Impact of intrauterine balloon tamponade on emergency peripartum hysterectomy following vaginal delivery.

OBJECTIVE: To assess the impact of intrauterine balloon tamponade as a second-line technique before resorting to emergency peripartum hysterectomy in cases with severe postpartum hemorrhage and uterotonic treatment failure following vaginal delivery. STUDY DESIGN: A retrospective, monocentric study evaluating cases of uterotonic treatment failure with severe postpartum hemorrhage following vaginal delivery between January 2005 and June 2018. Cases of cesarean section, amniotic embolism, uterine rupture, placenta accreta, and postpartum hemorrhage by vaginal laceration were excluded. The primary study outcome was incidence of emergency peripartum hysterectomy before and after use of intrauterine balloon tamponade was initiated. RESULTS: Among the 55,776 women who gave birth vaginally at our site during the study period, 161 (0.3 %) had severe postpartum hemorrhage with medical treatment failure (78 during the period prior to intrauterine balloon tamponade use, and 83 after intrauterine balloon tamponade use was initiated). The intrauterine balloon tamponade failure rate was 21.9 % (n = 18). Emergency peripartum hysterectomy was performed in 7 cases prior to intrauterine balloon tamponade use and 2 cases during use of intrauterine balloon tamponade. Thus, we observed a nonsignificant decrease in emergency peripartum hysterectomy after use of intrauterine balloon tamponade was implemented (9.0 % vs. 2.4 %, p = 0.09). However, the decrease was significant among patients who underwent conservative surgical treatment before intrauterine balloon tamponade use (53.8 % vs. 12.5 %, p = 0.041). CONCLUSIONS: Though we did not find a significant overall reduction in emergency peripartum hysterectomy following implementation of intrauterine balloon tamponade, there was a decrease in these cases when conservative surgical treatment was followed by intrauterine balloon tamponade.

[International and French maternal mortality]. / Mortalité maternelle en France et dans le monde.

International and French maternal mortality. Maternal mortality, defined as the death of a woman during pregnancy and 42 days following delivery, remains a major challenge to health systems worldwide and a known indicator of development. As did the Millennium Development Goal 5, France health ministry targeted a reduction in maternal mortality ratio. Organizations have been developed through the last decade to reach this objective: a triennial maternal deaths national enquiry analyzes the reported cases and evaluates the evitability of the event. Recommendations are produced regarding the major causes of maternal deaths. French maternal mortality ratio varies from 8 to 12 /100,000 births. The major causes are direct obstetric causes (postpartum hemorrhage, thromboembolism, amniotic fluid embolism and preeclampsia, but also rarely sepsis and anaesthesia). The major indirect obstetric causes are cardiopathies, vascular diseases and miscellaneous. Deaths may be due to non-obstetrical causes such as suicides and trauma. In France, the first cause of maternal death is postpartum hemorrhage that represented 33% of the mortality, two triennium ago. This rate have been reduced to 18% and the factors contributing to this reduction were 2004 PPH prevention and management practice guidelines publication updated in 2014 and their diffusion supported by the French society of Anesthesia Intensive Care (SFAR) and the French National Society of Gynecologists and Obstetricians (CNGOF) as well as the midwifes organizations. The perinatal health care networks were actors of this improvement in medical care practices and organization. However a large improvement margin exists to better reduce the maternal mortality ratio in our country.

Mortalité maternellle en France et dans le Monde. La mortalité maternelle est définie comme le décès d'une femme pendant la grossesse et dans les 45 jours suivant l'accouchement. Elle représente un indicateur de santé publique et de performance du système de soins dans le monde. À l'image de l'Organisation mondiale de la santé, la France s'est fixé pour objectif de réduire le taux de ces décès. Les moyens mis en oeuvre sont l'analyse des dossiers par une enquête nationale triennale, l'organisation des maternités en réseaux, l'édition et la diffusion de recommandations par les sociétés savantes et l'évaluation des pratiques professionnelles. Le taux de la mortalité maternelle en France se situe entre 8 et 12 pour 100 000 naissances. Les causes de ces décès peuvent être obstétricales directes (hémorragie du post-partum, maladie thromboembolique, prééclampsie, embolie amniotique, sepsis et complications anesthésiques). Elles peuvent être obstétricales indirectes (cardiopathies, accidents vasculaires cérébraux et autres causes diverses) ou non obstétricales (traumatismes ou suicides). La première cause de mort maternelle est l'hémorragie. Le taux de morts par hémorragie a été réduit de 33 à 18 %. Les facteurs qui ont contribué à réduire le nombre de ces décès sont l'édition en 2004 des recommandations de pratique clinique et la diffusion de ces recommandations par les sociétés savantes et les réseaux de santé en périnatalité, organisation créée à partir des décrets dits de périnatalité de 1998. Une marge de progrès reste possible en termes d'organisation des soins et de pratique clinique pour réduire la mortalité évitable.

Evaluation and management of postpartum hemorrhage: consensus from an international expert panel.

BACKGROUND: Postpartum hemorrhage (PPH) remains one of the leading causes of maternal morbidity and mortality worldwide, although the lack of a precise definition precludes accurate data of the absolute prevalence of PPH. STUDY DESIGN AND METHODS: An international expert panel in obstetrics, gynecology, hematology, transfusion, and anesthesiology undertook a comprehensive review of the literature. At a meeting in November 2011, the panel agreed on a definition of severe PPH that would identify those women who were at a high risk of adverse clinical outcomes. RESULTS: The panel agreed on the following definition for severe persistent (ongoing) PPH: "Active bleeding >1000 mL within the 24 hours following birth that continues despite the use of initial measures including first-line uterotonic agents and uterine massage." A treatment algorithm for severe persistent PPH was subsequently developed. Initial evaluations include measurement of blood loss and clinical assessments of PPH severity. Coagulation screens should be performed as soon as persistent (ongoing) PPH is diagnosed, to guide subsequent therapy. If initial measures fail to stop bleeding and uterine atony persists, second- and third-line (if required) interventions should be instated. These include mechanical or surgical maneuvers, i.e., intrauterine balloon tamponade or hemostatic brace sutures with hysterectomy as the final surgical option for uncontrollable PPH. Pharmacologic options include hemostatic agents (tranexamic acid), with timely transfusion of blood and plasma products playing an important role in persistent and severe PPH. CONCLUSION: Early, aggressive, and coordinated intervention by health care professionals is critical in minimizing blood loss to ensure optimal clinical outcomes in management of women with severe, persistent PPH.

Systematic use of carbetocin during cesarean delivery of multiple pregnancies: a before-and-after study.

PURPOSE: Cesarean deliveries of multiple pregnancies are associated with a high risk of hemorrhage. The aim of this study is to evaluate the efficacy of carbetocin administered systematically during cesarean deliveries of multiple pregnancies. METHODS: Single-center retrospective before-and-after study comparing the use of carbetocin to that of oxytocin during cesareans during two consecutive 6-month periods. A composite variable was predefined as the principal endpoint: any one or more of bleeding ≥1,500 mL, transfusion, hemoglobin reduction of 4 g/dL or more or operative intervention (surgery, embolization). RESULTS: In an intention-to-treat analysis, the comparison of the two groups (n = 24 before and n = 39 after) showed no difference for the occurrence of the composite variable (16.7 vs. 15.4 %, p = 0.89). Nor did the per-protocol analysis (n = 24 before and n = 27 after) differ for it (16.7 vs. 14.8 %, p = 0.86). Moreover, none of the secondary outcome measures studied-moderate blood loss, prescription of sulprostone, cell-saver use, and intravenous iron infusion-differed significantly between the two periods. CONCLUSION: In our population of multiple pregnancies delivered by cesarean, carbetocin did not appear more effective than oxytocin in preventing severe postpartum hemorrhage.

Development of a new model to investigate the fetal nociceptive pathways.

OBJECTIVE: The aim of the study was to develop an experimental model to investigate the fetal nociceptive pathways and fetal analgesia. METHODS: We tested the electromyographic (EMG) response from the biceps femoris to electrical stimulation of the sural nerve in chronically-prepared fetal lambs with and without sufentanil. RESULTS: An EMG response could be recorded 140 ms after the electrical stimulation above a threshold of current's intensity. The response presents the characteristics of a nociceptive flexion reflex. The reflex magnitude increased with the stimulus intensity. Sufentanil decreased the response. Bradycardia was noted 10 s after the stimulation and was not observed after sufentanilinfusion. Catecholamine concentrations were not altered by the stimulation. CONCLUSION: Our study shows that a nociceptive flexion reflex can be recorded in the ovine fetus. We suggest that this reflex can be used as a new tool to study the ontogenesis of the nociceptive pathways and the effects of analgesic drugs during fetal life.