[Maternal mortality by stroke in France 2016-2018]. / Mortalité maternelle par accident vasculaire cérébral en France 2016­2018.

Between 2016 and 2018, twenty maternal deaths were associated with a stroke. The 20 deaths whose main cause was stroke represent 7.4% of all maternal deaths, i.e. a maternal mortality ratio (MMR) of 0.9 per 100,000 live births (95%CI 0.6-1.3). Among the 20 stroke deaths, it was hemorrhagic in 17 cases (85%), ischemic in 2 cases, and due to thrombophlebitis in 1 case. Stroke occurred during pregnancy in 8 women (40%) - one case before 12 weeks, 3 cases between 28 and 32 weeks, and 4 cases between 34 and 40 weeks; in 3 cases the stroke occurred intrapartum, and for the other 9 cases (45%) the stroke occurred postpartum between Day 1 and Day 15. Care was assessed as non-optimal in 10/19 (56%) of cases but mortality as possibly avoidable in 24% of cases (4/17 cases with conclusion established by the CNEMM) and not established in two cases. The potentially improvable elements identified were a delay in carrying out initial brain imaging in three cases (one case antepartum, two cases postpartum) and insufficient hemodynamic monitoring in intensive care in one case.

[Maternal deaths and management by emergency departments in France 2016-2018]. / Mortalité maternelle et prise en charge par les services d'urgence en France 2016­2018.

In France, 272 maternal deaths occurred during the period 2016-2018, of which 131 were initially treated by healthcare professionals not specialized in obstetric. Fifty-six files were excluded because they did not concern emergency services or because there was insufficient data to allow analysis. Seventy-five cases of maternal deaths initially treated by emergency services (in-hospital emergency department [ED] or emergency medical ambulance [SAMU]) were analyzed. Fifty-six cases were treated by the SAMU and 22 by an ED (both in 3 cases). The causes of death were 20 cardiovascular events, 18 pulmonary embolisms, 9 neurological failures and 8 hemorrhagic shocks. The event occurred during pregnancy in 48 cases (64%) and during per or postpartum period in 27 cases (36%). The motivations for consultation at the ED were mainly pain (n=9), respiratory distress (n=6) or faintness (n=3). The reasons for calling emergency dispatching service (SAMU) were cardiorespiratory arrest in 32 cases (57%) and neurological failure (coma or status epilepticus) in 6 cases (11%). Among the 56 patients treated outside the hospital, 17 died on scene and 39 were transported to a resuscitation room (n=13), a specialized department (n=13), an obstetrics department (n=8) and less often in the ED (n=2). This was considered appropriate in 35 out of 39 cases (90%). Concerning the 75 files analyzed (ED and SAMU), death was considered unavoidable in 37 cases (49%) and potentially avoidable in 29 cases (38%) (maybe=23, probably=6). Avoidability could not be established in 9 cases. Among the 29 potentially avoidable deaths (38%), one of the criteria of avoidability concerned emergency services in 14 cases (ED=9, SAMU/SMUR=5, 18% of the files studied). ED's cares were considered optimal in 11 cases (50%) and non-optimal in 11 cases (50%). SAMU's cares were considered optimal in 45 cases (80%).

[Maternal mortality due to venous thromboembolism in France 2016-2018]. / Mortalité maternelle par thromboembolie veineuse en France 2016­2018.

Pregnancy and the post-partum period represent a thromboembolic risk situation, with pulmonary embolism (PE) remaining one of the leading causes of direct maternal deaths in developed countries. Between 2016 and 2018 in France, twenty maternal deaths were caused by venous thromboembolic complications (VTE), yielding a Maternal Mortality Ratio (MMR) of 0.9 per 100,000 live births (95%CI 0.6-1.3), with no change compared to the periods 2013-2015 or 2010-2012. Among these 20 deaths, 1 death was related to cerebral thrombophlebitis, and the remaining 19 were due to PE. Regarding the timing of death, 2 deaths occurred after an early termination of pregnancy, 40% (8/20) during an ongoing pregnancy, and 50% (10/20) in the post-partum period. Among the 20 VTE deaths, 20% (4/20) occurred outside of a healthcare facility (at home or in a public place). Among the nineteen cases with documented BMI, seven women had obesity (37%), three times more than in the population of parturients in France (11.8%, ENP 2016). Among the nineteen PE deaths and the case of cerebral thrombophlebitis, eleven were considered preventable, six possibly preventable (35%), two probably preventable (12%), and three preventability undetermined. The identified preventability factors were inadequate care and the patient's failure to interact with the healthcare system. From the case analysis, areas for improvement were identified, including insufficient consideration of major and minor risk factors, the early initiation of appropriate prophylactic treatment, and the absence of fibrinolysis in cases of s refractory cardiac arrest due to suspected PE.

[Indirect causes of maternal deaths (except stroke, cardiovascular diseases and infections) in France 2016-2018]. / Mortalité maternelle de causes indirectes (hors AVC, maladies cardiovasculaires et infections) en France 2016­2018.

Maternal deaths from indirect obstetric cause result from a preexisting condition or a condition that occurred during pregnancy without obstetric causes but was aggravated by the physiological effects of pregnancy. Twenty-nine deaths with an indirect cause related to a preexisting condition, excluding circulatory diseases or infections, were analysed by the expert committee. Pre-pregnancy pathology was documented in 16 women (epilepsy, n=7; amyloid angiopathy, n=1; Dandy-Walker syndrome, n=1; autoimmune diseases, n=3; diffuse infiltrative pneumonitis, n=1; thrombotic thrombocytopenic purpura, n=1; ovarian cancer in fragile X, n=1; major sickle cell disease, n=1). In 13 women, the pathology was unknown before pregnancy (breast cancer, n=9, epilepsy diagnosed during pregnancy, n=1, brain tumours, n=2 meningioma type, macrophagic activation syndrome, n=1). Death was associated with neoplastic or tumour pathology in 13 women (45%). At the same time, epilepsy was responsible for the death of 8 women (27%), making it the most common cause of death. For both neoplasia and epilepsy, about 50% of deaths were preventable, mainly due to undiagnosed and/or delayed treatment in the case of cancer and failure to monitor or adjust treatment in the case of epilepsy. Pre-conception counselling is therefore strongly recommended if a woman has a known chronic medical condition prior to pregnancy. Finally, if there is a family history of breast cancer, a breast examination is strongly recommended from the first visit during pregnancy, and any breast lumps should be investigated as soon as possible to avoid delaying appropriate treatment.

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.

Maternal Intensive Care Unit Admission as an Indicator of Severe Acute Maternal Morbidity: A Population-Based Study.

BACKGROUND: Severe acute maternal morbidity (SAMM) accounts for any life-threatening complication during pregnancy or after delivery. Measuring and monitoring SAMM seem critical to assessing the quality of maternal health care. The objectives were to explore the validity of intensive care unit (ICU) admission as an indicator of SAMM by characterizing the profile of women admitted to an ICU and of their ICU stay, according to the association with other SAMM criterion. METHODS: We performed a secondary analysis of the 2540 women with SAMM included in the epidemiology of severe acute maternal morbidity (EPIMOMS) multiregional prospective population-based study (2012-2013, n = 182,309 deliveries). The EPIMOMS definition of SAMM, based on national experts' consensus, is a combination of diagnosis, organ dysfunctions, and intervention criteria, including ICU admission. Among women with SAMM, we identified characteristics associated with maternal ICU admission with or with no other SAMM criterion compared with ICU admission, by using multivariable multinomial logistic regression models. RESULTS: Overall, 511 women were admitted to an ICU during or up to 42 days after pregnancy, for a population-based rate of 2.8 of 1000 deliveries (511/182,309; 95% confidence interval [CI], 2.6-3.1); 15.5% of them (79/511; 95% CI, 12.4-18.9) had no other SAMM criterion compared with ICU admission. Among women with SAMM, the odds of ICU admission with no other morbidity criterion were increased in women with preexisting medical conditions (adjusted odds ratio (aOR), 2.13; 95% CI, 1.17-3.86) and cesarean before labor (aOR, 3.12; 95% CI, 1.47-6.64). Women admitted to ICU with no other SAMM criterion had more often decompensation of a preexisting condition, no interventions for organ support, and a shorter length of stay than women admitted with other SAMM criteria. CONCLUSIONS: Among women with SAMM, 1 in 5 is admitted to an ICU; 15.5% of those admitted in ICU have no other SAMM criterion and a less acute condition. These results challenge the use of ICU admission as a criterion of SAMM.

Guidelines for the management of women with severe pre-eclampsia.

OBJECTIVE: To provide national guidelines for the management of women with severe pre-eclampsia. DESIGN: A consensus committee of 26 experts was formed. A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised. METHODS: The last SFAR and CNGOF guidelines on the management of women with severe pre-eclampsia were published in 2009. The literature is now sufficient for an update. The aim of this expert panel guidelines is to evaluate the impact of different aspects of the management of women with severe preeclampsia on maternal and neonatal morbidities separately. The experts studied questions within 7 domains. Each question was formulated according to the PICO (Patients Intervention Comparison Outcome) model and the evidence profiles were produced. An extensive literature review and recommendations were carried out and analysed according to the GRADE® methodology. RESULTS: The SFAR/CNGOF experts panel provided 25 recommendations: 8 have a high level of evidence (GRADE 1+/-), 9 have a moderate level of evidence (GRADE 2+/-), and for 7 recommendations, the GRADE method could not be applied, resulting in expert opinions. No recommendation was provided for 3 questions. After one scoring round, strong agreement was reached between the experts for all the recommendations. CONCLUSIONS: There was strong agreement among experts who made 25 recommendations to improve practices for the management of women with severe pre-eclampsia.

Time-frequency scattering accurately models auditory similarities between instrumental playing techniques.

Instrumentalplaying techniques such as vibratos, glissandos, and trills often denote musical expressivity, both in classical and folk contexts. However, most existing approaches to music similarity retrieval fail to describe timbre beyond the so-called "ordinary" technique, use instrument identity as a proxy for timbre quality, and do not allow for customization to the perceptual idiosyncrasies of a new subject. In this article, we ask 31 human participants to organize 78 isolated notes into a set of timbre clusters. Analyzing their responses suggests that timbre perception operates within a more flexible taxonomy than those provided by instruments or playing techniques alone. In addition, we propose a machine listening model to recover the cluster graph of auditory similarities across instruments, mutes, and techniques. Our model relies on joint time-frequency scattering features to extract spectrotemporal modulations as acoustic features. Furthermore, it minimizes triplet loss in the cluster graph by means of the large-margin nearest neighbor (LMNN) metric learning algorithm. Over a dataset of 9346 isolated notes, we report a state-of-the-art average precision at rank five (AP@5) of 99.0%±1. An ablation study demonstrates that removing either the joint time-frequency scattering transform or the metric learning algorithm noticeably degrades performance.

Efficient similarity-based data clustering by optimal object to cluster reallocation.

We present an iterative flat hard clustering algorithm designed to operate on arbitrary similarity matrices, with the only constraint that these matrices be symmetrical. Although functionally very close to kernel k-means, our proposal performs a maximization of average intra-class similarity, instead of a squared distance minimization, in order to remain closer to the semantics of similarities. We show that this approach permits the relaxing of some conditions on usable affinity matrices like semi-positiveness, as well as opening possibilities for computational optimization required for large datasets. Systematic evaluation on a variety of data sets shows that compared with kernel k-means and the spectral clustering methods, the proposed approach gives equivalent or better performance, while running much faster. Most notably, it significantly reduces memory access, which makes it a good choice for large data collections. Material enabling the reproducibility of the results is made available online.

Postpartum hemorrhage: guidelines for clinical practice from the French College of Gynaecologists and Obstetricians (CNGOF): in collaboration with the French Society of Anesthesiology and Intensive Care (SFAR).

Postpartum haemorrhage (PPH) is defined as blood loss ≥500mL after delivery and severe PPH as blood loss ≥1000mL, regardless of the route of delivery (professional consensus). The preventive administration of uterotonic agents just after delivery is effective in reducing the incidence of PPH and its systematic use is recommended, regardless of the route of delivery (Grade A). Oxytocin is the first-line prophylactic drug, regardless of the route of delivery (Grade A); a slowly dose of 5 or 10 IU can be administered (Grade A) either IV or IM (professional consensus). After vaginal delivery, routine cord drainage (Grade B), controlled cord traction (Grade A), uterine massage (Grade A), and routine bladder voiding (professional consensus) are not systematically recommended for PPH prevention. After caesarean delivery, placental delivery by controlled cord traction is recommended (grade B). The routine use of a collector bag to assess postpartum blood loss at vaginal delivery is not systematically recommended (Grade B), since the incidence of severe PPH is not affected by this intervention. In cases of overt PPH after vaginal delivery, placement of a blood collection bag is recommended (professional consensus). The initial treatment of PPH consists in a manual uterine examination, together with antibiotic prophylaxis, careful visual assessment of the lower genital tract, a uterine massage, and the administration of 5-10 IU oxytocin injected slowly IV or IM, followed by a maintenance infusion not to exceed a cumulative dose of 40IU (professional consensus). If oxytocin fails to control the bleeding, the administration of sulprostone is recommended within 30minutes of the PPH diagnosis (Grade C). Intrauterine balloon tamponade can be performed if sulprostone fails and before recourse to either surgery or interventional radiology (professional consensus). Fluid resuscitation is recommended for PPH persistent after first line uterotonics, or if clinical signs of severity (Grade B). The objective of RBC transfusion is to maintain a haemoglobin concentration (Hb) >8g/dL. During active haemorrhaging, it is desirable to maintain a fibrinogen level ≥2g/L (professional consensus). RBC, fibrinogen and fresh frozen plasma (FFP) may be administered without awaiting laboratory results (professional consensus). Tranexamic acid may be used at a dose of 1 g, renewable once if ineffective the first time in the treatment of PPH when bleeding persists after sulprostone administration (professional consensus), even though its clinical value has not yet been demonstrated in obstetric settings. It is recommended to prevent and treat hypothermia in women with PPH by warming infusion solutions and blood products and by active skin warming (Grade C). Oxygen administration is recommended in women with severe PPH (professional consensus). If PPH is not controlled by pharmacological treatments and possibly intra-uterine balloon, invasive treatments by arterial embolization or surgery are recommended (Grade C). No technique for conservative surgery is favoured over any other (professional consensus). Hospital-to-hospital transfer of a woman with a PPH for embolization is possible once hemoperitoneum is ruled out and if the patient's hemodynamic condition so allows (professional consensus).

Renal arteriovenous fistula revealed by severe hypertension during pregnancy.

A 35-year-old woman developed severe hypertension resistant to antihypertensive treatment during the second trimester of pregnancy at 24 weeks gestation. Doppler ultrasonography achieved the diagnosis of idiopathic renal arteriovenous fistula in the left kidney associated with parenchymal hypoperfusion. A Caesarean section was performed 6 days after the diagnosis because of severe pre-eclampsia. After delivery, the symptoms disappeared. Fistula persisted after follow-up for over 1 year but with a dramatic decrease in its blood flow and normalisation of the left kidney hemodynamics. Nevertheless, embolisation was performed without complications to prevent recurrence during the next pregnancy expected by the patient.

Diagnostic accuracy of insulin-like growth factor binding protein-1 for amniotic fluid embolism*.

OBJECTIVE: To test whether serum insulin-like growth factor binding protein-1 could be used as a biomarker of amniotic fluid passage into the maternal circulation. DESIGN: Case-control study. SETTING: Thirteen centers in France. PATIENTS: This case-control study included a group with amniotic fluid embolism (the amniotic fluid embolism group) and a group with symptoms unrelated to amniotic fluid embolism (the non-amniotic fluid embolism group). Serum insulin-like growth factor binding protein-1 level was measured within 6 hrs from onset of symptoms. We also determined serum insulin-like growth factor binding protein-1 in four additional groups of patients with 1) postpartum hemorrhage, 2) uncomplicated labor, 3) normal pregnancy, and 4) non-pregnant patients with acute pulmonary embolism. INTERVENTIONS: None. MEASUREMENTS: Serum insulin-like growth factor binding protein-1 levels were determined using an immuno-enzymatic assay. MAIN RESULTS: The amniotic fluid embolism group included 25 patients, the non-amniotic fluid embolism group had 20 patients, the postpartum hemorrhage group had 24 patients, and the uncomplicated labor group had 50 patients. The serum levels of insulin-like growth factor binding protein-1 were higher in the amniotic fluid embolism group (234 134-635 µmol/L) compared with the non-amniotic fluid embolism, postpartum hemorrhage, and uncomplicated labor groups, which had serum levels of 56 36-91 µmol/L, 65 39-91 µmol/L and 49 30-78 µmol/L, respectively (p < .001). Serum insulin-like growth factor binding protein-1 level was not different in women during normal pregnancy (57 37-85 µg/L) compared to the uncomplicated labor group. Patients with acute pulmonary embolism had the lowest insulin-like growth factor binding protein-1 level (5 2-14 µg/L). The area under the receiver-operating-characteristic curve for serum insulin-like growth factor binding protein-1 was 0.98 0.97-1.00 for the amniotic fluid embolism diagnostic. Insulin-like growth factor binding protein-1 rose from 56 43-90 µg/L before symptoms to 458 161-1514 µg/L after the onset of symptoms in ten patients with available measurements of baseline serum insulin-like growth factor binding protein-1. CONCLUSION: Increased serum levels of insulin-like growth factor binding protein-1 appear to be a valuable biomarker of amniotic fluid passage into the maternal circulation and may be used to diagnose amniotic fluid embolism.

Uterine conservation despite severe sepsis in a case of placenta accreta first treated conservatively: 3-month delayed successful removal of the placenta.

OBJECTIVE: To report a case of successful delayed removal of a placenta accreta first treated conservatively. Secondary infectious complications can occur after conservative management in cases of placenta accreta, most often leading to hysterectomy. DESIGN: Case report. SETTING: A French teaching hospital. PATIENT(S): A 33-year-old woman. INTERVENTION(S): A healthy 33-year-old woman underwent Cesarean section for her first pregnancy. Diagnosis of placenta accreta was made at ultrasound scanning for her second pregnancy. She was first treated conservatively. Hysterectomy was planned 3 months after conservative treatment because of sepsis attributed to uterine retention. (Hysterotomy was first realized.)-?? MAIN OUTCOME MEASURE(S): Uterine conservation. RESULT(S): The placenta was easily and successfully removed with no subsequent bleeding. The uterus was sutured and conserved. CONCLUSION(S): In cases of delayed sepsis because of uterine retention after conservative treatment for placenta accreta, when medical treatment remains unsuccessful, manual removal of the placenta should be attempted. This approach might allow improved uterine conservation rates in women with placenta accreta treated conservatively.

High incidence of myocardial ischemia during postpartum hemorrhage.

BACKGROUND: Postpartum hemorrhage remains a major cause of global maternal morbidity and mortality, even in developed countries, despite the use of intensive care units. This study sought to (1) assess whether myocardial ischemia could be associated with and even aggravate hemorrhagic shock in young parturients admitted for postpartum hemorrhage, and (2) identify the independent risk factors for myocardial ischemia. METHODS: On their referral to the intensive care unit, a multidisciplinary team managed parturients with severe postpartum hemorrhage. Ventilation, transfusion, catecholamines, surgery, or angiography with uterine embolization were provided as clinically indicated. Plasma cardiac troponin I levels were used as a surrogate marker of acute myocardial injury and electrocardiograms of myocardial ischemia. RESULTS: A total of 55 parturients were referred with severe postpartum hemorrhage, all in hemorrhagic shock. Twenty-eight parturients (51%) had elevated serum levels of cardiac troponin I (9.4 microg/l [3.7-26.6 microg/l]), which were associated with electrocardiographic signs of ischemia and deteriorated myocardial contractility and correlated with the severity of hemorrhagic shock. Indeed, multivariate analysis identified low systolic and diastolic arterial blood pressure (< 88 and < 50 mmHg, respectively) and increased heart rate (> 115 beats/min) as independent predictors of myocardial injury. In addition, all patients who were given catecholamines also had elevated cardiac troponin I levels. CONCLUSIONS: These results suggest that treatment of postpartum hemorrhage-induced hemorrhagic shock should be coupled with concomitant prevention of myocardial ischemia, even in young parturients.

Association between a genomic polymorphism within the CD14 locus and septic shock susceptibility and mortality rate.

OBJECTIVE: Genetic differences in immune responses may affect susceptibility to and outcome of septic shock. CD14 seems to be an important part of the innate immune system, initiating antimicrobial response. We evaluated the frequency of a recently discovered CD14 promoter gene polymorphism (C to T transition at base pair -159) among patients with septic shock compared with those in a control group. DESIGN: Multiple-center study. SETTING: Hospital research department. PATIENTS: Ninety consecutive white patients with septic shock were included. The control group consisted of 122 age- and gender-matched white subjects. INTERVENTIONS: In both groups, the C-159T CD14 promoter genetic polymorphism was determined by using polymerase chain reaction and subsequent Hae III restriction enzyme digestion of the polymerase chain reaction products. MEASUREMENTS AND MAIN RESULTS: The C-159T polymorphism and the TT genotype were significantly overrepresented among septic shock patients compared with controls. Within the septic shock group, the mortality of patients with TT genotype (71%) was significantly higher than in patients with other genotypes (48%; Pearson chi-square, p =.008). In a multiple logistic regression model, the TT genotype was independently associated with an increased relative risk of death (odds ratio, 5.30; 95% confidence interval, 1.20-22.50, p =.02). CONCLUSIONS: The C-159T polymorphism affects susceptibility to septic shock and seems to be a new genetic risk factor for death.