Intrauterine balloon tamponade in the management of severe postpartum haemorrhage after vaginal delivery: Is the failure early predictable?

Postpartum haemorrhage (PPH) is one of the leading causes of maternal morbidity and mortality world-wide. The arrival of intrauterine balloon devices has revolutionised PPH management. However, it seems interesting to know the situations of failure to improve the management. The objective is to define the factors related to failure of intrauterine balloon tamponade (IUBT) in women with a postpartum haemorrhage (PPH) after vaginal delivery, and especially blood loss after placement to avoid delaying management. Retrospective cohort study was conducted in 2 centers. All PPH after vaginal deliveries treated by IUBT were included. Two groups were defined (successes and failures) and compared. Failure was defined as the need of invasive procedure. Calculated area under receiver operating characteristic (ROC) curves and thresholds of bleeding at 10 min were also calculated for prediction of failure. 127 women were included. The overall success rate was 78.0 % (95 % CI 70.7-85.1 %). Blood loss at 10 min was factor prognostic of early IUBT failure. The ROC curve of blood loss at 10 min for prediction of failure of IUBT had an area under the curve of 0.876 (95 % CI 0.782-0.970). The predictive positive value of blood loss at 10 min were respectively 0.53, 0.8 and 0.94 for blood loss of 100, 200 and 250 mL. Physicians should be alerted if blood loss are more than 200 mL at 10 min after placement of IUBT and considered invasive procedure if more than 250 mL to avoid delaying management of PPH.

[Oncoplastic breast surgery for the management of ductal carcinoma in situ]. / Place de l'oncoplastie dans la prise en charge des carcinomes canalaires in situ.

DCIS (Ductal carcinoma in situ) constitutes 15,2% of breast cancers. Conservative surgery coupled with adjuvant radiotherapy is often recommended. The rate of revision surgery is high, from 30 to 60%. The concern is a high quality resection within clear margins with a satisfactory aesthetic result. The objective of this review is to precise the place of oncoplastic surgery in DCIS care. Among risk factors of recurrence, tumoral invasion of surgical margins is capital. In histology, clear margins usually adopted for DCIS are 2mm, even though there is no international consensus. Recent studies show that a 10mm limit would be better. Aesthetic damage caused by surgery, often increased by radiotherapy, has a negative impact on women quality of life: oncoplastic surgery may minimize it. Techniques of plastic surgery, arranged into level 1 and 2, allow pushing back conservative treatment limits by removing a larger tumor with clear margins. Often used in invasive cancers, few data exist regarding oncoplastic surgery and DCIS. It allows to increase the dimensions of surgical resection by 20% and to decrease positive margins significantly therefore the rate of revision surgeries. Patients are satisfied with it. Specific indications need to be clarified according to age, size and "comedonecrosis" presence. Oncoplastic surgery should be developed in DCIS specific care.

[Reexcision for positive margins in the surgery of ductal carcinoma in situ: are there any risk factors?]. / Reprise chirurgicale des carcinomes canalaires in situ pour exérèse non in sano : existe-t-il des facteurs de risque ?

OBJECTIVES: Ductal carcinoma in situ (DCIS) is a common breast lesion (10% of breast cancers). In most of the cases the standard treatment is a partial mastectomy combined with adjuvant irradiation. However, when positive margins (<2mm) occur, surgical re-excision is necessary. The purpose of our study was to determine the rate of reoperation for positive margins in DCIS and identify potential preoperative risk factors of unhealthy margins. PATIENTS AND METHODS: This is a retrospective study of 63 patients. We collected cases of DCIS at the Lille and Valenciennes' hospitals from the 1st of January 2007 till the 1st of January 2012. RESULTS: Fifty patients have had a partial mastectomy and 28 patients (56%) have had one or two complementary interventions to get healthy resection margins. The pathologic tumor size (>10mm) appears to be a risk factor for positive margins. DISCUSSION AND CONCLUSION: Few studies were aimed at identifying risk factors for unhealthy margins for DCIS. The main risk factors found in the literature are: the presence of comedonecrosis, tumor greater than 10mm, a palpable tumor, the absence of a preoperative biopsy, the low-grade lesions. Our study confirmed the influence of tumor size greater than 10mm as a risk factor for positive margins.