Mohamed Faouzi Gara

Reduced maternal mortality in Tunisia and voluntary commitment to gender-related concerns

To estimate the number and causes of maternal deaths in Tunisia from 1999 to 2007, and compare the results with the last report (1993–1994).

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.

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