FIGO opinion paper: Drivers and solutions to the cesarean delivery epidemic with emphasis on the increasing rates in Africa and Southeastern Europe

Cesarean delivery rates are rapidly increasing in Southeastern Europe (to more than 60%), North Africa (with a rate as high as 72% in Egypt), and in urban areas in Southern Africa (a rate of over 50% in Lagos, Nigeria). Data on the background to these increases are scarce, but likely to include poor birthing facilities in general hospitals, convenience for the doctor, private medicine, fear of litigation, socioeconomic status, shortage of midwives and nurses, and disappearance of vaginal instrumental deliveries. Options to reverse cesarean delivery trends are discussed. In this context there is a need to be better informed about how women are being counseled regarding vaginal or cesarean delivery. The long-term consequences in subsequent pregnancies for mothers and children may well be largely ignored, while these risks are highest in LMICs where higher birth numbers are desired. FIGO has begun discussions with obstetric and gynecologic societies, healthcare bodies, and governments in several countries discussed in this article, to find ways to lower the cesarean delivery rate. The requests came from the countries themselves, which may prove beneficial in helping advance progress.

Abdominal wall endometriosis: A challenging iatrogenic disease

INTRODUCTION AND IMPORTANCE

Abdominal wall endometriosis is a rare clinical condition associated with abdominal pain and psychologic disorders. It's pathophysiology remains unclear. Clinical history and imaging findings are necessary for the diagnosis. Its management is challenging, and requires close collaboration between gynaecologists and visceral surgeons specially in complex procedures. The aims of our study are to present risk factors, clinical presentation, imaging findings and management features. It was a retrospective descriptive study including fifteen patients presenting abdominal wall endometriosis. Data about age, medical history, imaging findings, surgical procedures and outcome are reported.

CASES PRESENTATION

Fifteen women were included in our study. The most common symptom was cyclic abdominal pain. Twelve of them had history of caesarean section, and three had history of myomectomy. All patients underwent ultrasound and MRI. We performed surgical excision to all cases. One patient needed large excision with abdominoplasty procedure.

CLINICAL DISCUSSION

Abdominal wall endometriosis is a rare clinical condition with unclear pathophysiology. It occurs frequently after gynaecologic or obstetric surgery. Most reported complaint was catamenial abdominal pain with abdominal wall mass. Ultrasonography, computed tomography and MRI are useful for diagnosis, specially to eliminate differential diagnoses. Abdominal wall endometriosis management is based on surgery. Excision goals are to remove the mass and to confirm histological diagnosis of parietal endometriosis.

CONCLUSION

Parietal endometriosis is a rare and challenging condition with unclear pathophysiology. It requires specific management. This pathology will be encountered more frequently considering the increasing rate of caesarean section.

Cecal volvulus: A rare post-partum complication

Introduction and importance

Cecal volvulus is a rare clinical condition. It is characterized by axial twist of caecum, terminal ileum and the ascendant right colon around their mesenteric pedicles. The main pathophysiologic mechanism is cecal hyper mobility associated to precipitating factor such as colonic tumor, abdominal mass or pregnancy. Cecal volvulus during pregnancy was reported, but it remains exceptional during postpartum period.

Clinical presentation

We report a case of cecal volvulus occurring in 37-year-old woman ten days after cesarean section delivery. She presented an acute abdominal pain associated to vomiting and nausea. X ray imaging and abdominal CT showed a large colonic obstruction, the caecum was dilated and located in the left hypochondrium. An open surgery was performed showing twisted bowels involving the caecum, the ileocecal junction and the right colon. There were necrotic areas on the colonic wall. Right hemicolectomy was performed with end to side ileo-colostomy. The evolution was marked by a serious septic shock causing patient's death.

Clinical discussion

Cecal volvulus is a rare condition. Its suggested mechanism associates cecal hyper mobility to a precipitating factor. Increased uterine volume may explain cecal volvulus during pregnancy. In post-partum period, it may be explained by rapid uterine size variation. Cecal volvulus diagnosis is challenging. In fact, its symptoms can be confused with post operative ileus after cesarean section delivery. Delayed management leads to worst prognosis.

Conclusion

Cecal volvulus during post-partum period is a rare condition, it may be serious in case of delayed diagnosis.

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Cecal volvulus in post-partum period is a rare and serious condition.

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Clinical presentation of cecal volvulus after cesarean section can be confused with post operative ileus.

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Abdominal CT is useful in case of atypic ileus clinical presentation.

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Surgery is the corner stone of cecal volvulus management.

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Worst prognosis is associated with delayed diagnosis.

Pelvic actinomycosis: A confusing diagnosis

Introduction and importance

Actinomycosis is a rare chronic and suppurative infection caused by anerobic Gram Positive bacteria: actinomyces. Pelvic location is extremely rare, usually associated with history of IUD contraception and doesn't have specific signs. Pelvic actinomycosis diagnosis may be confused with pelvic gynecologic malignancies or abscess. We present a retrospective and descriptive study of twelve patients with pelvic actinomycosis diagnosed and managed in our department from January 2000 to December 2011.

Cases presentation

The patients' mean age was 47 years. 75% of them had a history of IUD for a mean period of 8,44 years. Pelvic pain was the most common complaint. In four cases, pre-operative clinical presumption was tubo-ovarian abscess. Gynecologic malignancies were suspected in 8 patients. Pelvic actinomycosis management was based on surgery and long-term antibiotic.

Clinical discussion

Pelvic actinomycosis is an extremely rare chronic infection, presenting 3% of human actinomycosis. Common clinical presentations include vaginal discharge, tubo-ovarian abscess and pelvic tumors mimicking gynecologic malignancies. It is difficult to diagnose. Association with IUD history was recognized. Management is based on surgery and long-term antibiotic administration.

Conclusion

Pelvic actinomycosis is an extremely rare chronic infection. This entity is difficult to diagnose. Accurate diagnosis can reduce complications and unnecessary surgeries, and can preserve fertility.

Lotus petal flap for unusual indication: A recto-vaginal fistula with perineal defect after vaginal delivery

Introduction and importance

Three to five percent of vaginal deliveries are complicated by third or fourth degree perineal laceration. Misdiagnosed perineal injuries may be associated with a poor sexual and psychological prognosis. Management of old perineal tears and laceration is challenging with a high failure rate. In such condition, interposition tissue technic or local flap can be a good surgical alternative. Lotus petal Flap, usually indicated in management of large perineal defect in gynecological oncology can be used.

Case presentation

We report a case of 32-year-old women presenting complex and relapsed perineal fistula after vaginal delivery associated with perineal defect treated by lotus petal flap with a good outcome.

Discussion

Perineal defects are commonly encountered after oncologic, traumatic or infectious perineal excisions and described as a challenging situation. In case of perineal defects after obstetrical tears, no validated surgical filler technics are recommended. Inspired from oncologic surgical technics to fill perineal defects, Lotus Flap can be used. Its advantages are to mobilize a satisfactory tissue volume to fill important perineal defect compared to the small bulbocavernous flap with a hidden scar comparing to gracilis muscle flap. This technic is associated with a good sexual and self-imaging outcome.

Conclusion

Lotus petal flap may be required as a solution to manage perineal defect in case of perineal fistula. This technique provides aesthetic and good results for perineal reconstruction.

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Perineal defects secondary to obstetrical tears and injuries are challenging to manage.

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Many flaps and surgical technics were reported to cover perineal defects after oncologic perineal surgery.

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Lotus petal flap is one of the most used technics to cover perineal defects after oncologic perineal surgery.

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In literature, no recognized procedure was described to fill in perineal defects complicating obstetrical injuries.

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Lotus petal flap can be an efficient and safe procedure to cover perineal defects after obstetrical tears.

[Anti-D prophylaxis in fetal-maternal erythrocyte incompatibility in Tunisia]

Generalization of postnatal prophylaxis using anti-D immunoglobulins decreased the incidence of erythrocyte fetal-maternal incompatibility (EFMI) in the Rhesus system. Few recent studies have investigated the situation of anti-D prophylaxis in Tunisia and its effects on maternal and neonatal health. The aim of this study was therefore to analyze the situation of anti-D prophylaxis in Tunisia to detect defects and propose solutions. We conducted a retrospective descriptive study of IFME cases in the rhesus system in the Department of Medicine and Neonatal Resuscitation of the Tunis Maternity and Neonatology Center (CMNT) during an 8-year period from 1 January 2006 to 31 December 2015. We collected 51 cases of IFME. The prevalence of IFME was 3.4 per 10 000 live births; 41 % of the patients were transferred in utero and they were from the northwest of the country (17 %). The rate of women with a history of at least one spontaneous miscarriage (SCF) was 45 %. In 42 % of the cases, pregnancies were monitored at local clinics. The search for irregular agglutinins (RAI) was performed in 86 % of the women studied. RAI was positive in 97 % of the cases. Anti-D prophylaxis was correctly performed in only 27 % of the cases. The systematic prophylaxis of the third trimester and a systematic Kleihauer test must be combined with postpartum prophylaxis to better identify dysfunctions and improve the application of the recommendations.

Spontaneous acute intussusception in a pregnant woman

Acute intussusception in adults is rare and particularly so in pregnant women. Its incidence ranges from 0.067% to 0.0015% (Choi et al., 2005 Choi et al. (2005) [1]). The non-specific presenting symptoms may be attributed to the pregnancy itself, making the diagnosis difficult. When it happens, however, it causes considerable morbidity and mortality for the pregnant woman and the fetus. In adults, such intussusceptions are mainly secondary to an intestinal disease and frequently a tumor. We present the case of a 21-year-old pregnant woman who was diagnosed of spontaneous acute intussusception at nine weeks of gestation and therapeutic management.

[How to predict spontaneous resolution of early pregnancies?]

BACKGROUND

Assessment of early pregnancy is indicated in women with suspected abnormalities. It is based on biochemical assessment and on trans vaginal sonography .

AIM

To identify clinical, biological and ultrasonographic parameters that are predictive of spontaneous pregnancy resolution. methods: A prospective observational study was performed interesting women with a positive pregnancy test without visualization of the pregnancy on the initial scan. All parameters measured during the initial visit were tested by univariate and multivariate analysis to identify parameters predicting spontaneous resolution of pregnancy.

RESULTS

A total of 2675 women were included in the study. In 94 cases (4 %) the location of pregnancy was unknown. Univariate and multivariate analysis showed that four parameters contributed significantly to the predictive power of the logistic model: Absence of pain (p =0,036), endometrial thickness < à 12 mm (p =0,021), initial serum βhCG level < 1000 UI/l (p =0,015) and progesterone level < 29 nmol/l (p <0,001).

CONCLUSION

Women with a high probability of spontaneous resolution of their pregnancies can benefit from a spaced monitoring until the rate of ß-hCG will be negative.

Prediction of ectopic pregnancy in early pregnancy of unknown location

BACKGROUND

Women having pregnancies of unknown location (PUL) can be defined as those having positive pregnancy test when no pregnancy is visualized on transvaginal ultrasound (TVS).

AIM

To identify diagnostic parameters which are predictive of ectopic pregnancies in women with early pregnancies of unknown location.

METHODS

We undertook a prospective observational study of pregnant women with suspected early pregnancy complications. Ninety-four patients were classified as having a pregnancy of unknown location (PUL) by transvaginal ultrasound; blood sample was taken on presentation to measure the serum human chorionic gonadotrophin (,-HCG) and progesterone levels. All collected data were tested by univariate analysis and then analyzed in a stepwise procedure to form a logistic model for predicting ectopic pregnancy.

RESULTS

A total of 2675 women were referred for suspected early pregnancy complications. In 94 (4%) patients the location of the pregnancy was unknown. Three parameters were found to be statistically significant for predicting ectopic pregnancy:progesterone level, vaginal bleeding associated with pain and the presence of free fluid in the pouch of Douglas. The overall model described by these variables offer a sensitivity of 79 %and a specificity of 59% in the prediction of ectopic pregnancy.

CONCLUSION

Logistic regression model can help in the clinical decision-making in women with pregnancy of unknown location.

Primary leiomyosarcoma of broad ligament

BACKGROUND

Primary broad ligament leiomyosarcoma (LMS) is an extremely rare tumor with few well-documented cases. We are aware of 15 previously reported observations.

AIM

Report of a new case.

CASE

In this report we report a case of a right pelvic sidewall leiomyosarcoma with involvement of the appendix in a 49-year-old woman. A hysterectomy, bilateral salpingo-oophorectomy, omentectomy and appendicectomy were done, without complications. The patient died five months later. The case illustrates the difficulty of correct diagnosis before intervention. On this occasion, review of the literature confirms that this site remains unusual and the management is difficult.

Primary leiomyosarcoma of the vagina. Case report and literature review

BACKGROUND

The vast majority of primary vaginal cancers are squamous cell carcinoma. The leiomyosarcoma of the vagina is extremely rare neoplasm. It comprising 2% to 3% of vaginal malignancies. Only 77 cases have been reported up to date in Anglo-Saxon literature .

AIM

Report of a new case

CASE

We report a case of a patient 43 years old, single and presented a tumor of 7 cm to the detriment of the posterior wall of the vagina. The treatment consisted of a radical colpohysterectomy followed by postoperative radiotherapy. After 40 months, she is still alive without local or distant recurrence.

CONCLUSION

This is a rare observation. The surgery is the basic treatment, the poor prognosis of these tumors remains linked especially to the histological grade.

[Primitive adenocarcinoma of the fallopian tube: a case report]

Tubal carcinoma is rare and its prognosis is poor. His diagnosis before intervention is not easy because clinic is poor and complementary exams not specifics. His treatment is radical surgery by laparoscopy associated with chemotherapy. The prognosis is correlated with cancer stage and residual tumoral volume after surgery. We report a 55 years case who underwent coelioscpic annexectomy for left pyosalpinx. Definitive histology answered tubal cancer. Patient dead after three months because disseminated and parietal metastasis.

[Management of adnexal torsion]

Adnexal torsion is a current emergency in gynecology because it may compromises young women fertility. We have conducted a retrospective study about 26 adnexal torsion cases managed in B service of C.M.N.T during 4 years (1997-2001). Objective of our study is to improve patient fertility prognosis; we propose a diagnosis and therapeutic attitude which respect the time between diagnosis and treatment. Laparoscopy authorizes diagnosis, treatment and prognosis of this situation. It must usually be done in young woman who declare acute pelvic pain.

[Diagnosis of holoprosencephalia. Report of 17 cases]

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.

[Microinvasive carcinoma uterine cervix. Which approach in 1998?]

Numerous definitions of microinvasive carcinoma (MIC) have been proposed. The SGO takes into account the depth of stromal invasion and presence of capillary like space involvement (LVI). The Figo uses the lesion width and describes different substages according to the depth of stromal invasion. Two major prognostic factors can be identified in the literature: the depth of invasion and the presence of LVI. The lesion volume is probably more accurate than the depth of stromal invasion but cannot be measured in routine. Taking into account that a classification must be a guide for the evaluation of prognosis and treatment, the SGO definition seems more reliable. Pelvic lymph node metastasis rate and recurrence increase with these two factors. MIC with stromal invasion under 3 mm and without LVI have a little risk of parametrial and nodal involvement: with a high rate of survival. Conversely, MIC with invasion over 3.1 mm depth or LVI have a greater risk of spread beyond the cervix (1% versus 7.7%) and many authors now consider them as true invasive cancers. For lesion invading the stroma within 3 mm, the treatment can be limited to a standard hysterectomy with good results. Some authors have proposed more conservative therapy as conization. This procedure is interesting for young women willing to preserve their anatomy, fertility and sexual function. In selected cases, short term results are similar to those of hysterectomy but there is a lack of controlled studies with long term follow-up. Lesions over 3.1 mm with LVI should be treated as true invasive cancers. Intermediate cases should have a conservative therapy associated with a laparoscopic lymphadenectomy.

Microinvasive carcinoma of the cervix. Rationale for conservative treatment in early squamous cell carcinoma

Numerous definitions of microinvasive carcinoma (MIC) have been proposed. Taking into account that a classification must be a guide for the evaluation of prognosis and treatment, the authors reviewed the risk of spread in MIC. Two major prognostic factors can be identified in the literature: the volume of the lesion and the presence of capillary-like space involvement (LVI). The former item is generally assessed by the depth of invasion. Two kinds of MIC can be distinguished. Those with stromal invasion under 3 mm and without LVI, and those with invasion over 3.1 mm depth or LVI. The former have little risk of parametrial and nodal involvement and a high rate of survival. The latter have a greater risk of spread beyond the cervix and many authors now consider them as true invasive cancers. The Society of Gynaecologic Oncologists (SGO) definition seems more reliable. For lesions invading the stroma within 3 mm, treatment can be limited to a standard hysterectomy with good results. Some authors have proposed more conservative therapy such as conization. This procedure could be desirable for young women who want to preserve their anatomical integrity, fertility and sexual function. In selected cases, short term results are similar to those of hysterectomy but there is a lack of controlled studies with long term follow-up.

Laparoscopic pelvic lymphadenectomy in an anatomical model: results of an experimental comparative trial

OBJECTIVES

The aim of this paper was to compare the accuracy of laparoscopic versus open pelvic lymphadenectomy in an experimental trial.

STUDY DESIGN

We performed unilateral laparoscopy pelvic lymphadenectomy (LPL) in 33 non-embalmed cadavers between the external iliac vein, the obliterated umbilical artery and the obturator nerve. Then a laparotomy was performed to inspect the LPL limits, look for laparoscopic complications and finally realize a controlateral lymphadenectomy. The LPL side was randomly decided. A pathologist counted the number of lymph nodes collected with both techniques. We compared the number of retrieved lymph nodes, the completeness of the dissection and the complication rate with those two procedures. Student's t-test, chi 2-test and non-parametric tests were used when appropriate.

RESULTS

No dissection had to be aborted. One hundred and twelve nodes were removed laparoscopically (mean, 3.73; S.E., 2.9) and 84 at laparotomy (mean, 2.77; S.E., 2.06). There was no significant difference in the number of nodes retrieved with both procedures. Effectiveness of laparoscopy was not significantly different in the first ten procedures, in the second ten or in the last ten LPL. Residual tissue was observed after LPL in 13.3% of the procedures whereas all open lymphadenectomies were complete. LPL sensitivity reached at least 86% in this paper. Failures were more frequent at the beginning of the study (50% among the first ten dissections), in obese subjects or in subjects with prior history of laparotomy (but the difference was not significant). Two venous injuries occurred during LPL (6.7%). Complication rates for the two techniques were not significantly different. However, the LPL complication rate was higher at the beginning of the study and increased significantly in subjects with prior history of laparotomy (P < 0.05).

CONCLUSIONS

This randomized study shows that LPL and laparotomy have similar effectiveness. Incomplete dissections and complications are more frequent in obese subjects or in case of prior history of laparotomy. Fifteen procedures seems necessary to learn the technique and provide constant and safe results in routine practice.

[Lymphatic drainage of the uterus. Preliminary results of an experimental study]

We carried out an experimental study on the lymphatic drainage of the uterus in 11 female cadavers. We performed 5 injections of a colored fluid in the corpus uterinum and 6 in the cervix. We observed 2 main routes along the external iliac vessels. The first was anterior and drains the lower limb. The second is medial and posterior to the external iliac vessels and drained the uterus (2.4 lymph nodes/side). The number and location of the lymph nodes varied between subjects but also in the same subject (45.5% of cases). The cervix was essentially drained to lymph nodes located on the posterior aspect of the external iliac vein, especially near the hypogastric artery origin. We did not observe any direct connexion between the cervix and the para-aortic area. The corpus uterinum was drained to the lymph nodes located in the lateral part of the parametrium and or under the external iliac vein. One other main route ran along the infudibulo-pelvic ligament. These findings confirm that the first lymph nodes metastases of the cervical carcinoma are under the external iliac vein. and particularly near the hypogastric artery. On the other hand, endometrial carcinomas spread along two lymphatic connections: one extending to the external iliac area and another to the para-aortic area. These results have to be considered in order to define lymphadenectomy margins for these cancers.

[Sacrococcygeal teratomas. Apropos of a case of teratoma weighing 4200 g]

We report a clinical case of a large sacro-coccygeal teratoma diagnosed antenatally by ultra-sound at 35 weeks gestation. A review of the literature shows that their outcome depends upon the size of the tumor, its degree of maturity, whether its location is pelvic or not, the presence of any associated malformations, prematurity, atraumatic delivery and upon prompt and complete removal of the tumor.

[Hysteroscopy and hysterosalpingography. Which examination to chose?]

The authors report 58 patients undergoing hysterosalpingography (HSG) then hysteroscopy (HC) for investigation of the uterine cavity. Comparison of HSG and HC findings revealed the following: In 26.9 per cent of cases HC disproved or rectified the result of HSG. Results of the two investigations were in agreement in 74.1 per cent of cases. In the light of our results, and after a review of the literature, HSG is indicated as the first line investigation for exploration of the uterine cavity and/or the tuboperitoneal level. HC alone is sufficient for exploration of the cervical canal and of the uterine cavity.

[Peripartum cardiomyopathy. Analysis of 3 cases and review of the literature]

Peripartum cardiomyopathy is defined as a syndrome of cardiac failure occurring in the latter part of pregnancy or in the puerperium without obvious cause and without prior evidence of heart disease. Analysis of the particular features of this syndrome and a review of the literature indicate its similarity with other cardiomyopathies in terms of clinical features, natural history and treatment, but maternal and fetal prognosis is poor.