Place of Tranexamic Acid and Fibrinogen Association in the Management of Severe Postpartum Haemorrhage

Introduction: Severe postpartum hemorrhage (PPH) is the main cause of death in Tunisia. Its management is multidisciplinary and requires perfect knowledge of a regularly updated protocol and consistent with available resources. We propose an evaluation of the impact of different therapeutic attitudes, in particular the combination of tranexamic acid and fibrinogen concentrates in the management of this hemorrhage. Material and Methods: This was a retrospective, descriptive and analytical study, conducted in the departments of Gynecology-Obstetrics and Surgical Resuscitation anesthesia of the Farhat Hached University Hospital, Sousse, Tunisia. The study was conducted over six years (2009-2014), and included all parturients who were treated for severe PPH that occurred on a term greater than 24 weeks of amenorrhea. Patients were divided into two groups according to the study period: 1) Group 1 (G1): from 1 January 2009 to 31 December 2011, 2) Group 2 (G2): from January 1, 2012 to December 31, 2014, a group that benefited particularly from the combination of tranexamic acid and fibrinogen concentrates for the management of their PPH. Results: 166 patients were included: 57 in G1 and 109 in G2. The overall incidence of severe PPH was 3.15/1000 deliveries. We noted a significant decrease in the fall of hemoglobin in per and post haemorrhagic manifestations in favor of G2 with a p value of 0.003 and p = 0.025, respectively. The use of blood transfusion decreased significantly, in frequency and in number of packed red cells per patient, between the two groups;transfusion ratio was 1/1.7/1.5 for G1, and 1/2/1.8 for G2. Fluid therapy, use of macromolecules and catecholamines were less important in G2. The use of tranexamic acid, fibrinogen and the association of both increased significantly between the two groups (p 10-4). Haemostasis hysterectomies were less performed (p 10-3) in G2. Conclusion: The management of PPH has evolved over the years. The use of tranexamic acid in association with fibrinogen concentrates had proved his interest.

Special Features of Metaplastic Breast Cancer in Tunisian Women

Introduction: Metaplastic breast carcinomas are a rare, heterogeneous group of breast malignancies characterized by an intrinsically aggressive histology and an unfavorable prognosis. Objective: To determine the clinical and pathological characteristics of metaplastic breast cancers in Tunisian patients, and evaluate their impact on its evolution. Methods: A retrospective study of 44 cases of metaplastic cancers archived during a 26-year period in the Cancer Registry of the Tunisian Center. Results: The frequency of metaplastic cancer was 0.97%. Mean age at diagnosis was 55.4 years (range 26 - 84). Average time to diagnosis was 5.5 months. Average clinical tumor size was 4.95 cm (range 1.5 - 15). Axillary ipsilateral adenopathy was present at diagnosis in 45.9%. The clinical stages IIB (31.8%) and IIA (22.7%) predominated. Squamous metaplasia was the most common (68%) followed by the heterologous mesenchymal subtype. Ganglionic invasion was histologically proven in 17 cases, of which 77% had only adenocarcinomatous contingents. Absence of hormone receptor expression and HER2 overexpression predominated. Primary surgery was carried out in 95% of cases. Average follow-up was 40 months (range 2 - 135). Average overall survival (OS) was 74 months, 63% at 5 years and 60% at 10 years. Average progression free survival (PFS) was 29 months (range 3 - 129), 38% at 5 years and 32% at 10 years. Factors significantly influencing OS and PFS were histological lymph node involvement (p = 0.001 and p = 0.002 respectively). Conclusion: Metaplastic breast cancer observed in Tunisian women constitutes a histological type with an unfavorable prognosis whose improvement requires a more adapted therapeutic strategy.