Prediction of Iron Deficiency Anemia in Third Trimester of Pregnancy Based on Data in the First Trimester: A Prospective Cohort Study in a High-Income Country.

Background: Systematic iron supplementation may be harmful in pregnant women with non-depleted iron. Our objectives were to estimate the prevalence of anemia at the third trimester of pregnancy (T3) and to identify the parameters at the first trimester (T1), which best predict anemia at T3. Methods: This prospective cohort study in France included pregnant women at T1 without non-iron deficiency anemia. Clinical and social characteristics, health-related quality of life, blood count, and a frozen blood sample were collected at T1 and/or T3. Secondly, a matched nested case−control study was built for women with anemia at T3 but not at T1. Multivariate analyses and ROC curves were used to identify the best predictive parameter(s) of anemia at T3. Results: The prevalence of anemia at T3 in the cohort (629 women) was 21.9% (95% CI 18.7−25.2%). In the matched nested case−control study (256 women), hemoglobin (Hb), serum ferritin (SF) and the SF/soluble transferrin receptor ratio at T1 were predictive of anemia at T3 (p < 0.001); however, clinical and social characteristics, as serum hepcidin were not. In multivariate analyses, Hb at T1 was the best predictive biomarker of anemia at T3 with a cut-off value of 120 g/L (specificity 87.5%). Conclusions: The prevalence of anemia at the end of pregnancy remained high in a High-Income Country. Clinical, social, and biochemical parameters did not seem useful to predict anemia at T3 and could not guide iron supplementation. We suggest systematically performing a simple blood count in the first trimester of pregnancy and offering oral iron supplementation for women with Hb < 120 g/L.

Implication of folate deficiency in CYP2U1 loss of function.

Hereditary spastic paraplegias are heterogeneous neurodegenerative disorders. Understanding of their pathogenic mechanisms remains sparse, and therapeutic options are lacking. We characterized a mouse model lacking the Cyp2u1 gene, loss of which is known to be involved in a complex form of these diseases in humans. We showed that this model partially recapitulated the clinical and biochemical phenotypes of patients. Using electron microscopy, lipidomic, and proteomic studies, we identified vitamin B2 as a substrate of the CYP2U1 enzyme, as well as coenzyme Q, neopterin, and IFN-α levels as putative biomarkers in mice and fluids obtained from the largest series of CYP2U1-mutated patients reported so far. We also confirmed brain calcifications as a potential biomarker in patients. Our results suggest that CYP2U1 deficiency disrupts mitochondrial function and impacts proper neurodevelopment, which could be prevented by folate supplementation in our mouse model, followed by a neurodegenerative process altering multiple neuronal and extraneuronal tissues.

Is directed open-glottis pushing more effective than directed closed-glottis pushing during the second stage of labor? A pragmatic randomized trial - the EOLE study.

OBJECTIVE: To compare the effectiveness of directed open-glottis and directed closed-glottis pushing. DESIGN: Pragmatic, randomised, controlled, non-blinded superiority study. SETTINGS: Four French hospitals between July 2015 and June 2017 (2 academic hospitals and 2 general hospitals). PARTICIPANTS: 250 women in labour who had undergone standardised training in the two types of pushing with a singleton fetus in cephalic presentation at term (≥37 weeks) were included by midwives and randomised; 125 were allocated to each group. The exclusion criteria were previous caesarean birth or fetal heart rate anomaly. Participants were randomised during labour, after a cervical dilation ≥ 7 cm. INTERVENTIONS: In the intervention group, open-glottis pushing was defined as a prolonged exhalation contracting the abdominal muscles (pulling the stomach in) to help move the fetus down the birth canal. Closed-glottis pushing was defined as Valsalva pushing. MEASUREMENTS: The principal outcome was "effectiveness of pushing" defined as a spontaneous birth without any episiotomy, second-, third-, or fourth-degree perineal lesion. The results in our intention-to-treat analysis are reported as crude relative risks (RR) with their 95% confidence intervals. A multivariable analysis was used to take the relevant prognostic and confounding factors into account and obtain an adjusted relative risk (aRR). FINDINGS: In our intention-to-treat analysis, most characteristics were similar across groups including epidural analgesia (>95% in each group). The mean duration of the expulsion phase was longer among the open-glottis group (24.4 min ± 17.4 vs. 18.0 min ± 15.0, p=0.002). The two groups did not appear to differ in the effectiveness of their pushing (48.0% in the open-glottis group versus 55.2% in the closed-glottis group, for an adjusted relative risk (aRR) of 0.92, 95% confidence interval (CI) 0.74-1.14) or in their risk of instrumental birth (aRR 0.97, 95%CI 0.85-1.10). KEY CONCLUSIONS: In maternity units with a high rate of epidural analgesia, the effectiveness of the type of directed pushing does not appear to differ between the open- and closed-glottis groups. IMPLICATIONS FOR PRACTICE: If directed pushing is necessary, women should be able to choose the type of directed pushing they prefer to use during birth. Professionals must therefore be trained in both types so that they can adequately support women as they give birth.

Do estimates of blood loss differ between student midwives and midwives? A multicenter cross-sectional study.

OBJECTIVE: the principal objective of this study was to assess the quality of blood loss estimates by midwives and student midwives. The secondary objectives were: to assess the intraobserver agreement of visual blood estimates and the rate of underestimation of blood loss by participants, and to estimate the sensitivity, specificity, and negative likelihood ratio of these estimates for clinically pertinent blood losses (≥ 500mL and ≥ 1000mL). DESIGN: multicenter cross-sectional study. SETTING: thirty-three French maternity units and 35 French midwifery schools participated in this study. PARTICIPANTS: volunteer French midwifery students (n = 463) and practicing midwives (n = 578). INTERVENTION: an online survey showed 16 randomly ordered photographs of 8 different simulated blood quantities (100, 150, 200, 300, 500, 850, 1000, and 1500mL) with a reference 50-mL image in each photo and asked participants to estimate the blood loss. The visual blood loss estimates were compared with Fisher's exact test. Intraobserver agreement for these estimates was assessed with a weighted kappa coefficient, and the negative predictive values (probability of no hemorrhage when visual estimate was negative) were calculated from prevalence rates in the literature. FINDINGS: of the 16,656 estimates obtained, 34.1% were accurate, 37.2% underestimated the quantity presented, and 28.7% overestimated it. Analyses of the intraobserver reproducibility between the two estimates of the same photograph showed that agreement was highest (weighted kappa ≥ 0.8) for the highest values (1000mL, 1500mL). For each volume considered, students underestimated blood loss more frequently than midwives. In both groups, the negative predictive values regarding postpartum hemorrhage (PPH) diagnosis (severe or not) were greater than 98%. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: student midwives tended to underestimate the quantity of blood loss more frequently than the midwives. Postpartum hemorrhage (≥ 500mL) was always identified, but severe postpartum hemorrhage (≥ 1000mL) was identified in fewer than half the cases. These results should be taken into account in training both student midwives and practicing professionals.

Positions during the first stage and the passive second stage of labor: A survey of French midwives.

OBJECTIVE: the objective of our study was to describe the practices reported by French midwives during labor (first stage and passive phase of the second stage). DESIGN: this cross-sectional internet questionnaire surveyed French midwives who attended at least one delivery in 2013. SETTING: this open survey was posted on a website from June 15 through December 1, 2014. PARTICIPANTS: 1496 midwives from 377 maternity units participated in the study. Nearly 93% of the midwives worked in an obstetric unit, 5.9% had a mixed practice, and 1.3% worked in private practice. MEASUREMENTS AND FINDINGS: during the first stage of labor, midwives reported suggesting that women without epidural analgesia use a birthing ball (98.1%) and that they walk around (97.4%). For women with epidural analgesia, most suggested motion in horizontal positions. Epidural analgesia was proposed more often by midwives from level II (75.7%) and level III (73.5%) maternity wards than by those at level 1 units (57.7%) (p<0.0001). The midwives preferred a lateral position during the first stage for women with epidural analgesia and during the second stage for women both with and without it. Midwives in practice for 5 years or less suggested a kneeling position for women with epidural analgesia more often than more experienced midwives. KEY CONCLUSION: the practices of French midwives vary with their place of practice and their experience. IMPLICATIONS FOR PRACTICE: to promote normal labor, French midwives must reappropriate vertical positions and analgesic alternatives to epidurals.

Reliability of student midwives' visual estimate of blood loss in the immediate postpartum period: a cross-sectional study.

BACKGROUND: In France, postpartum hemorrhage (blood loss≥500mL in the first 24h postpartum) is the leading direct obstetric cause of maternal mortality. In French practice, PPH is mainly diagnosed by a quantitative assessment of blood loss, performed by subjective methods such as visual estimates. Various studies have concluded that visual estimates are imprecise, tend to underestimate blood loss, and thus to delay diagnosis of PPH. OBJECTIVES: The principal objective of this study was to assess the accuracy of visual estimates of blood loss by student midwives. The secondary objectives were to study intraobserver agreement of these assessments, to assess the accuracy of visual estimates for threshold values, and to look for a region effect. DESIGN: A cross-sectional multicentre study. SETTING: All French midwifery schools (n=35). PARTICIPANTS: Volunteer French student midwives at their fifth (final) year (n=463). METHODS: The online questionnaire contained 16 photographs (8 different, each presented twice) of simulated volumes of blood loss (100, 150, 200, 300, 500, 850, 1000, and 1500mL). A 50-mL reference standard for calibration accompanied each photograph. Only one answer could be selected among the 7 choices offered for each photograph. Comparisons used χ(2) and Kappa tests. RESULTS: The participation rate was 48.43% (463/956), and 7.408 visual estimates were collected. Estimates were accurate for 35.34% of the responses. The reproducibility rate for the visual estimates (0.17≤к≤0.48) and for the accurate visual estimates (0.11≤к≤0.55) were moderate for 4 of the 8 volumes (100, 300, 1000, and 1500mL). The percentage of accurate responses was significantly higher for volumes≤300mL than for those ≥500mL (52.94% vs. 17.17%, p<0.0001) and those ≥1000mL (52.94% vs. 18.30%, p<0.0001). The percentage of accurate responses varied between the regions (p=0.042). CONCLUSION: Despite the help of a visual aid, both the accuracy and reproducibility of the visual estimates were low.