the image resolution by 50% [3]. Fig. 1 depicts the image of the cervix before (Fig. 1E) and after (Fig. 1F) the elevation of a patients hips. In the present study, the difference in median measured cervical length between TPUS and TVUS was insignificant (0.378 mm, 95% confidence interval−0.37 to 1.126; P=0.316) and there was a strong correlation between themeasurements recorded using the two techniques (r = 0.96, 95% confidence interval 0.88–1.035; P b 0.001). The majority of studies in the literature have concluded that there is good correlation between the two methods. However, some studies [2,4] differ in inclusion criteria and the results should be discussed in the appropriate specific context. Bland–Altman analysis illustrated a negligible level of systematic bias (0.37 mm) and the 95% limits of agreement were −5.19 mm to 5.95 mm. These results could be the result of inter-examiner variability. Indeed, to ensure objectivity and demonstrate the ease of learning to perform TPUS, TPUS measurements performed by trainees were comparedwith TVUSmeasurements performed by a referent. Consequently, each cervix was measured by two different methods, which were performed by two different individuals. However, this method could lead to bias, potentially altering the agreement. Finally, when asked, all of the patients expressed a preference for TPUS over TVUS. These finding are in agreement with those of Gauthier et al. [2]. International Journal of Gynecology and Obstetrics 133 (2016) 375–379