Binational confidential enquiry of maternal deaths due to postpartum hemorrhage in France and the Netherlands: Lessons learned through the perspective of a different context of care.

OBJECTIVE: To learn lessons for maternity care by scrutinizing postpartum hemorrhage management (PPH) in cases of PPH-related maternal deaths in France and the Netherlands. METHODS: In this binational Confidential Enquiry into Maternal Deaths (CEMD), 14 PPH-related maternal deaths were reviewed by six experts from the French and Dutch national maternal death review committees regarding cause and preventability of death, clinical care and healthcare organization. Improvable care factors and lessons learned were identified. CEMD practices and PPH guidelines in France and the Netherlands were compared in the process. RESULTS: For France, new insights were primarily related to organization of healthcare, with lessons learned focusing on medical leadership and implementation of (surgical) checklists. For the Netherlands, insights were mainly related to clinical care, emphasizing hemostatic surgery earlier in the course of PPH and reducing the third stage of labor by prompter manual removal of the placenta. Experts recommended extending PPH guidelines with specific guidance for women refusing blood products and systematic evaluation of risk factors. The quality of CEMD was presumed to benefit from enhanced case finding, also through non-obstetric sources, and electronic reporting of maternal deaths to reduce the administrative burden. CONCLUSION: A binational CEMD revealed opportunities for improvement of care beyond lessons learned at the national level.

[Fetal death beyond 14 weeks of gestation: induction of labor and obtaining of uterine vacuity]. / Mort fœtale in utero au-delà de 14SA : induction du travail et obtention de la vacuité utérine.

The objective of this review was to assess benefits and harms of different management options for induction of labor and obtaining of uterine vacuity in case of fetal death beyond of 14 weeks of gestation. In second-trimester, the data are numerous but low methodological quality. In terms of efficiency (induction-expulsion time and uterine evacuation within 24 hours rate) and tolerance in the absence of antecedent of caesarean section, the best protocol for induction of labor in the second-trimester of pregnancy appears to be mifepristone 200mg orally followed 24-48 hours later by vaginal administration of misoprostol 200 to 400 µg every 4 to 6 hours. In third-trimester, there is very little data. The circumstances are similar to induction of labor with living fetus. A term or near term, oxytocin and dinoprostone have a marketing authorization in this indication but misoprostol may be an alternative as the Bishop score and dose of induction of labor with living fetus. In case of previous caesarean section, the risk of uterine rupture is increased in case of a medical induction of labor with prostaglandins. The lowest effective doses should be used (100 to 200 µg every 4 to 6 hours). Prior cervical preparation by the administration of mifepristone and possibly the use of laminar seems essential in this situation.

[Iron deficiency anemia and pregnancy. Prevention and treatment]. / Anémie par carence martiale et grossesse. Prévention et traitement.

OBJECTIVE: To assess the effectiveness and the safety of prevention and treatment of iron deficiency anemia during pregnancy. METHODS: French and English publications were searched using PubMed and Cochrane library. RESULTS: Early screening of iron deficiency by systematic examination and blood analysis seemed essential. Maternal and perinatal complications were correlated to the severity and to the mode of appearance of anemia. Systematic intakes of iron supplements seemed not to be recommended. In case of anemia during pregnancy, iron supplementation was not associated with a significant reduction in substantive maternal and neonatal outcomes. Oral iron supplementation increased blood parameters but exposed to digestive side effects. Women who received parenteral supplementation were more likely to have better hematological response but also severe potential side effects during pregnancy and in post-partum. The maternal tolerance of anemia motivated the choice between parenteral supplementation and blood transfusion. CONCLUSION: Large and methodologically strong trials are necessary to evaluate the effects of iron supplementation on maternal health and pregnancy outcomes.

[Fetal pulse oximetry: clinical practice]. / Oxymétrie de pouls foetal en pratique clinique.

OBJECTIVE: To assess in current practice the application of our protocol of using fetal pulse oximetry during labor, to evaluate whether fetal scalp blood sampling can be reduced and to determinate reliability of fetal pulse oximetry on the prediction of poor neonatal outcomes. STUDY DESIGN: Prospective observational unicenter cohort including 449 patients during two years. All pregnancies were singleton, greater than or equal to 37 weeks' gestation, cephalic presentation, and had non reassuring fetal heart rate. The poor neonatal outcome was defined by one of the followings: arterial umbilical cord pH

Rupture of the scarred uterus.

OBJECTIVE: To assess the risk of uterine rupture of the scarred uterus according to mode of delivery in subsequent births recorded as spontaneous labour, labour induced by oxytocin, labour after ripening with prostaglandin E2, and planned cesarean section. METHODS: Retrospective study of 2,128 births with a low transversal scar after a previous cesarean section. The study population was realised in a level III university hospital from 1995 to 2003. The association between mode of delivery and uterine rupture was studied in a multivariate logistic regression model, and adjusted for specific antenatal confounding factors. RESULTS: Over 9 years, we collected 22 cases (1%), including 11 asymptomatic ruptures in a population of 2,128 scarred uteri out of 28,248 deliveries. Uterine rupture occurred at a rate of 0.3 per 100 among women with repeated cesarean delivery without labour, 1 per 100 among women with spontaneous onset of labour, 1.4 per 100 among women with oxytocin-induced labour, and 2.2 per 100 among women with prostaglandin cervical ripening. Compared to women with a planned cesarean section, women with spontaneous onset of labour were more likely to have uterine rupture (OR: 4.0; 95% CI: 0.8-42.0). A greater relative risk was observed among women with oxytocin-induced labour (OR: 4.3; 95% CI: 0.3-60.0), and particularly those with prostaglandin-induced labour (OR: 8.7; 95% CI: 1.5-97.3, p=0.01). CONCLUSION: In women with a scarred uterus, prostaglandin E2 induction of labour is a risk factor for uterine rupture. The practice of a systematic cesarean section in cases with Bishop score<3, appropriate induction procedure, and rigorous monitoring of the labour, could make for a safer delivery.

[Rectal prolapse resection by trans-anal approach and stapling technique]. / Utilisation d'une agrafeuse linéaire coupante dans l'exérèse par voie basse des prolapsus rectaux.

We are introducing a simplified cure, derived from Alteimeier's intervention, of rectal prolapse by perineal way resection using a linear cutting stapler. It's a reproducible, quick and easy technique, which permits the elderly patients to come back in their middle of life rapidly with few complications.

[Obstetrical complications of morbid obesity]. / Complications obstétricales de l'obésité morbide.

OBJECTIVE: To determine whether morbidly obese women have an increased risk of pregnancy complications and adverse perinatal outcome. METHODS: In a retrospective study, 2472 women with morbid obesity, defined as a body mass index (BMI) more than 40 were compared with normal weight women (BMI 20-25). Fisher and Student tests were used for statistical analysis. RESULTS: In the group of morbidly obese mothers (BMI greater than 40) as compared with the normal weight mothers, there was an increased risk of the following outcomes: gravidic hypertension (7.7 vs 0.5%; p<0.05). preeclampsia (11.5 vs 2%; p<0.05), gestational diabetes (15.4 vs 1.8%; p<0.05), cesarean delivery (50 vs 15.4%; p<0.05), and macrosomia (42.3 vs 10.3%; p<0.05). However, we noted a lower rate of prematurity in the obese group (0 vs 11%). Even when morbidly obese women with preexisting diabetes and chronic hypertension were excluded from the analysis, significant differences in the perinatal outcomes still persisted. CONCLUSION: Morbid obesity appears to be an independent risk factor for perinatal and gestational complications.