Effectiveness of uterine tamponade devices for refractory postpartum haemorrhage after vaginal birth: a systematic review.

OBJECTIVES: To evaluate uterine tamponade devices' effectiveness for atonic refractory postpartum haemorrhage (PPH) after vaginal birth and the effect of including them in institutional protocols. SEARCH STRATEGY: PubMed, EMBASE, CINAHL, LILACS, POPLINE, from inception to January 2021. STUDY SELECTION: Randomised and non-randomised comparative studies. OUTCOMES: Composite outcome including surgical interventions (artery ligations, compressive sutures or hysterectomy) or maternal death, and hysterectomy. RESULTS: All included studies were at high risk of bias. The certainty of the evidence was rated as very low to low. One randomised study measured the effect of the condom-catheter balloon compared with standard care and found unclear results for the composite outcome (relative risk [RR] 2.33, 95% CI 0.76-7.14) and hysterectomy (RR 4.14, 95% CI 0.48-35.93). Three comparative studies assessed the effect of including uterine balloon tamponade in institutional protocols. A stepped wedge cluster randomised controlled trial suggested an increase in the composite outcome (RR 4.08, 95% CI 1.07-15.58) and unclear results for hysterectomy (RR 4.38, 95% CI 0.47-41.09) with the use of the condom-catheter or surgical glove balloon. One non-randomised study showed unclear effects on the composite outcome (RR 0.33, 95% CI 0.11-1.03) and hysterectomy (RR 0.49, 95% CI 0.04-5.38) after the inclusion of the Bakri balloon. The second non-randomised study found unclear effects on the composite outcome (RR 0.95, 95% CI 0.32-2.81) and hysterectomy (RR 1.84, 95% CI 0.44-7.69) after the inclusion of Ebb or Bakri balloon. CONCLUSIONS: The effect of uterine tamponade devices for the management of atonic refractory PPH after vaginal delivery is unclear, as is the role of the type of device and the setting. TWEETABLE ABSTRACT: Unclear effects of uterine tamponade devices and their inclusion in institutional protocols for atonic refractory PPH after vaginal delivery.

[Maternal mortality estimation in France, according to a new method]. / Estimation de la mortalité maternelle en France: une nouvelle méthode.

OBJECTIVE: Ten years after implementation of maternal mortality monitoring in France, we established a new estimate of the current maternal mortality ratio (MMR) and revisited maternal death data collection. MATERIAL AND METHODS: Linkages were set up between female deaths and childbirths and between female deaths and causes of death. Information provided by confidential inquiries into maternal deaths carried out by the National Committee for maternal mortality study was added. The World Health Organization (WHO) definitions were used for maternal death and maternal mortality ratio. The study concerned deaths occurring in 1999. Results were compared with data from 1989. RESULTS: The official data showed 20% fewer maternal deaths than our inquiry. Estimated from our data, the MMR was 9 per 100000 live births in 1999. Direct obstetric causes were more often recorded than indirect causes. Hemorrhage was the leading obstetric cause of maternal death (21%). In comparison with the 1989-90 data, the underestimation of maternal deaths and maternal mortality ratios are improving (from 18 to 9 per 100000). CONCLUSION: These results, obtained while the mean maternal age at childbirth increased regularly, are interpreted as a sign of improvement in care. But the persistence of post partum hemorrhages as the leading cause of maternal death and the high rate of avoidable deaths, disclose important targets for further progress.

Phenotype-genotype correlation in 56 women with nonclassical congenital adrenal hyperplasia due to 21-hydroxylase deficiency.

Complete analysis of the CYP21 gene was performed in 56 unrelated French women with symptomatic nonclassical congenital adrenal hyperplasia. The mutational spectrum and the phenotype-genotype correlation were examined. The overall predominant mutation was V281L, which was present on 51% of alleles and in 80% of women. Three novel mutations were found: L317M, R435C, and a 5'-end gene conversion. Sixty-three percent of the women were carrying a severe mutation of the CYP21 gene, and hence risk giving birth to children with a classical form of the disease. In such cases, screening for heterozygosity in the partner is crucial. Potential genotype/phenotype correlations were examined by classifying the patients into three groups according to the CYP21 allelic combinations: A (mild/mild), B (mild/severe), and C (severe/severe). Primary amenorrhea was more frequent, and mean basal and stimulated 17-hydroxyprogesterone levels were higher in compound heterozygotes for mild and severe mutations (group B) compared with women with two mild mutations (group A), but there was a considerable overlap for individual values. Surprisingly, in two women, a severe mutation was found on both alleles (group C). Therefore, the phenotype cannot be accurately predicted from the genotype. Variability in phenotypic expression may be conditioned by mechanisms other than genetic heterogeneity at the CYP21 locus.

Risk of ectopic pregnancy and previous induced abortion.

OBJECTIVES: This study investigated the role of prior history of induced abortion in subsequent ectopic pregnancies. METHODS: Data from two French case-control studies were used to examine the effect of induced abortion on ectopic pregnancy risk. Case patients (n = 570) were women admitted for ectopic pregnancy during the study period; controls (n = 1385) were women who delivered in the same center. RESULTS: The analysis among women with no previous ectopic pregnancy showed that, after control for the main ectopic pregnancy risk factors, prior induced abortion was associated with an increased risk of ectopic pregnancy (odds ratio [OR] = 1.5, 95% confidence interval [CI] = 1.0, 2.0); there was a significant trend between number of previous induced abortions and ectopic pregnancy risk (ORs = 1.4 for 1 previous induced abortion and 1.9 for 2 or more). CONCLUSIONS: This study suggests that induced abortion may be a risk factor for ectopic pregnancy for women with no previous ectopic pregnancy, particularly in the case of women who have had several induced abortions.

Hormonal replacement therapy in menopausal women with a history of hyperprolactinemia.

Hyperprolactinemia is involved in almost 30% of infertility problems. At the onset of menopause, prolactin levels often decrease; however, no data are available regarding the course of hyperprolactinemia after menopause with hormonal replacement therapy (HRT). A retrospective study was undertaken in our department to evaluate the potential role of estrogens in women with a history of hyperprolactinemia. Twenty-two patients, with hyperprolactinemia before menopause, were followed-up. Group I included 11 patients who withdrew bromocriptine treatment when menopause was confirmed. These patients were placed on HRT with no other medication administered. HRT was a combination of percutaneous estradiol gel and an oral progestin. Group II included 7 women treated by bromocriptine before menopause and after menopause concomitantly with HRT. Group III included 4 patients who did not receive HRT or other treatments once menopause was diagnosed. The mean serum prolactin level was unchanged in Group I (22.8+/-21.7 before and 22.8+/-16.1 ng/ml after HRT) while it increased but not significantly from 8.1+/-5.2 to 16.0+/-11.7 ng/ml in Group II. The mean duration of HRT was 42.8+/-23.8 (7-81) and 37.3+/-31.0 (6-99) months in Group I and II respectively. In Group III patients, PRL levels decreased spontaneously from 61.2+/-39.8 to 33.0+/-34.7 ng/ml. In conclusion, in this population of menopausal patients with a history of moderate hyperprolactinemia, HRT did not seem to affect plasma prolactin levels.

[Ectopic pregnancy: factors related to ovum anomalies?]. / Grossesse extra-utérine : des facteurs liés à des anomalies de l'oeuf?

Identified risk factors for ectopic pregnancy (prior pelvic inflammatory disease, smoking at the time of conception, intrauterine device, obstetrical and surgical history) explain from 60 to 65% of the cases. Egg anomalies may also be a risk factor as it is likely that the transport of an abnormal egg along the uterine tube is less efficient than a normal one. We tested this hypothesis with data from two case-control studies with the same design covering a total of 1955 women. The risk of ectopic pregnancy increased specifically with age, which is compatible with our hypothesis. We also studied the associations with spontaneous abortion, considered to be a marker of the risk of pregnancies involving chromosomal malformations. We observed an association between ectopic pregnancy and spontaneous abortions (especially recurrent abortions), not explained by other known risk factors. Although our data do not supply a single definitive demonstration, our results converge to suggest that egg chromosomal anomalies may play a part in ectopic pregnancy aetiology.

The prevalence of colonic polyps in acromegaly: a colonoscopic and pathological study in 103 patients.

Patients with acromegaly are reported to be at risk of developing adenomatous colonic polyps, which are considered to be preneoplastic lesions. This assumption is, however, usually drawn from results obtained in rather small series of patients or without a control group. We, therefore, undertook a prospective colonoscopic and pathological study comprising 103 acromegalic patients and 138 nonacromegalic control subjects referred for irritable bowel syndrome. The prevalence of adenomatous colonic polyps was significantly increased in acromegalic patients compared to that in control subjects (22.3% vs. 8.0%; P = 0.0024). The significance was similarly present in male acromegalic patients (28.6% vs. 5.5% in male control subjects; P = 0.0026), but was absent in female acromegalic patients. The prevalence of colonic polyps was also significantly increased in the group of acromegalic patients under 55 yr of age (20.0% vs. 3.0% in the control group of the same age; P = 0.0026). Other characteristics of adenomatous colonic polyps in acromegaly were the multiplicity and the presence proximal to the splenic flexure. No difference in the duration of acromegaly was found between patients with or without adenomatous polyps. The prevalence of hyperplastic colonic polyps was also significantly increased to 24.3% in acromegalic patients vs 4.4% in control subjects (P < 0.001). In conclusion, in view of the increased incidence of adenomatous colonic polyps, colonoscopy should be part of the follow-up examination in acromegaly.