Abdominopelvic ultrasonographic findings after uncomplicated delivery.

PURPOSE: To prospectively determine the range of abdominopelvic ultrasonographic findings, including Doppler resistance index (RI) of uterine arteries, 2 and 24 hours after uncomplicated delivery. METHOD: Women who delivered vaginally or after cesarean section without complication from January 2012 to April 2012 in a tertiary care hospital were prospectively included. Abdominopelvic ultrasonography, including uterine artery resistance index (RI) at duplex Doppler ultrasonography, was performed 2 hours and 24 hours after delivery. RESULTS: Ninety-two women (mean age, 32.7 years) were included. Sixty-one (66%) delivered vaginally and 31 (34%) had cesarean section. Twenty-four hours after vaginal delivery, endometrial and anterior wall thicknesses dropped and uterine width increased (P<0.001). No changes in uterine length and posterior wall thickness were observed between 2 and 24 hours after delivery. Transient pelvic free-fluid effusion was observed in 1/92 woman (1%). Uterine artery RI increased significantly from 2 to 24 hours (0.50 vs 0.57, respectively; P<0.001). CONCLUSION: Pelvic free-fluid effusion is exceedingly rare in the early course of uncomplicated delivery. A significant increase in uterine artery RI during the 24 hours following uncomplicated delivery is a normal finding. It can be anticipated that familiarity with these findings would result in more confident diagnosis of complications.

Emergency hysterectomy for life-threatening postpartum haemorrhage: Risk factors and psychological impact.

BACKGROUND: Emergency postpartum hysterectomy (EPH) is usually considered the final resort for the management of postpartum hemorrhage (PPH). The aim of this observational study was to identify the risk factors for EPH, to evaluate the ability of EPH to stop bleeding and, finally, to estimate its psychological impact. METHODS: This was a retrospective analysis of postpartum hysterectomy in all patients with PPH admitted between 2004 and 2011 to Lariboisière Hospital. We compared women for whom EPH was successful and those who required an advanced interventional procedure (AIP) to stop the bleeding despite hysterectomy. We also evaluated the severe PPH (SPPH) score in this particular setting. The psychological impact of emergency hysterectomy was also assessed. RESULTS: A total of 44 hysterectomies were performed among 869 cases of PPH. Twenty were successful, while an additional AIP was required in 22 others (50%). Prothrombin time<50% and a shorter interval between the onset of PPH and hysterectomy were independently associated with the need for an additional AIP. The area under the ROC curve of the SPPH score to predict the need for another AIP was 0.738 (95% confidence interval 0.548-0.748). Furthermore, 64% of the hysterectomized patients suffered from post-traumatic stress disorder. CONCLUSION: Failure of postpartum hysterectomy to control bleeding was frequent, and it was associated with persistence of coagulopathy. Hysterectomy in this context had important psychological impacts.

[Evaluation of the respect of the clinical practice guidelines in maternal transfer for postpartum haemorrhage in 2011: about 84 cases]. / État des lieux en 2011 du respect des recommandations pour la pratique clinique du transfert maternel en cas d'hémorragie du post-partum: à propos de 84 cas.

OBJECTIVES: Guidelines for the management of post-partum haemorrhage (PPH) were defined by the "Collège National des Gynécologues Obstétriciens Français (CNGOF)" since 2004. The aim of this work was to assess whether the management of PPH before and during the transfer was in accordance with national recommendations. PATIENTS AND METHODS: This is an observational monocentric prospective study concerning 84 patients transferred for PPH in a referent centre in 2011. RESULTS: In 62 cases (73.8%), transfusionnal files were found. Time noted PPH for 60 (71.4%) and amount of blood loss in 55 cases (65.5%) were notified. Evacuation of retained placenta was always performed; the broad-spectrum antibiotic prophylaxis covered only 21 cases of intra uterine procedures. Less than 5% of the patients received intravenous sulprostone before the transfer; 72.6% (n=61) of the patients were transfused before transfer 25% of the patients (n=21) had a very high risk of PPH in ante partum and were not addressed to a centre with appropriate medical and technical facilities. DISCUSSION AND CONCLUSION: Thus improvement can be made in the communication between the health care centre during transfer for PPH and the ante partum transfer of patients with high risk of PPH.

[Placenta accreta: screening, management and complications]. / Placenta accreta : dépistage, prise en charge et complications.

Abnormal placental invasion can result in major obstetric haemorrhage during delivery. The most important risk factors are the following: previous caesarean delivery, placenta praevia maternal age over 35, smoking, previous myomectomy, dilatation and curettage. When placenta accreta is suspected on ultrasound, an RMI can complete the diagnostic. Therefore, patients must be managed, as far as possible, in a reference centre, by a trained medical team. Birth must be planned in order to decrease complications rate. Treatment can consist in radical management (caesarean-hysterectomy) or conservative management (preservation of both uterus and placenta). Conservative management allows patients to keep fertility but can also decrease blood loss during delivery. Side effects of this therapy are secondary haemorrhage, sepsis, long-term follow-up and vaginal loss. There are few studies describing fertility after conservative management, but it seems to be a secure treatment for future pregnancies. Embolization can be a very useful, already demonstrated, help when massive haemorrhage occurs. Management of placenta accreta is multidisciplinary and patients must be informed of all options. Treatment is decided regarding history of the patients, operative findings and peri-partum blood loss.

[Post-partum haemorrhage associated with genital tract lacerations: series of 44 cases]. / Hémorragie du post-partum liée à des plaies de la filière génitale: étude de 44 cas.

OBJECTIVES: Genital tract lacerations are responsible for potentially serious postpartum hemorrhage (PPH), and are often underestimated. The objective of this study was to analyze the characteristics of genital tract lacerations associated with severe PPH in a reference center. PATIENTS AND METHODS: All women transferred for treatment of PPH due to genital tract lacerations between January 2008 and April 2011 were included in this observational study. Two populations of patients with genital tract lacerations were defined : patients with "complex" lesions and patients with "simple" genital tract laceration. RESULTS: Forty-four patients were treated for PPH associated with genital tract lacerations. The average age of patients was 30.6 years (17-41 years). All the patients had a vaginal delivery, combined with an instrumental in 70.5% of cases. With the exception of one patient, all patients had a revision of the cervix and vagina before the transport in our Institution. Twenty nine patients (70.7%) had received a suture of genital tract in their maternity. In our Hospital, the patient having a "simple" genital tract lesion received in 54.5% of cases medical drugs alone against 33.3% for patients with complex genital tract lacerations. In 39.4% of cases an embolization was necessary for the group of patients with complex genital tract lacerations against 9.1% in the simple genital tract lesion group. DISCUSSION AND CONCLUSION: Genital tract lacerations are a serious cause of HDD. Their management should be multidisciplinary combining appropriate and timely decisions (resuscitation, embolization and/or surgery). The sequence of these treatments depends on the clinical condition of the patient and justifies a transfer to a referral center.

[Invasive conservative care in cases of severe post-partum haemorrhage: future fertility and pregnancy outcome consequences]. / Prise en charge invasive conservatrice pour hémorragie du post-partum : fertilité et devenir obstétrical.

The development of conservative surgical approaches and interventionnal radiology for conservative treatment in cases of severe post-partum haemorrhage allows nowadays a preservation of the genital tract in most of the cases in developed countries. The consequences of these techniques for the future fertility and pregnancy outcome are not fully evaluated. Very few cases of infertility are reported and the majority of the patients seem to recover regular menstrual menses after application of any of the described conservative approach. Pregnancy outcomes appear unchanged without any consequence concerning foetal growth. However, complications might occur, impairing future fertility or pregnancy outcome: uterine synechia have been described after arterial embolization, ovarian failures occurred after stepwise surgical approach including lombo-ovarian artery ligature, synechia and uterine infection impaired uterine compression sutures. Furthermore, recurrence of post-partum haemorrhage and abnormal placentation rates seem to be higher for future pregnancies.

[Impact of precariousness on quality of prenatal detection: Lariboisière hospital experience in Paris]. / Impact de la précarité sur la qualité du dépistage anténatal : expérience de l'hôpital Lariboisière à Paris.

CONTEXT: The objective of our study was to estimate the impact of the precariousness on the quality of the care in antenatal diagnosis of the patients followed to Lariboisière (Parisian service of gynaecology obstetrics situated in a district of the capital discriminated socially) over a period of 3 months. PATIENTS: All the patients undergoing a prenatal diagnosis consultation in Lariboisière Hospital between February and April 2008. Patients were split in two groups according to their precariousness (economic or psychosocial) or not. Criteria studied were: initial purpose of the prenatal consultation, quality of the first trimester ultrasound exam, access to the integral calculus in Down Syndrome detection, lateness of care between the diagnosis and the prenatal consultation. The second part of this analysis was to evaluate if precariousness was associated with organizational problem in prenatal diagnosis. RESULTS: Fifty-nine patients were included: 29 (49%) were identified as being in a precariousness situation. The initial purpose of the consultation was the same in the two groups. Precariousness was associated to organizational problems for the prenatal diagnosis consultation (72 vs. 47%, P=0.004). Thirty-five patients (59%) have met organizational problems for the prenatal diagnosis consultation. Were associated to organizational problems: precariousness (60% vs. 33%, P=0.04), low education level (86 vs. 54%, P=0.007) and single mother (23% vs. 0%, P=0.001). CONCLUSION: This work shows the negative impact of precariousness on the prenatal diagnosis. Prevention may improve the information and the quality of care given to these patients.

[Transfers for postpartum haemorrhage in a Reference center (Lariboisière hospital): our experience during two years (2008 and 2009)]. / État des lieux des transferts pour hémorragie de la délivrance dans un centre de référence (hôpital Lariboisière) en 2008 et 2009.

OBJECTIVES: The postpartum haemorrhage (PPH) is the main cause of maternal mortality and is responsible in France every year of a quarter of the maternal deaths. We realized a study on the transfers for postpartum haemorrhage in 2008 and 2009 in a Reference center (Lariboisière Hospital). PATIENTS AND METHODS: It is a descriptive retrospective study over a period of two years, including all the patients cared for a postpartum haemorrhage. RESULTS: Two hundred and ninety-nine patients were cared for a PPH in 2008 and 2009 at the hospital Lariboisière. For transferred patients, the average age of the patients was of 30.9 years with varying extremes from 16 to 43 years old. It was the first pregnancy for 45.4% of the patients, having given birth to singletons (90.3%) by natural way in 63.8% of the cases. The care on arrival to Lariboisière based on surveillance in recovery room in 71.4% of the cases. The rate of embolisation was 22.4% and was stable over these two periods. DISCUSSION AND CONCLUSION: A supervision in recovery room associated with measures of resuscitation and with use of prostaglandins is mostly sufficient for the most part of the care of the PPH. In case of persistent bleeding, the embolisation remains an excellent therapeutic option and a good alternative in the hysterectomy of haemostasis, which however has to keep its place in severe PPH.