Impact of discontinuing oxytocin in active labour on neonatal morbidity: an open-label, multicentre, randomised trial.

BACKGROUND: Oxytocin is effective in reducing labour duration but can be associated with fetal and maternal complications that could potentially be reduced by discontinuing the treatment during labour. We aimed to assess the impact of discontinuing oxytocin during active labour on neonatal morbidity. METHODS: STOPOXY was a multicentre, randomised, open-label, controlled, superiority trial conducted in 21 maternity units in France. Participants who received oxytocin before 4 cm dilation were randomly assigned 1:1 to either discontinuous oxytocin (oxytocin infusion stopped beyond a cervical dilation equal to or greater than 6 cm) or continuous oxytocin (administration of oxytocin continued until delivery). Randomisation was stratified by centre and parity. The primary outcome, neonatal morbidity, was assessed at birth using a composite variable defined by an umbilical arterial pH at birth less than 7·10, a base excess greater than 10 mmol/L, umbilical arterial lactates greater than 7 mmol/L, a 5-min Apgar score less than 7, or admission to the neonatal intensive care unit. Efficacy and safety was assessed in participants who were randomly assigned (excluding those who withdrew consent or were deemed ineligible after randomisation) and had reached a cervical dilation of at least 6 cm. This trial is registered with ClinicalTrials.gov, NCT03991091. FINDINGS: Of 2459 participants randomly assigned between Jan 13, 2020, and Jan 24, 2022, 2170 were eligible to receive the intervention and were included in the final modified intention-to-treat analysis. The primary outcome occurred for 102 (9·6%) of 1067 participants (95% CI 7·9 to 11·5) in the discontinuous oxytocin group and for 101 (9·2%) of 1103 participants (7·6 to 11·0) in the continuous oxytocin group; absolute difference 0·4% (95% CI -2·1 to 2·9); relative risk 1·0 (95% CI 0·8 to 1·4). There were no clinically significant differences in adverse events between the two groups of the safety population. INTERPRETATION: Among participants receiving oxytocin in early labour, discontinuing oxytocin when the active phase is reached does not clinically or statistically significantly reduce neonatal morbidity compared with continuous oxytocin. FUNDING: French Ministry of Health and the Département de la Recherche Clinique et du Développement de l'Assistance Publique-Hôpitaux de Paris.

[Placenta percreta management in a patient with a severe congenital hypofibrinogenemia]. / Gestion d'un placenta percreta chez une patiente atteinte d'une hypofibrinogénémie congénitale sévère.

The obstetrical follow-up of patients with a severe hypofibrinogenemia requires a multidisciplinary collaboration because of potential maternal-fetal complications (recurrent miscarriages, intrauterine fetal demise, post-partum hemorrhage, thrombosis). We report the obstetrical management of a multiparous patient with a severe congenital hypofibrinogenemia associated with a platelet disorder (abnormal phospholipid externalization). A therapeutic strategy based on a biweekly administration of fibrinogen concentrates associated with enoxaparin and aspirin allowed the maintenance of pregnancy. But this last one got complicated by a placenta percreta requiring a salvage hysterectomy with an appropriate hemorrhage prophylaxis.

Benefits of cord blood collection in the prevention of post-partum hemorrhage: a cohort study.

OBJECTIVE: The aim of this study was to assess the benefit of umbilical cord drainage through cord blood collection (CBC) for the prevention of post-partum hemorrhage (PPH). METHODS: This is a retrospective cohort study based on data collected prospectively including all vaginal delivery of singletons pregnancies after 37 weeks of gestation between July 2011 and May 2013 at the Strasbourg Teaching Hospital. We performed a univariate comparison of PPH risk factors with χ(2) tests and then we built multivariate logistic regressions to predict PPH, severe PPH (>1000 cc), retained placenta over 30 min and manual removal of the placenta. RESULTS: A total of 7810 vaginal deliveries were analyzed, among which 1957 benefited from CBC (25%). In the CBC group, 71 PPH (3.6%) were observed versus 260 (4.4%) in the control group (p = 0.12). In multivariate analysis, after adjustment on PPH risk factors, CBC revealed to be a protective factor of PPH: OR = 0.69 (95% CI 0.50-0.97; p = 0.03). CBC is neither a significant predictive factor of severe PPH, time to placental delivery nor rate of manual removal of the placenta. CONCLUSIONS: In our study, CBC and thus umbilical cord drainage was a protective factor against PPH but it did reduce neither retained placenta nor the need for artificial placental delivery.

Prediction of spontaneous preterm delivery in the first trimester of pregnancy.

OBJECTIVE: To develop a model for predicting premature delivery before 37 weeks' gestation based on maternal factors, obstetric history and biomarkers in the first trimester of pregnancy. STUDY DESIGN: Cohort study based on data collected prospectively between 1 January 2000 and 30 November 2011. Multivariate logistic regression was used to construct a model of the risk of premature delivery. RESULTS: 31,834 pregnancies were included, of which 1188 cases were spontaneous premature deliveries before 37 weeks (3.7%). We built a predictive model based on maternal age, body mass index, smoking status and previous obstetric history. This could identify 23.3% of premature deliveries in our study population, with a false positive rate of 10%. In the group of patients who had already had at least one pregnancy at or beyond 16 weeks, the detection level increased to 29.7%. The positive predictive value was 7.4 and 7.3% respectively, while negative predictive value was 97.2 and 97.9%. CONCLUSIONS: Predicting preterm delivery on the basis of maternal characteristics and obstetric history needs to be further improved. PAPP-A levels and ultrasonographic measurement of cervical length could not be integrated in the model but require further investigations.

Amniotic fluid embolism: 10-year retrospective study in a level III maternity hospital.

OBJECTIVE: To provide updated data on amniotic fluid embolism (AFE) based on our population over a 10 year period, and to propose steps for improving current practice. STUDY DESIGN: Retrospective study carried out in the Department of Gynaecology and Obstetrics at the Strasbourg University Teaching Hospital between 1 January 2000 and 31 December 2010. Dossiers of patients with AFE were identified using medical information system programme (MISP) coding and cross-checked with the pathology reports (hysterectomy, post-mortem examination). RESULTS: Eleven dossiers were found (0.28/1000). Eight cases (73%) of AFE occurred during labour, two (18%) in the post-partum period and one (9%) outside of parturition. Induction was initiated in four patients (45%) and labour sustained with oxytocin in 9 patients (90%). Acute circulatory collapse with cardio-respiratory arrest (CRA) was the herald symptom of AFE in 2 patients, and secondary cardio-respiratory arrest occurred rapidly in 6 patients (55%) following a relatively non-indicative prodromal phase. Disseminated intravascular coagulopathy (DIC) was observed in 10 cases (91%) and massive transfusion was necessary in all patients. Seven haemostatic hysterectomies (63%) were performed, with secondary arterial embolisation in 2 cases (22%). Although all patients presented a clinical picture of AFE, confirmation through histology or laboratory test results was forthcoming in only 7 cases (63%). Three patients died (27%). When AFE occurred during labour, 8 fetuses (75%) received intensive care support. In all, 11 newborns survived (85%). Their pH was less than 7.00 in 3 cases (27%) and 4 fetuses (36%) had an Apgar score of less than 5 at 5 minutes of life. CONCLUSION: AFE is a rare but extremely serious disease. Some risk factors for AFE have been identified but they do not allow its occurrence to be predicted. The diagnosis may be supported by specific laboratory test results but only a post-mortem examination provides a pathognomonic diagnosis: unfortunately it is always retrospective. Obstetrical and intensive care management is complex and must be adapted to the situation bearing in mind the significant risk of haemorrhage and DIC. Hysterectomy must be performed if there is the least doubt.

[Tubal sterilization]. / Stérilisation tubaire.

A recent French law, passed on July 4th, 2001, authorizes a person of age to voluntarily undergo a sterilisation on her request. The practitioner has the legal obligation to inform the person of the consequences and the possible complications of the operation. Recent technical progress as well as its assessment on a large epidemiological scale has modified the given data. In this perspective, we are presenting the different and current techniques of tubal sterilisation, their efficiency and their immediate and long-term complications. During the consultation preceding the operation, the doctor should be certain that the patient (or the couple) is well aware and he will help her (or them) in finding the right contraception. Finally, we will mention relevant passages of the new law.