Maternal mortality due to obstetric hemorrhage by surgical injury during cesarean section: A nationwide study.

INTRODUCTION: Obstetric hemorrhage remains a largely preventable cause of maternal mortality globally. The contribution of uterine atony to hemorrhage-related maternal mortality has decreased in France, while the contribution of other causes of obstetric hemorrhage such as surgical injury during cesarean has been reported to increase. However, little evidence exists regarding the risk factors and care processes of women who died from this cause of hemorrhage. Therefore, we aimed to describe the clinical profile, underlying mechanisms, and preventability factors among women who died from obstetric hemorrhage by surgical injury during cesarean section. MATERIAL AND METHODS: Nationwide analysis of all hemorrhage-related maternal deaths by surgical injury during cesarean in France identified by the nationwide permanent enhanced maternal mortality surveillance system (ENCMM) between 2007 and 2018. We described the characteristics of the women, delivery hospitals, circumstances of hemorrhage, features of obstetric and resuscitation/transfusion care, and main preventability factors. RESULTS: Between 2007 and 2018, hemorrhage-related maternal mortality in France decreased from 1.6/100 000 live births (95% CI 1.1-2.2) (39/2 472 650) in 2007-2009 to 0.8/100 000 live births (95% CI 0.5-1.3) (19/2 311 783) in 2016-2018. Hemorrhage-related maternal mortality ratio due to surgical injury during cesarean increased from 0.08 (95% CI 0.01-0.3) (2/2 472 650) to 0.2 (95% CI 0.07-0.5) (5/2 311 783) per 100 000 live births. Among the 18 women who died from surgical injury during cesarean over the 12-year study period, we report a high prevalence of obesity (67%, 12/18), previous cesarean (72%, 13/18), and second-stage cesareans (56%, 10/18). In 22% (4/18), cesarean section was performed in a hospital providing <1000 births annually, with no blood bank (39%, 7/18) or no adult intensive care (44%, 8/18) on-site. Overall preventability of deaths was 94% (17/18). Main preventability factors were related to delay in hemorrhage diagnosis (77%, 14/18) due to late recognition of abnormal parameters (33%, 6/18) and late bedside ultrasound (56%, 10/18), and delay in management due to insufficient surgical skills (56%, 10/18). CONCLUSIONS: In France, surgical injury during cesarean section is an increasing, largely preventable contributor to hemorrhage-related maternal mortality, as other causes of fatal hemorrhage have become less frequent. The profile of these women showed a high prevalence of obesity, previous cesarean, second-stage cesarean, and delivery in hospitals with limited medical and surgical resources, which suggests explanatory mechanisms for the fatal outcome and opportunities for prevention.

Trends in Maternal Mortality From Obstetric Hemorrhage in France: 15 Years of Confidential Enquiry Into Maternal Deaths.

BACKGROUND: The aim of this study was to assess temporal trends in incidence and underlying causes of maternal deaths from obstetric hemorrhage in France and to describe clinical care before and after implementation of the first national guidelines published in 2004 and updated in 2014. METHODS: Data from all hemorrhage-related maternal deaths between 2001 and 2015 were extracted from the French Confidential Enquiry into Maternal Deaths. We compared the maternal mortality ratio (MMR), cause of obstetric hemorrhage, and death preventability by triennium. Critical care, transfusion, and obstetric management among women who died were described for 2001 to 2003 and 2013 to 2015. RESULTS: The MMR from obstetric hemorrhage significantly decreased over time from 2.3 of 100,000 livebirths (54 of 2,391,551) in 2001 to 2003 to 0.8 of 100,000 livebirths (19 of 2,412,720) in 2013 to 2015. In 2001 to 2003, uterine atony accounted for 50% (27 of 54) of maternal deaths vs 21% (4 of 19) in 2013 to 2015. As compared to 2001 to 2003, an increased proportion of women had hemodynamic continuous monitoring in 2013 to 2015 (30%, 9 of 30, vs 47%, 8 of 18) and received vasopressor infusion therapy (57%, 17 of 30, vs 72%, 13 of 18), and a smaller proportion was extubated during active hemorrhage (17%, 5 of 30, vs 0 of 18). Transfusion therapy was initiated more frequently and earlier in 2013 to 2015 (71 vs 58 minutes). In 2013 to 2015, 88% of maternal deaths due to hemorrhage remained preventable. The main identified improvable care factors were related to delays in diagnosis and surgical management, particularly after cesarean delivery. CONCLUSIONS: Maternal mortality by obstetric hemorrhage decreased dramatically in France between 2001 and 2015, particularly mortality due to uterine atony. Among women who died, we detected fewer instances of substandard transfusion management or critical care. Nevertheless, opportunities for improvement were observed in most of the recent cases.

[Maternal mortality due to obstetric haemorrhage in France 2016-2018]. / Mortalité maternelle par hémorragie obstétricale en France 2016­2018.

Between 2016 and 2018, 20 maternal deaths were related to obstetric haemorrhage, excluding haemorrhage in the first trimester of pregnancy, representing a mortality ratio of 0.87 per 100,000 live births (95% CI 0.5 -1.3). Obstetric haemorrhage is the cause of 7.4% of all maternal deaths up to 1 year, 10% of maternal deaths within 42days, and 21% of deaths directly related to pregnancy (direct causes). Between 2001 and 2018, maternal mortality from obstetric haemorrhage has been considerably reduced, from 2.2deaths per 100,000 live births in 2001-2003 to 0.87 in the period presented here. Nevertheless, obstetric haemorrhage is still one of the main direct causes of maternal death, and remains the cause with the highest proportion of deaths considered probably (53%) or possibly (42%) preventable according to the CNEMM's collegial assessment (see chapter 3). The preventable factors reported are related to inadequate content of care in 94% of cases and/or organisation of care in 44% of cases. In this triennium, maternal death due to haemorrhage occurred mainly in the context of caesarean delivery (65% of cases, i.e. 13/20), and mostly in the context of emergency care (12/13). The main causes of obstetric haemorrhage were uterine rupture (6/20) in unscarred uterus or in association with placenta accreta, and surgical injury during the caesarean delivery (5/20). Every maternity hospital, whatever its resources and/or technical facilities, must be able to plan any obstetric haemorrhage situation that threatens the mother's vital prognosis. Intraperitoneal occult haemorrhage following caesarean section and uterine rupture require immediate surgery with the help of skilled surgeon resources with early and appropriate administration of blood products.

[Maternal mortality and health care organization in France 2016-2018]. / Mortalité maternelle et organisation des soins en France 2016­2018.

Organization of care is one of the elements examined when assessing cases. Organization of care is a factor, which is considered in addition to the content of care when assessing mortality cases. The factors related to the organization of care concern the suitability of the place of care, the completion of a necessary transfer, the adequacy of human and material resources, and the communication between caregivers. For the 2016-2018 triennium these preventability factors are the subject of a dedicated chapter. Overall, one or more preventability factors linked to the organization of care were reported in 51 cases, i.e. 24% of all assessed cases. The field of communication was the most frequently reported (32/51), followed by inappropriate place of care (20/51), insufficient human resources (13/51), transfers not performed or performed late (11/51) and insufficient material resources (9/51). An overall analysis can be made along two dimensions: organization within the maternity unit, and coordination with other sectors or outpatient medicine. Areas for improvement within the maternity unit relate to the ability to deal with life-threatening emergencies, to organize the call for specialized and/or trained human reinforcements, to organize intensive monitoring of patients in the event of organ failure, and to facilitate good communication between caregivers. Regarding coordination with other units, it is proposed to improve collaboration between the maternity unit's emergency department and the general emergency department, and to improve the transfer of information required by all those involved, including primary care physicians, in the pre-, per- and postpartum period. Finally, the place of care for patients presenting with a psychiatric and somatic pathology is a situation that requires careful consultation.

[Maternal mortality due to cardiovascular diseases in France 2016-2018]. / Mortalité maternelle par pathologies cardiovasculaires en France 2016­2018.

Between 2016 and 2018, cardiovascular diseases were responsible for 41 deaths, making it the leading cause of maternal death within 42 days postpartum in France. The maternal mortality ratio (MMR) for cardiovascular disease is 1.8 per 100,000 NV, a non-significant increase compared with the 2013-2015 triennium (MMR of 1.5 per 100,000 NV). Deaths from cardiac causes accounted for the majority (n=28), with 26 deaths secondary to cardiac disease aggravated by pregnancy (indirect deaths) and 2 deaths related to peripartum cardiomyopathy (direct deaths). Deaths from vascular causes (n=13) corresponded to 9 aortic dissections and 4 ruptures of large vessels, including 3 ruptures of the splenic artery. Preventability of death (possible or probable) was found in 56% of cases compared with 66% in the previous triennium. Care was considered sub-optimal in 57% of cases, down from 72% in the 2013-2015 triennium. In women with known cardiovascular disease, the areas for improvement concern multidisciplinary follow-up, repeated assessment of the cardiovascular risk (WHO grade) and early referral to an expert centre (expert cardiologists, obstetricians, anaesthetists and intensive care). In all pregnant women or women who have recently given birth, a cardiovascular etiology should be considered in the presence of suggestive symptoms (dyspnea, chest or abdominal pain). Ultrasound "point of care" examination (fluid effusions, cardiac dysfunction) and cardiac enzymes assay can help in the diagnosis. Finally, the woman must be involved in her own care.

[Maternal mortality due to Amniotic Fluid Embolism in France 2016-2018]. / Mortalité maternelle par embolie amniotique en France 2016­2018.

Amniotic embolism remains the 3rd leading cause of maternal death in France, with 21 maternal deaths over the 2016-2018 triennium. The women who died were more likely to be obese (25%), to benefit from induction of labor (71%) and be cared in a maternity hospital <1500 deliveries/year (45%), compared with the reference population (ENP 2016). The symptom occurred mainly during labor (95%) and the course was rapid, with a symptom-to-fatality interval of 4hours 45minutes (min: 25minutes - max: 8 days). Preventability was proposed for 35% of the deaths assessed, with areas for improvement identified in terms of technical skills (haemostasis procedures, management of polytransfusion), non-technical skills (communication) and health care organization (human resources, vital emergency plan, wide access to PSL). An autopsy was performed in 38% of deaths.

Teleconsultation compared with face-to-face consultation in the context of pre-anesthesia evaluation: TELANESTH, a randomized controlled single-blind non-inferiority study.

STUDY OBJECTIVE: During the COVID crisis, pre-anesthesia teleconsultations were widely used leading to savings in time and money. However, the non-inferiority of this system has not yet been evaluated. DESIGN: Prospective, randomized, controlled, single-blind non-inferiority study. SETTING: University hospital. PATIENTS: Patients scheduled for surgery requiring a single pre-anesthesia consultation (PAC). INTERVENTION: Pre-anesthesia teleconsultation (PATC) from patient's home. MEASUREMENTS: Primary outcome: concordance between the pre-anesthesia visit (PAV), performed on the day of surgery, and PAC or PATC on: Secondary outcomes: cancellation rate, immediate perioperative complications, patient satisfaction, organization, and economic and ecological costs. MAIN RESULTS: Out of 172 patients included, 149 were analyzed. PATC was no less effective than PAC in terms of the primary outcome or each of its components: the difference between groups was: - 0.044[90% CI: -0.135; 0.047] (p = 0.0002). There was no difference in cancellation rates (PAC 1.99% vs. PATC 1.27%, p = 0.6) or in immediate perioperative complications (none). Satisfaction was 9.48 (±1.45) in the PAC group and 8.96 (±1.68) in the PATC group (p = 0.0006). In the PATC group, the mean savings per patient were 30 km (± 29), 36 min (± 27), and 18 (± 18) euros, respectively. CONCLUSIONS: According to our criteria, PATC was not inferior to PAC for preoperative patient evaluation and may be an interesting economical, ecological alternative.

Pre-anaesthesia Telephone Consultation: A Safe Alternative for Anaesthesia Assessment in Case of Repeated Low or Intermediate Risk Surgeries: A Prospective Cohort Study.

Objective: Telemedicine has widely expanded during the coronavirus disease-2019 pandemic. Our objective was to evaluate the feasibility, safety, effectiveness, and satisfaction of pre-anaesthesia telephone consultation (PATC). Methods: From December 2015 to October 2016, a prospective survey was administered to anaesthesiologists, nurse anaesthetists, and patients of the ambulatory and maxillofacial departments. Patients having a pre-anaesthesia consultation (PAC) within the previous year in the department, whose health state was considered stable, and for whom the surgical procedure was related to the previous one, were eligible for PATC. Three questionnaires concerning the pre- (Q1), per- (Q2), and postoperative (Q3) periods were answered by the patient, the anaesthesiologist, and the anaesthesiologist nurse to evaluate the feasibility and satisfaction of the PATC. We collected the cancelation rate and any incident occurring during the surgery. Results: Over the study period, 210 patients were included. The response rate was 200/210 (95.2%) for Q1, 108/208 (51.9%) for Q2 and 146/208 (70.2%) for Q3. PATC was performed in a median (IQR) of 13 (7-20) days before the procedure. Patients answered directly in 73% of cases without the need for recall. During surgery, 4 incidents occurred and none were attributable to PATC. Patient satisfaction was 93.3% and 85.8% of them preferred PATC to conventional PAC. The kilometric saving was 74 (30-196) km per PATC. Conclusion: Both patients and professionals were satisfied with PATC, which did not impact safety. On the selected patients, PATC brings many practical benefits and increases organizational flexibility.

Timing and Preventability of Cardiovascular-Related Maternal Death.

OBJECTIVE: To describe the clinical profile, management, and potential preventability of maternal cardiovascular deaths. METHODS: We conducted a retrospective, descriptive study of all maternal deaths resulting from a cardiovascular disease during pregnancy or up to 1 year after the end of pregnancy in France from 2007 to 2015. Deaths were identified through the nationwide permanent enhanced maternal mortality surveillance system (ENCMM [Enquête Nationale Confidentielle sur les Morts Maternelles]). Women were classified into four groups based on the assessment of the national experts committee: those who died of a cardiac condition and those who died of a vascular condition and, within these two groups, whether the condition was known before the acute event. Maternal characteristics, clinical features and components of suboptimal care, and preventability factors, which were assessed with a standard evaluation form, were described among those four groups. RESULTS: During the 9-year period, 103 women died of cardiac or vascular disease, which corresponds to a maternal mortality ratio from these conditions of 1.4 per 100,000 live births (95% CI 1.1-1.7). Analyses were conducted on 93 maternal deaths resulting from cardiac (n=70) and vascular (n=23) disease with available data from confidential inquiry. More than two thirds of these deaths occurred in women with no known pre-existing cardiac or vascular condition. Among the 70 deaths resulting from a cardiac condition, 60.7% were preventable, and the main preventability factor was a lack of multidisciplinary prepregnancy and prenatal care for women with a known cardiac disease. For those with no known pre-existing cardiac condition, preventability factors were related mostly to inadequate prehospital care of the acute event, in particular an underestimation of the severity and inadequate investigation of the dyspnea. Among the 23 women who died of a vascular disease, three had previously known conditions. For women with no previously known vascular condition, 47.4% of deaths were preventable, and preventability factors were related mostly to wrong or delayed diagnosis and management of acute intense chest or abdominal pain in a pregnant woman. CONCLUSION: Most maternal deaths attributable to cardiac or vascular diseases were potentially preventable. The preventability factors varied according to the cardiac or vascular site and whether the condition was known before pregnancy. A more granular understanding of the cause and related risk factors for maternal mortality is crucial to identify relevant opportunities for improving care and training health care professionals.

Maternal sudden death: A nationwide retrospective study.

OBJECTIVE: To determine the prevalence of maternal sudden death (MSD) and to compare the characteristics of death between women with explained and unexplained sudden death. DESIGN: A national retrospective study in France. POPULATION: Maternal deaths related to an unexpected sudden cardiac arrest were extracted from the French National Confidential Enquiry into Maternal Deaths database for 2007-2012. METHODS: Maternal, pregnancy, sudden death characteristics and maternal investigations were compared between women with explained and unexplained cause of death. RESULTS: A total of 83 maternal sudden deaths and 4 949 890 live births occurred over the period studied, thus accounting for 16% of all maternal deaths (n = 510). Death was explained in 51 (61%) women and unexplained in 32 women (39%). Compared with women with unexplained death, women with explained death were more often found to have in-hospital cardiac arrest (47% versus 12%, P < 0.01), witnessed cardiac arrest (86% versus 62%, P = 0.03) and in-hospital death (82% versus 47%, P < 0.01). Postmortem investigations such as autopsy and/or CT scan (65% versus 31%, P < 0.01) were also more often carried out in women with explained death. The proportion of deaths for which the preventability factors could not be assessed was 58% among unexplained MSD and 7% among explained MSD. CONCLUSION: Maternal sudden death is a rare event but accounts for a high proportion of all maternal deaths. This highlights the importance of providing training in diagnostic and management strategy for care providers. Systematic postmortem investigations are required to help understand causes and improve practices.

Telemedicine for Preanesthesia Consultations During the First COVID-19 Lockdown.

Introduction: In an effort to avoid travel and interpersonal contact, the COVID-19 health crisis was an opportunity to offer preanesthesia teleconsultation (TCs) to patients scheduled for surgery. Materials and Methods: We studied the technical feasibility and patient experiences of these TCs using a 4-point Likert scale questionnaire. Results: Eighty-six patients out of 139 responded. Technical difficulties (no connection, picture, or sound) occurred in 24% of cases. The patient's experience was considered very positive both in terms of feelings and understanding instructions: 4 (4-4). No deprogramming was required. Conclusion: TCs were approved by patients despite technical problems. Further studies are required to ensure that this type of consultation is not inferior to face-to-face consultations. NCT04920604.

Guidelines for the management of urgent obstetric situations in emergency medicine, 2022.

OBJECTIVE: To provide recommendations on the management of urgent obstetrical emergencies outside the maternity ward. DESIGN: A group of 24 experts from the French Society of Emergency Medicine (SFMU), the French Society of Anaesthesia and Intensive Care Medicine (SFAR) and the French College of Gynaecologists and Obstetricians (CNGOF) was convened. Potential conflicts of interest were formally declared at the outset of the guideline development process, which was conducted independently of industry funding. The authors followed the GRADE (Grading of Recommendations Assessment, Development and Evaluation) method to assess the level of evidence in the literature. The potential drawbacks of strong recommendations in the presence of low-level evidence were highlighted. Some recommendations with an insufficient level of evidence were not graded. METHODS: Eight areas were defined: imminent delivery, postpartum haemorrhage (prevention and management), threat of premature delivery, hypertensive disorders in pregnancy, trauma, imaging, cardiopulmonary arrest, and emergency obstetric training. For each field, the expert panel formulated questions according to the PICO model (population, intervention, comparison, outcomes) and an extensive literature search was conducted. Analysis of the literature and formulation of recommendations were conducted according to the GRADE method. RESULTS: Fifteen recommendations on the management of obstetrical emergencies were issued by the SFMU/SFAR/CNGOF panel of experts, and 4 recommendations from formalised expert recommendations (RFE) established by the same societies were taken up to answer 4 PICO questions dealing with the pre-hospital context. After two rounds of voting and several amendments, strong agreement was reached for all the recommendations. For two questions (cardiopulmonary arrest and inter-hospital transfer), no recommendation could be made. CONCLUSIONS: There was significant agreement among the experts on strong recommendations to improve practice in the management of urgent obstetric complications in emergency medicine.

Use of Remifentanil Associated with Lidocaine for Feticides in Late Terminations of Pregnancy: A Randomized Clinical Trial.

INTRODUCTION: In France, performance of a termination of pregnancy is legally possible without any gestational age limit. After 22 weeks of gestation, a feticide is ethically performed using usually sufentanil and lidocaine. The aim of this study was to compare the use of remifentanil, a fast-acting morphine-derivating product, instead of sufentanil. METHODS: This 2-center randomized, controlled, single-blinded phase-III treatment trial had 2 parallel arms: an experimental group using remifentanil with lidocaine versus a control group receiving sufentanil associated with lidocaine. This trial took place over a 40-month period. The primary outcome was time to fetal asystole after lidocaine injection. The secondary outcome measures were the procedure's success rate, the rate of serious maternal side effects, and the presence of cellular or tissue modifications. RESULTS: The study included 66 women, randomized into 2 groups of similar size and characteristics. Time to fetal asystole did not differ significantly between the groups, with a delay of 4 min (Q1-Q3, 2-11) in the sufentanil group and 4 min (Q1-Q3, 1-10) in the remifentanil group (p = 0.84). Similarly, the success rate of the procedure did not differ significantly. Fetal asystole was procured in <2 min and persisted >1 min for 16 (25.8%) women in our total population: 7 (22.5%) in the sufentanil group and 9 (29.0%) in the remifentanil group, p = 0.77. No severe maternal side effects were observed. Among the 49 fetopathological examinations performed, the few tissue and cell modifications observed did not cause any interpretation difficulties in either group. DISCUSSION/CONCLUSION: Use of remifentanil instead of sufentanil for feticide procedure did not improve time to fetal asystole. No harmful effect was observed for either maternal tolerance or interpretation of the histologic slides.

Guidelines: Anaesthesia in the context of COVID-19 pandemic.

OBJECTIVES: The world is currently facing an unprecedented healthcare crisis caused by the COVID-19 pandemic. The objective of these guidelines is to produce a framework to facilitate the partial and gradual resumption of intervention activity in the context of the COVID-19 pandemic. METHODS: The group has endeavoured to produce a minimum number of recommendations to highlight the strengths to be retained in the 7 predefined areas: (1) protection of staff and patients; (2) benefit/risk and patient information; (3) preoperative assessment and decision on intervention; (4) modalities of the preanaesthesia consultation; (5) specificity of anaesthesia and analgesia; (6) dedicated circuits and (7) containment exit type of interventions. RESULTS: The SFAR Guideline panel provides 51 statements on anaesthesia management in the context of COVID-19 pandemic. After one round of discussion and various amendments, a strong agreement was reached for 100% of the recommendations and algorithms. CONCLUSION: We present suggestions for how the risk of transmission by and to anaesthetists can be minimised and how personal protective equipment policies relate to COVID-19 pandemic context.