Mehdi Kehila

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.

Efficacy and safety of pelvic packing after emergency peripartum hysterectomy (EPH) in postpartum hemorrhage (PPH) setting

OBJECTIVES To study the safety and effectiveness of pelvic packing in the control of post emergency peripartum hysterectomy (EPH) bleeding in a postpartum hemorrhage (PPH) setting. STUDY DESIGN From 39 patients with a severe PPH leading to an EPH (January 2010-December 2013), we identified a group of 17 patients requiring a pelvic packing (packing group) and a second group of 22 patients not requiring a pelvic packing (non-packing group). For each group, transfusion requirements were recorded from time of PPH diagnosis to end of the surgical procedure (P1: Period 1) and from that point to the end management in the SICU (P2: Period 2). Laboratory values, transfusion requirements and complications were compared between the 2 groups. Statistical comparisons were performed using Mann-Whitney test, Fishers exact test and chi-square test. A p-value <0.05 was considered statistically significant. RESULTS Pelvic packing was successful in the control of bleeding in all the cases. During the second laparotomy for pack removal, none of the patients developed complications such as bowel injuries or necrosis. The 2 groups were similar in term of laboratory values at the end of the surgical procedure and 24h after the end of the surgical procedure. The number of PRBC units required in P1 was higher in the packing group compared to the non-packing group (16.6±5.3 vs 14±5; p=0.04), however the decrease in the amount of PRBCs transfused between P1 and P2 was higher in the packing group (13.3) compared to the non-packing group (9.1) (p<0.01). The incidence of febrile morbidity was higher in the packing group compared to the non-packing group (53% vs 9%; p=0.04); but no significant difference was shown in term of generalized sepsis, as well as renal failure, ARDS, deep vein thrombosis, pulmonary embolism and MOF. CONCLUSION The pelvic packing is a valuable method with a high success rate in the control of hemorrhage after an EPH in PPH setting with a low rate of complications. It is quite simple and quick to perform, and therefore should be kept in mind by all obstetricians as a lifesaving technique.

Ultrasound cervical length measurement in prediction of labor induction outcome

Induction of labor is one of the most common procedures in modern obstetrics, with an incidence of approximately 20% of all deliveries. Not all of these inductions result in vaginal delivery; some lead to cesarean sections, either for emergency reasons or for failed induction. Thats why, It seems necessary to outline strategies for the improvement of the success rate of induced deliveries. Traditionally, the identification of women in whom labor induction is more likely to be successful is based on the Bishop score. However, several studies have shown it to be subjective, with high variation and a poor predictor of the outcome of labor induction. Transvaginal sonography for cervical measurement can be a more objective criterion in assessing the success of labor induction. Many studies have been done recently to compare cervical measurement and Bishop Score in labor induction.This paper reviewed the literature that evaluated sonographic cervical length measurement to predict induction of labor outcome.

Vulvar cancer in Tunisia: Epidemiological and clinicopathological features multicentric study

OBJECTIVE To describe for the first time the epidemiologic and clinico-pathologic characteristics of vulvar cancer in Tunisia. DESIGN Two parts are distinguished in this study: Part1: Multicentric retrospective study about the characteristics of all cancer cases diagnosed during a 17-years period (January 1998-December 2014) in three departments of Gynecology and Obstetrics: one in south Tunisia and two in the capital. Part 2: To determine the Incidence trend of invasive vulvar cancer in North Tunisia 1994-2009, on the basis of North Cancer Registry of Tunisia. RESULTS A total of 76 cases of vulvar cancer were recorded. The median age at diagnosis was 65.4years and 86.9% of patients were more than 55years old. The symptomatology was dominated by vulvar pruritus in 48.7%. The average size of the tumor was 3.96cm. Stage III was the most frequent (53.7%) followed by stage II (28.3%). Only 10.4% of tumors were at stage I. The most common histologic type of vulvar malignancy was squamous cell carcinoma (SCC) (94.7%). Standardized incidence varied from 1.2/100 000 (1994) to 0.5/100 000 (2009). There was significant decrease of Standardized incidence (APC of -8.8% per year, 95% CI: -5.5%, -9.0%-p<0.001). CONCLUSION Vulvar cancer in Tunisia is a rare disease, occurs mostly in elderly women, and is diagnosed at advanced stages. Our findings emphasize that a greater effort should be made to facilitate early diagnosis, as treatment in earlier stages is less extensive and potentially curative.

Are the Wells Score and the Revised Geneva Score valuable for the diagnosis of pulmonary embolism in pregnancy

OBJECTIVES To evaluate and to compare the predictive accuracy of the Wells score and the revised Geneva scores for the diagnosis of pulmonary embolism in the pregnant and postpartum population. STUDY DESIGN All pregnant or post-partum patients with a suspected PE and for whom a diagnostic imaging testing was performed (VQ scintigraphy or computed tomography pulmonary angiography) over a 3-year period were included in the study. The Wells and Revised Geneva Scores were calculated on the same cohort of patients and dichotomized into low and intermediate/high probability groups. The sensitivities and specificities were calculated. Overall accuracy was determined using receiver operator characteristic curve analysis. RESULTS A total of 103 patients were included. The overall prevalence of PE was 26.2% (27/103). Using the Wells Score, the prevalence of patients with PE in the low, intermediate and high probability categories was 20.5%, 43.5% and 50% respectively. Using the Revised Geneva Score, the prevalence of patients with PE in the low, intermediate and high probability categories was 17%, 36.2 and 33.3% respectively. In low risk groups of the Wells score and the simplified revised Geneva score the prevalence of PE was not statistically significantly different: respectively: 20.5% and 17.5% (p = 0,232). The agreement on clinical assessment using the Wells score and using the revised Geneva score was weak (κ coefficient = 0.154). In total, 26 (25.2%) patients were classified differently using the 2 scores. There was no significant difference in the overall accuracies of the Wells (0.67, 95% CI 0.54-0.79) and Revised Geneva Scores (0.64, 95% CI 0.52-0.76) as determined by the area under the ROC curves (P = 0.628). The sensitivity, specificity, PPV and NPV of the Wells score and the revised Geneva score were respectively: 40.7%, 81.5%, 44%, 79.4% and 62.9%, 59.2%, 35.4%, 81.8%. CONCLUSION(S) The Wells score and the revised Geneva seems not to be valuable in the pregnant and post partum population. A specific risk score of PE for pregnant and postpartum population is needed to reduce the rate of unnecessary imaging studies, especially in this specific population were the use of radiation and contrast agent is problematic.

Increased plasmatic soluble HLA-G levels in endometrial cancer

HIGHLIGHTSsHLA‐G is significantly increased in patients with EC.sHLA‐G is highly increased in early stages and in high grade EC.HLA‐G5 are more represented than sHLA‐G1 molecules in patients with EC.sHLA‐G are represented majorly in monomeric forms.sHLA‐G dimeric forms are specifically associated to early stages of EC. ABSTRACT Human Leukocyte Antigen‐G (HLA‐G) is known as an immune suppressive molecule; it interacts with several immune cells and inhibits their functions. HLA‐G molecule is highly represented in pathological conditions including malignant transformation. To the best of our knowledge this is the first study that focuses on the expression of soluble HLA‐G (sHLA‐G) in endometrial cancer (EC). We aimed at exploring sHLA‐G plasma levels and its prognostic value in EC. We examined total sHLA‐G expression as well as the sHLA‐G1 and HLA‐G5 isoforms expression in plasma samples from 40 patients with EC and 45 healthy controls by a specific sandwich ELISA. Immunoprecipitation and Coomassie blue staining were performed to explore the presence of plasmatic sHLA‐G monomers and dimers. sHLA‐G plasma level was significantly enhanced in patients with EC compared to healthy controls (p=0.028). Additionally, HLA‐G5 molecules were highly represented than sHLA‐G1 molecules in EC, at the borderline of significance (p=0.061). Interestingly, sHLA‐G has been shown to be increased in early stages (Stages I and II) as well as in high grade EC (Grade 3) that is associated with rapid spread of the disease (p=0.057). sHLA‐G positive EC plasma were majorly in monomeric form (75%). Clinically, all the HLA‐G dimers were detected in early stages and in high grade of EC. Our data strengthen the implication of HLA‐G molecules in EC etiology and especially in progression.

Lobe placentaire accessoire: penser aux vaissaux praevia

Il s’agit d’une patiente âgee de 36 ans, deuxieme geste, deuxieme pare hospitalisee a deux reprises pour des metrorragies au troisieme trimestre de la grossesse. A chaque hospitalisation, une echographie a ete pratiquee par voie sus-pubienne et a conclu a un placenta anterieur normalement insere sans images de decollement. A l’occasion de la troisieme hospitalisation, a 36 semaines d’amenorrhee, une echographie transvaginale a ete realisee. Celle-ci a revele une structure d’echogenicite similaire a celle du placenta, situee sur la face posterieure de l’uterus, a 24mm de l’orifice interne du col, evocatrice d’un lobe placentaire accessoire. L’application du Doppler couleur a montre un vasa praevia connecte a ce lobe. Une cesarienne a alors ete programmee a 37SA donnant naissance a un bebe de sexe masculin, pesant 3800g en bon etat de sante. L’etude macroscopique du placenta a montre le lobe placentaire accessoire separe du principal disque placentaire par des membranes et relie a celui-ci par de larges vaisseaux.

Correlation between umbilical resistance index and fetal growth: Pilot study

To investigate normal pregnancies to determine whether there is a relationship between umbilical resistance and fetal growth.

Confrontation échographique et fœtopathologie après interruption thérapeutique de grossesse dans une maternité Tunisienne de référence

This study aims to evaluate the value of prenatal ultrasound diagnosis by comparing it with the results of the fetopathological examination in case of therapeutic interruption of pregnancy for fetal indication. We conducted a retrospective descriptive and analytical study carried out over a three-year period from January 2013 to December 2015. It involved 66 fetuses autopsied after therapeutic interruption of pregnancy for fetal indication. Fetopathological examination confirmed ultrasound results in 63 cases (95.4%). In 18 cases (27.2%) there was a full match between the results of the prenatal diagnosis and those of the autopsy. Nine percent of fetal malformations were detected in the first trimester. The majority of malformations (72%) were detected in the second timester. Neurological malformations were the most frequent (60%), dominated by hydrocephalus and anencephaly. This study shows that, in our clinical context, even if ultrasound diagnosis is often non-exhaustive, its signs indicating the need for interruptions of pregnancy are correct. Fetopathological examination is used, in this case, to detect unknown malformations, making it possible to specify the diagnosis and to implement a strategy for subsequent pregnancies.

Macrosomie, dystocie des épaules et élongation du plexus brachial: quelle est la place de la césarienne?

The delivery of a macrosomic infant is associated with a higher risk for maternofoetal complications. Shoulder dystocia is the most feared fetal complication, leading sometimes to a disproportionate use of caesarean section. This study aims to evaluate the interest of preventive caesarean section. We conducted a retrospective study of 400 macrosomic births between February 2010 and December 2012. We also identified cases of infants with shoulder dystocia occurred in 2012 as well as their respective birthweight. Macrosomic infants weighed between 4000g and 4500g in 86.25% of cases and between 4500 and 5000 in 12.25% of cases. Vaginal delivery was performed in 68% of cases. Out of 400 macrosomic births, 9 cases with shoulder dystocia were recorded (2.25%). All of these cases occurred during vaginal delivery. The risk for shoulder dystocia invaginal delivery has increased significantly with the increase in birth weight (p <10-4). The risk for elongation of the brachial plexus was 11 per thousand vaginal deliveries of macrosomic infants. This risk was not correlated with birthweight (p = 0.38). The risk for post-traumatic sequelae was 0.71%. Shoulder dystocia affectd macrosoic infants in 58% of cases. Shoulder dystocia is not a complication exclusively associated with macrosomia. Screening for risky deliveries and increasing training of obstetricians on maneuvers in shoulder dystocia seem to be the best way to avoid complications.