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ObjectivesPostpartum haemorrhage (PPH) is a major cause of maternal mortality and morbidity worldwide. Experimental studies support the hypothesis that oxytocin administration during labour, a common although not evidence-based practice, may increase the risk of atonic PPH. The clinical studies, however, are inconclusive. The objectives of this study was to investigate the association between the level of oxytocin exposure during labour and the risk of severe PPH and to explore whether the prophylactic use of oxytocin after birth modifies this association.DesignPopulation-based, cohort-nested case–control study.Setting106 French hospitals from December 2004 through November 2006.ParticipantsWomen with term singleton vaginal deliveries, after an uncomplicated pregnancy. Cases were 1483 women with severe PPH, defined by peripartum change in haemoglobin of ≥4 g/dl or need for blood transfusion. Controls were 1758 women from a random sample of parturients without PPH.Main outcome measuresThe independent association between the level of oxytocin during labour and the risk of severe PPH was tested and quantified with ORs through two-level multivariable logistic regression modelling.ResultsOxytocin was administered during labour to 73% of cases and 61% of controls (crude OR: 1.7, 95% CI 1.5 to 2.0). After adjustment for all potential confounders, oxytocin during labour was associated with a significantly higher risk of severe PPH (adjusted OR: 1.8, 95% CI 1.3 to 2.6) in women who did not receive prophylactic oxytocin after delivery; the OR for haemorrhage increased from 1 to 5 according to the level of oxytocin exposure. In women who had prophylactic oxytocin after delivery, this association was significant only for the highest exposure categories.ConclusionsOxytocin during labour appears to be an independent risk factor for severe PPH. The results emphasise the need for guidelines clarifying the evidence-based indications for this procedure and the minimal useful regimens.

Spontaneous ruptures of a liver tumour are often considered as a potentially life-threatening situation. The aim of the present study was to evaluate both clinical features and treatment in a subgroup of patients with ruptured liver tumours. From 1995 to 2000, 20 patients were referred to our centre for spontaneous rupture of a liver tumour associated with haemoperitoneum. Hepatocellular carcinoma (HCC) was present in 13 patients (11 men and 2 women) aged from 48 to 72 years (mean 62) and adenoma in 7 women aged from 23 to 52 years (mean 35). Although all patients experienced sudden abdominal pain and anaemia, shock at admission was present in 4 (20%) patients including 3 with HCC. In patients with HCC, severe liver insufficiency (Child-Pugh C) was present in 5 cases including the 3 shocked patients. No treatment was undertaken in 2 patients, transarterial embolization was performed in 9 cases and 5 patients underwent delayed resection. In hospital, mortality was observed in 3 (23%) patients, all of them had severe liver insufficiency. Long-term survival was observed in patients with good liver function who underwent resection. In patients with adenoma, shock at admission was observed in only 1 patient under anticoagulation treatment. Emergency resection was performed in 3 cases. A decrease of the tumour size was observed in patients who underwent delayed resection resulting in a lower rate of peri-operative transfusion. In conclusion, this study confirms that the majority of patients with ruptured liver tumours had no evidence of haemodynamic instability and therefore should be initially managed conservatively. In patients with single ruptured HCC associated with good liver function, long-term survival can be observed after liver resection. Delayed resection facilitated the operative procedure in patients with ruptured adenoma.

Endoscopic ultrasonography (EUS) was compared to ultrasonography (US) and CT scan (CT) in order to evaluate its role in the diagnosis and the locoregional spread assessment of pancreatic cancer. Sixty-four patients suspected of pancreatic cancer were studied prospectively, and the results of imaging techniques were compared to histology and surgical exploration. There were 49 cases of pancreatic adenocarcinoma, 11 of pancreatitis, 2 of common bile duct carcinoma, 1 lymphoma and 1 hepatocellular carcinoma with peripancreatic metastatic lymph nodes. EUS was significantly more accurate (91%) than CT (66%) and US (64%) for diagnosis of pancreatic cancer. EUS was able to image all 7 cancers less than 25 mm in diameter, US and CT only one. There were 4 false positives with EUS which were all cases of pseudotumorous pancreatitis. For detecting lymph node involvement, EUS was significantly more sensitive (62%) and accurate (74%) than US (8% and 37%) and CT (19% and 42%), respectively. Invaded lymph nodes adjacent to large tumors and micrometastatic involvement were responsible for this lack of sensitivity. EUS was significantly more sensitive (100%) than CT (71%) and US (17%) for detecting venous involvement. The specificity of EUS was lower (67%) because of duodenal bulb stenosis and large tumors. In conclusion, this prospective and comparative study confirms that EUS is an accurate tool for diagnosis and locoregional spread assessment of pancreatic cancer when performed in a reference center. EUS is of particular interest for small tumours. However, EUS does not enable differentiation of pseudotumorous pancreatitis from adenocarcinoma.