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Sonographic approach for labour monitoring was introduced in order to improve the shortcomings of digital vaginal examination (DVE). This was a prospective study. We aimed to investigate the agreement between transperineal ultrasound (TPUS) measurements and DVE during first and second stages of labour. Patients in the first stage of labour were included. Cervical length (CL), cervical dilation (CD), cervical position (CP), foetal head descent (FHD) and foetal head rotation (FHR) were assessed by both DVE and TPUS. Agreement between two methods was examined. Eighty-five patients were included. One hundred and eighty-three paired TPUS and DVE assessments were performed. Satisfactory agreement between both methods was obtained regarding CL: systematic bias= −0.05 cm (95%CI, –0.13; 0.03), R = 0.7, p<.0001; CD: systematic bias = 0.07 cm (95%CI, –0.08 to 0.22), R = 0.93, p<.0001 and FHD: systematic bias = 0.83 cm (95%CI, 0.685–0.977), R = 0.55, p<.0001. There was a low correlation for the assessment of CP (kappa = 0.24) and FHR (kappa = 0.06). DVE was inefficient in determining FHR especially during latent phase with failure and error rates of 86% and 36%, respectively. A conceptual sonopartogram covering the hole childbirth process is presented based on reliable ultrasound measurements. What is already known on this subject? Digital vaginal examination (DVE) is used worldwide for labour monitoring. However, it is far from perfect. Some investigators have raised concerns about the value of the Bishop score because it is a subjective measure with great intra- and inter-observer variability, affected by a physician's clinical experience. Moreover, this method is intrusive, uncomfortable and may increase the risk of infection. The sonographic approach for labour monitoring was introduced in order to improve the shortcomings of DVE. Multiple studies focussed on the reliability of the sonographic method in assessing each parameter during labour. Hassan et al. were the first to determine whether it is feasible to perform assessment in the first stage of labour based only on US, and to describe a method of recording these observations: the 'sonopartogram'. What do the results of this study add? The outcomes concluded that sonographic approach was at least as accurate as the clinical examination. Moreover, a conceptual sonopartogram covering the hole childbirth process is presented based on reliable ultrasound measurements. What are the implications of these findings for clinical practice and/or further research? Clinical relevance of this sonopartogram should be evaluated in further studies. [ABSTRACT FROM AUTHOR]

Objective: To evaluate mother and newborn child safety after French ambulatory cesarean (FAUCS).Methods: Prospective comparative cohort study in Tunisia (January-June 2018). Pregnant women indicated for primary or repeat cesarean at term underwent FAUCS or Misgav Ladach cesarean (MLC). Surgical outcomes, overall morbidity, and maternal autonomy during recovery were compared.Results: Among 112 deliveries, 60 were performed by FAUCS and 52 by MLC. FAUCS was feasible in all cases; surgeons achieved a completely extraperitoneal approach in 39 (65.0%) cases. The main difficulty experienced was fetal extraction. Longer operative procedures were recorded in the FAUCS group; however, women in the FAUCS group reported lower pain scores (3 [2-5] vs 4 [3.7-5], P<0.001) and were more likely to decline analgesics (10 [17.0%] vs 0 [0%], P<0.001). They experienced greater autonomy during recovery (median [interquartile range] time to standing, 2 [1.0-2.5] vs 12.8 [8.9-17.9] hours, P<0.001; time to full meal, 4 [3-6[ vs 26.5 [21-31] hours, P<0.001; effective time to hospital discharge, 1 [1, 2] vs 2 [2, 3] days; P<0.001).Conclusion: Implementation of the FAUCS technique was safe and successful, and improved maternal condition after cesarean. These short-term results need long-term validation by randomized trials. [ABSTRACT FROM AUTHOR]

The article presents a case study of a 32-year-old woman suffering from pelvic pain and amenorrhea who was taken for a laparoscopic surgery for broad ligament pregnancy. Topics discussed include diagnosis of ectopic pregnancy, symptoms of abdominal pregnancy, and intraoperative management of ectopic risks.

Introduction: With the improvements in ultrasound equipment as well as the easy access to quantitative beta-human chorionic gonadotropin (β-hCG), the timing of diagnosis of ectopic pregnancy has moved to the early part of the first trimester. Ectopic pregnancies of unusual location are encountered much less frequently, but are perhaps more morbid. The treatment of these unusual ectopic gestations may not be as common place as treatment of tubal pregnancies, but with early diagnosis and effective planning, their treatment can be equally as effective. Objective: Describing cases of uncommon ectopic pregnancies which were managed with ultrasound-guided local injection of KCl, followed by intramuscular injection of MTX if appropriate. Explaining the modalities of the conservative treatment and detailing the clinical biological and ultrasound monitoring. Methods: It's a retrospective study over a period of 3 years which included patients presenting an ectopic pregnancy on uncommon implantation site and whose treatment was conservative. The medical treatment consisted in injection of KCl in the gestational sac by ultrasound guidance when the pregnancy was scalable. Then we proceed to one or more intramuscular Methotrexate injections in order to complete the treatment. Results: During the study's period we collected 04 observations of unusual ectopic pregnancies treated medically. There was an interstitial pregnancy in 2 cases: a cervical pregnancy in one case and a cesarean scar pregnancy in the other case. The diagnosis was made by ultrasound in all cases and confirmed by MRI in 2 cases. (Details will be shown in the poster). The medium term at diagnosis was 6 weeks of amenorrhea. Pregnancies were evolving with heart activity in 2 cases. The average number of injection of MTX was 1.3. In all of our cases, ectopic pregnancies have been successfully managed without surgical intervention or anesthesia using ultrasoundguided puncture and injection of KCl. Conclusion: The use of advanced ultrasonography in combination with ultrasensitive serum b-hCG assays should lead to early diagnosis of such pregnancies. Early diagnosis and use of multiple modalities can reduce morbidity and mortality in cases of ectopic pregnancy with unusual location and they can be successfully managed without surgical intervention through local injection of KCl. [ABSTRACT FROM AUTHOR]

Introducton: Ultrasonography is an essential tool in the management of twin pregnancies. Fetal weight estimation is useful to anticipate neonatal care in case of prematurity, growth restriction or growth discordance. Objective: The aims of this study were (1) to assess the accuracy of estimated fetal weight (EFW) in twins and (2) to assess the accuracy of sonographic examination to predict birth weight discordance (BWD). Methods: All twin pregnancies with at least one ultrasound (US) examination within 04 days of delivery were included in this study. EFW was calculated according Hadlock2 formula. Mean of the standardized errors and percentage of newborns with birth weight (BW) within 10% of EFW were calculated. Results: Absolute differences between EFW and BW were similar for both twins (187 g [0-850] for T1 and 156 g [0-600] for T2). Mean absolute percentage error was 7.7% (0-32 gr) for T1 and 8.2% (0-27gr) for T2. Mean absolute percentage error was superior to 10% for 42% of T1 and 46% of T2 with no significant difference. Obesity was associated with a better accuracy of ultrasonography. Chorionicity, gestational age as well as fetal presentation did not influence fetal weight estimation. Ultrasonography in the diagnosis of hypotrophy had a sensitivity of 90.32%, a specificity of 78.94%, a positive predictive value (PPV) of 83.5% and a negative predictive value (NPV) of 87.5%. For the prediction of growth discordance, sensitivity was 76.9%, specificity 81.8%, PPV 50% and NPV 93.5%. Conclusion: Sonographic prediction of inter-twin BWD within four days of delivery seems to be accurate enough for routine clinical use. Performance and predictive values depend on the threshold chosen to define EFW and BW discordance. [ABSTRACT FROM AUTHOR]

Introduction: Diastematomyelia, also termed split cord malformation (SCM), is a rare form of occult spinal dysraphism characterized by the cleft in spinal cord. Prenatal diagnosis is possible bu ultrasonography (US), and fetal MRI can be used to diagnose the type of diastelatommyelia precisely. This anomaly can be isolated or associated with other dysraphism, segmental anomalies of the vertebral bodies, or visceral malformations. In isolated diastematomyelia, the skin is intact ant the prognosis excellent. Objective: We present a case of SCM with low attached spinal cord and a lipoma of the conus diagnosed in our institution as well as a review of the literature in order to determine the prognodis of isolated case of this unusual condition. Case: Routine US in a 22 weeks pregnant woman revealed a spinal abnormality of the fetus. There was a intra spinal hyper echogenicity opposite the third lumbar vertebra, with a mature posterior vertebral integrated and intact skin surface. It was difficult to see the spinal cord due to acoustic shadowing. MRI was performed during the 33rd week of gestation and confirmed the presence terminal SCM and low attached spinal cord. After the vaginal delivery at term, the child's development was normal. The MRI was done after 2 months, it confirmed the prenatal diagnosis: there was no cerebral abnormalities, there was a spinal dysraphism consisting on a law attached spinal cord associated to a lumbar diastematomyelia and a spinal lipoma of the terminal conus. We classified this SCM type 2 with good prognosis. Conclusion: Prenatal knowledge of spinal cord anomalies is important for prenatal counseling as well assurgical treatment. Since MRI shows these lesions better and with less interobserver variation than US, in patients with suspected spinal anomalies, either diagnosed on US or based on clinical and laboratory criteria, fetal MRI should be used prior to further management. [ABSTRACT FROM AUTHOR]

Introduction: In the management of preterm labor (PL), transvaginal ultrasound (TVU) remains the gold standard in terms of diagnosis and prognosis. The transperineal ultrasound (TPU) can be a reliable alternative. Objective: Present the use of transperineal ultrasound technique in preterm labor. Compare results of TVU and TPU on cervical length measurements and visualization of the opening of the internal os. Methods: It is about a preliminary prospective study, including study patients between 14 and 36weeks' gestation with a preterm labor. All the patients underwent transperineal and transvaginal cervical length assessment. The Pearson correlation coefficient and Lin concordance coefficient were used. Acceptable concordance was defined as >0.82, with an acceptable correlation of >0.9. Results: 59 patients underwent the protocol. The Pearson correlation coefficient was 0.64.Close agreement between transperineal and transvaginal measurements was observed across the full range of cervical lengths. Conclusion: Transperineal ultrasound is a as reliable as transvaginal ultrasound. Moreover, this technique is, fast, precise, trivial and providing more comfort for anxious patients. [ABSTRACT FROM AUTHOR]

Objective: Twin anemia polycythemia sequence (TAPS) is caused by small placental vascular anastomoses leading to chronic anemia in the donor and polycythemia in the recipient. TAPS can result in severe fetal or neonatal hematologic complications, cerebral injury and perinatal death. The aim of this study is to ascertain the most relevant echographic signs that helps to make an early diagnosis so we can improve the outcome of this sparse complication. Methods: It's about two observations of patients treated in the department of gynecology and obstetrics of the Mongi Slim hospital Tunis in 2013. Results: The first case is about a 42 years old patient with one miscarriage, one childbirth, blood type O negative, actual pregnancy a spontaneous monochorionic according to the early first trimester echography, adressed at 31 SA for intra uterine death of one the twins and hydrops fetalis of the second. The second patient is aged of 28 years, first pregnancy hospitalized at 29 SA to explore an hydramnios accidently discovered.The ultrasound exam performed in our service showed for the first twin: no bladder and anamnios, for the second twin: a huge bladder with polyhydramnios. In this too cases, the blood flow in the MCA was superior to 1.5MoM. Furthermore ultrasound allowed the guidance for fetal transfusion. Conclusion: TAPS is fetal emergency. Ultrasound is the only mean for the diagnosis and for the fetal therapy. [ABSTRACT FROM AUTHOR]

Looking for the etiology of an increased nuchal translucency in a patient aged of 22 years G1P0, We performed initially a karyotype whose formula was normal: 46xy. A Fetal echocardiography realized at 18 and 22 weeks' gestation was normal and brain MRI was normal also. At 22 weeks' gestation, ultrasonography revealed a hepatic vascular abnormality without other symptoms. The suspected diagnosis was agenesis of the ductus venosus with creation of a high grade arteriovenous shunt between the umbilical vein and the inferior vena cava. The geneticist suspected also a genetic syndrome but the patient refused any investigation. Agenesis of the ductus venosus may be one expression of the different possible systemic-portalumbilical abnormalities. Physiological consequences vary according to the type of substitutive anastomoses. Agenesis of the ductus venosus can be strictly isolated. It can be also one of a manifestation of a genetic syndrome like NOONAN and JOUBERT SYNDROME. In our case, agenesia of the ductus venosus was associated to an increased nuchal translucency. We did not find a similar case in the literature. [ABSTRACT FROM AUTHOR]

Objective: 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. Methods: We conducted a prospective longitudinal study on a serie of 100 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 98,63%, a sensibility in 86.74% and specificity in 94.11%. 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 a succedaneum bump. [ABSTRACT FROM AUTHOR]

Objective: Selective intrauterine growth restriction (sIUGR) in monochorionic (MC) twins is associated with a substantial increase in perinatal mortality and morbidity for both twins. Clinical evolution depends on the combination of the effects of placental insufficiency in the IUGR twin with inter-twin blood transfer through placental anastomoses. Case 1: It is about a 30 years old women with a Spontaneous monochorionic twin pregnancy. A selective intrauterine growth restriction type 2 was diagnosed at 22 WA with a persistent absent diastolic flow in the umbilical Doppler of the twin with IUGR. The evolution was marked by the deterioration of the Doppler waveforms and the appearance of a reversed end-diastolic flow at 29 WA. Then, because of the faltering growth and the appearance of A reverse atrial flow in the Ductus venosus, a cesarian section was performed at 32 WA. Birth weights were respectively 1200gr and 1800gr for the twin with IUGR and the larger twin. The latest died of a hyaline membrane disease after 5 days. Case 2: It is about a Spontaneous monochorionic diamniotic twin pregnancy with a diagnosis of a type 2 sIUGR at 26 WA. Monitoring was regular and based on the study of fetal growth, and Doppler waveforms. The evolution was marked by a persistent absent diastolic flow in the umbilical Doppler of the twin with sIUGR and the conservation of growth in both twins. Delivery was scheduled at 34 WA. The birth weights were of 1300g and 1700g. At the age of 6 mouths, the pediatric exam did not revealed any brain injury for both twins. Conclusion: SIUGR is a common condition associated with MC pregnancy. It is increasingly considered to be an important complication of MC twins, with potentially significant risks of intrauterine fetal demise or neurological adverse outcome for both twins. Introduction of skilled sonographic evaluation, a better understanding of different Doppler patterns and of the anatomy of MC placenta, together with the development of fetoscopic techniques have all contributed to a deeper scientific understanding of this condition. [ABSTRACT FROM AUTHOR]

Background: The recent overmedication of childbirth process ignores mothers wishes.  In Tunisia, women are not involved in decision-making during childbirth., Aim: To analyze the opinion of a sample of Tunisian women regarding the possibility of making their own informed choices during childbirth and to determine the factors that may influence the requested mode of delivery., Methods: This was a 5-month descriptive cross-sectional survey. Were included: Tunisian women who were consultants or practitioners at a university obstetrics and gynaecology department in Tunis; female medicine students or members of women dedicated social network groups. The questionnaire was applied during direct interviews or posted online. The main judgment criteria was: participants' opinion regarding access to autonomous choice of delivery mode. Participants were initially enrolled into 2 groups: •    group of women requesting access to autonomous choice. •    group of women who do not request access to autonomous choice.  The participants were then divided into 2 other groups according to the requested mode of delivery: •    Group : Cesarean section •    Group: Vaginal delivery. A multivariate logistic regression was used to identify risk factors that may have influenced the responses., Results: The total number of participants was 197. Access to autonomous choice was requested by 63.45% of the participants. These were mainly: consultants: OR=7.76 95% CI [0.56-106.16] or practitioners: OR=3.93 95% CI [0.01-829.03], with a high level of education OR=1.22 95% CI [0-1174.40], with a past positive birth experience: OR=1.24 95% CI [0.27-5.74]. The women who did not claim access to autonomous choices were mainly: doctors OR=-0.31 95% CI [0-32.58], midwives: OR=-0.08, 95% CI [0-18.12] or even housewives OR=-0.42 95% CI [0-68.88]. The women who preferred to give birth by Caesarean section were mainly: practitioners: OR=2.03 95% CI [0.53-7.81], nulliparous OR=2.51 95% CI [0.243-25.98], pregnant OR= 4.44 95% CI [1.03-19.13], with a history of cesarean delivery: OR=5.68 95% CI [0.64- 50.43] or even a history of negative childbirth experience: OR=1.87 95% CI [0.22-15.85]., Conclusion: The request for an Autonomous choice during childbirth most often expresses a certain number of beliefs and fears. Obstetricians should take time to listen and explain, in order to understand the mother's anxieties and enable her to resolve them. Based on the principles of justice, the access to autonomous choices during childbirth process should be universally recognized by legislations and thus fairly respected for all.

Background: The current international context considers birth experiences as a focal point for women's health. However, this subject is rarely discussed in Tunisian literature., Aim: Analyze birth experience of a sample of Tunisian women., Methods: Transverse descriptive study. All women who gave birth in the study unit during August 2018 were included. A direct interview was conducted during the first postpartum day. The questionnaire used was developed by a multidisciplinary team and included 55 questions, divided into 4 items. We compared the group of women who described their delivery as physically or psychologically traumatic to the group of women who reported a serene birth experience.    A multivariate analysis of variance was used to identify the variables that can influence childbirth experience., Results: During the study period, 170 women were included with a response rate of 81%. Severe anxiety about delivery was reported by 74.5% (n = 127) of women. Delivery was experienced as a trauma in 48.2% (n = 82) of cases. In the group of women who expressed a negative experience, we found a significant association with the use of media and internet as a source of information (p=0.001) and repeated vaginal examinations (p=0.001). Pain significantly impacted women's experience (p = 0.02). Finally, main risk factors of a negative childbirth experience were: uterine revision: OR=7.04 95%CI [0.27-177.68]; Emergency caesarean section: OR=3.04 95%CI [0.94-9.85] and vaginal delivery: OR=2.13 95%CI [0.45-10.14]., Conclusion: We can intervene on modifiable factors with the introduction of a specific program preparing women for their childbirth and the improvement of the professional practices. However, the issue will benefit from being discussed and addressed at the national, cultural and societal levels.

Background: In our country, the introduction of simulation as a teaching tool for obstetric emergencies is very recent. Several studies are being developed to evaluate its benefit in the continuing education of health professionals., Objective: To evaluate the impact of a continuing medical education program based on High fidelity simulation drills (HFS) on professional skills in obstetrics., Methods: 91 Learners were able to benefit from HFS continuing education program. Mean job tenure was 7.94 years [1-40]., Results: We were able to highlight a positive impact of level 1 with satisfaction rates of more than 90%. 92% of participants said they left with tools applicable in the function framework. Midwives and emergency physicians were the most satisfied. The general evaluation before the beginning of the training had revealed an average score of 7.12/20 [2/20-13/20]. The variance of scores initially obtained was significantly related to the profession of the learner (p <0.0001, R = 0.61). We found significant improvement in post-training scores (p = 0.0001) and a mean difference of +1.46 [-6, +8.66]. These results highlight a level 2 impact of HFS training on learners' knowledge.

Uterine arteriovenous malformation (UAVM) is uncommon. They are usually acquired, due to previous intra uterine trauma. We report a case of acquired UAVM in a 28-years-old patient after a medical abortion, diagnosed with ultrasonography and successfully managed with uterine artery embolization.