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

To provide recommendations on the management of urgent obstetrical emergencies outside the maternity ward. 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. 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. 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. There was significant agreement among the experts on strong recommendations to improve practice in the management of urgent obstetric complications in emergency medicine.

[Unexpected out-of-hospital deliveries: Management and risk factors]. / Accouchement inopiné extrahospitalier : prise en charge et facteur de risque.

OBJECTIVES: To estimate the frequency of accidental out-of-hospital deliveries (OHDs), to describe the home care and the complications occurred, and to identify risk factors. MATERIALS AND METHODS: A retrospective case-control study from 1st January 2012 to 31 December 2012 in Lyon urban area. Cases were identified from the Emergency Medical Aid Service 69 (SAMU 69) registry and control from the birth registry of the maternity corresponding to the case, recruiting two controls per case. RESULTS: The frequency of the OHDs was 0.3% [0.2-0.4]. At home, the prophylactic administration of oxytocin was performed in 18.3% [9.31-27.3] of cases and prevention of neonatal hypothermia was performed in 45.7% [34.1%-57.3%] of cases. Multiparity [OR: 3.43 (1.65-7.23)], a precarious situation [OR: 37.63 (5.02-7.81)], and lack of antenatal care [OR: 3.36 (2.72-4.15)] were OHDs' risk factors. CONCLUSION: The practical prevention of postpartum hemorrhage, and that of the home neonatal hypothermia could be improved. Points of vigilance for the medical teams to look for during the pregnancy monitoring are precariousness and less than 3 consultations scheduled.

[2008 update of the 8th Consensus Development Conference of the Francophone Society of Medical Emergencies of 1999. The treatment of adult renal colic by the emergency services and in emergency rooms]. / Actualisation 2008 de la 8e Conférence de consensus de la Société francophone d'urgences médicales de 1999. Prise en charge des coliques néphrétiques de l'adulte dans les services d'accueil et d'urgences.

The care in the emergencies of the renal colic at the adult was the object in 1999 of a conference of consensus of the French Society of Emergency (SFMU) in association with the French Association of Urology and the Society of Nephrology. This already former text was the object of an update in 2008 by the subcommittee of scientific monitoring of the SFMU and was presented to the congress 2008. This public presentation in the presence of an expert urologist allowed to confront this new text with the practices and to publish an updating of the conference of consensus of 1999. A survey of practice was led with the emergency physicians, whose results are presented.

[Modalities for maternal transfer in the event of postpartum hemorrhage]. / Modalités d'un transfert maternel dans le cadre d'une hémorragie post-partum.

In the event of a postpartum bleeding, the decision to undertake a medical transfer should be made in concertation by the different physicians involved: the hospital that requests the transfer, the Emergency Medical and Mobile Service, the receiver. The choice of a health care provider depends on the health care facilities, the possibility to admit the patient and the time parameter. A transfer is contraindicated for patients with an unstable hemodynamic state and when hemostatic surgery is essential. During transportation, only cardiopulmonary techniques are allowed. Patient monitoring, anesthesia and resuscitation during the embolization process should be done by the critical care team in the hospital and not by emergency physicians and nurses. As a precaution, after the team has assessed the situation locally and before it worsens, a transfer, including intra uterine transfer, should be discussed and completed toward a health care facility equipped to provide rapid and varied emergency care. When postpartum bleeding occurs after an unexpected birth out of the hospital, rapid medical transportation toward a health care facility equipped to provide varied emergency care is required. The emergency care unit should be informed prior to the transfer.

Sympathovagal effects of spinal anesthesia assessed by the spontaneous cardiac baroreflex.

BACKGROUND: The changes in sympathovagal balance induced by spinal anesthesia remain controversial. The spontaneous baroreflex method allows the continuous assessment of the spontaneous engagement of the cardiac baroreflex, giving an index of sympathovagal balance. The purpose of this study was to follow the effects of spinal anesthesia on spontaneous baroreflex sensitivity. METHODS: Continuous electrocardiogram and noninvasive blood pressure were recorded in 24 patients scheduled for elective inguinal hernia repair and randomly assigned to three groups: (1) no volume loading, (2) volume loading of 15 ml/kg lactated Ringer's solution, and (3) continuous infusion of etilefrine (an ephedrine-like drug). Each patient was studied before, during, and after bupivacaine-induced spinal anesthesia (mean sensory block: T4). Spontaneous baroreflex sensitivity and parameters of time-domain analysis of heart rate variability were calculated from 30 min of recording of each period. RESULTS: No significant change in spontaneous baroreflex slope or parameters of time-domain analysis were observed after regional anesthesia in any group. However, three patients experienced episodes of bradycardia and hypotension in the absence of a high block; these three patients showed an increase in spontaneous baroreflex sensitivity and time-domain parameters. CONCLUSIONS: Using a noninvasive, continuous technique to estimate cardiac sympathovagal balance, no significant variation in autonomic balance induced by spinal anesthesia was observed. However, untoward episodes of bradycardia and hypotension occurred in three patients, who could not be prospectively identified by the parameters studied.

[Value of the combination of propofol-alfentanil and vecuronium for the anesthesia of laparoscopy in ambulatory patients]. / Intérêt de l'association propofol-alfentanil-vecuronium pour l'anesthésie des coelioscopies en hôpital de jour.

Laparoscopy without an important surgical act was executed in twenty patients. Anaesthetic protocol associated propofol, alfentanil and vecuronium. This protocol meet conditions for ambulatory patients. Only three were not suited to leave hospital six hours after coelioscopy.