[Severe hyperthermia and neurological disorders following prostaglandin treatment for uterine atonia after caesarean section]. / Hyperthermie sévère et troubles neurologiques après administration de sulprostone dans un contexte d'atonie utérine post-césarienne.

Uterine atony is the most frequent cause of post-partum haemorrhage. In France, the management is based on early administration of oxytocic agents and prostaglandin analogues (sulprostone-Nalador®). We report the case of a 30-year-old woman who presented soon after administration of sulprostone, a severe hyperthermia with neurological disorders. A complete reversibility was observed a few hours after discontinuation of sulprostone administration. Other causes were eliminated by biological and radiological findings.

Incidence and management of postpartum haemorrhage following the dissemination of guidelines in a network of 16 maternity units in France.

BACKGROUND: In France obstetric haemorrhage is the leading cause of maternal death. The aim of this study was to evaluate if the management of postpartum haemorrhage at individual maternity units followed guidelines established by the Aurore Network. METHODS: A descriptive study was carried out in 16 maternity units of the Aurore network between October 2004 and September 2005. Cases and data were prospectively identified and collected. RESULTS: Postpartum haemorrhage occurred in 1144 of 21 350 deliveries, an overall incidence of 5.4+/-0.3%. Of these, 316 cases were rated as severe. Diagnosis was clinical in 82.5% of severe cases and 77.5% of non-severe cases; the remainder were detected by postpartum laboratory tests. Uterotonic agents were given prophylactically to 46.7% of the 896 patients following vaginal delivery. In cases in which postpartum haemorrhage was due to uterine atony, 83.1% of women underwent examination of the uterine cavity and 96.3% received oxytocin, which proved therapeutic. Sulprostone was administered to 39.5% cases of persistent postpartum haemorrhage. A uterotonic was given prophylactically to 85.4% of the 247 patients at caesarean delivery. Oxytocin was therapeutic in 94.8% of cases of uterine atony. Sulprostone was administered in 84.4% of cases of persistent postpartum haemorrhage. CONCLUSION: The regional guidelines issued by the Aurore network were only partially followed. More effective guideline dissemination and implementation is required to improve the prevention and management of confirmed haemorrhage.

[Color-codes implementation shortens the decision-to-delivery interval of emergency C-sections]. / La mise en oeuvre des codes "couleur" réduit le délai décision-naissance des césariennes urgentes.

OBJECTIVES: To assess the efficiency of a new tool designed to shorten the decision-to-delivery interval (DDI) for emergency C-sections (CS). MATERIALS AND METHODS: DDI comparisons during three 6-month periods in a third level maternity. In stage A we evaluated the spontaneous DDI, in stage B the DDI was measured after the introduction of a color-code communication tool related to the degree of urgency for CS (amber code indicated urgent CS with an ideal DDI of 30 min and red code for very urgent CS with an ideal DDI of 15 min). In stage C we assessed the impact of the color-codes related protocols implementation. RESULTS: Two hundred and fifty-three C-sections were included (211 urgent CS and 42 very urgent CS). Mean DDI decreased significantly from 42 min to 24 min between period A and period C for amber codes (corresponding to 43.2% and 82.1% of the objectives respectively) and from 24.9 min to 10.7 min for red codes (20% et 83.3% of the objectives). CONCLUSION: This study suggests that color-codes and their related application protocols significantly shorten the DDI during the evaluation periods.

[Amniotic fluid embolism: successful evolution course of isolated disseminated intravascular coagulation and early biological diagnosis]. / Embolie de liquide amniotique : évolution favorable d'une CIVD isolée et diagnostic biologique précoce.

Amniotic embolism is a sudden, unexpected and devastating complication of pregnancy. The diagnosis is usually made on the basis of clinical presentation after excluding differential diagnosis or at autopsy in the event of death of the parturient. We need to develop simple, non-invasive, sensitive tests for a reliable and early diagnosis. We report the case of a 34-year-old woman, who presented soon after delivery, an isolated disseminated intravascular coagulation with severe haemorrhage, an haemostatic hysterectomy was required. A 3370 g child was delivered by caesarean section. The patient survived without sequelae. The diagnosis of amniotic embolism was established by the presence of amniotic cells in the maternal central venous blood as well as in the bronchoalveolar fluid.

[Amniotic fluid embolism: a review]. / Embolie de liquide amniotique: mise au point.

Amniotic fluid embolism occurs rarely but is a leading cause of maternal mortality. It is a difficult and somewhat intangible diagnosis that warrants a high index of suspicion by physicians. AFE is an unpredictable, unpreventable, and, for the most part, an untreatable obstetric emergency. Management of this condition includes prompt recognition of the signs and symptoms, aggressive resuscitation efforts, and supportive therapy. Any delays in diagnosis and treatment can result in increased maternal and/or foetal impairment or death. Whereas once the invariable outcome of AFE was death of the mother, today the prognosis is somewhat brighter thanks to increased awareness of the syndrome and advances in intensive care medicine. No laboratory test is specific to attest the diagnosis and autopsy must to be realised in case of maternal death. Although non-specific, the diagnosis of AFE could be supported by the observation of amniotic fluid in the central venous blood as well as in the bronchoalveolar fluid. This easy and quick test will be helpful in decision-making. Prompt and aggressive supportive treatment is required to lessen an otherwise dismal outcome, which may include death and permanent disability. This article provides an account of the protean clinical features, pathogenesis, and principles involved in treatment.

[Decision-to-deliver interval for forceps delivery and cesarean section: 137 extractions for abnormal fetal heart rhythm during labor]. / Rapidité d'extraction respective des césariennes et des forceps réalisés en urgence: à propos de 137 extractions pour anomalies du rythme cardiaque foetal en cours de travail.

AIM: Comparison of the decision to delivery interval in cases of forceps delivery and in cases of cesarean sections. MATERIAL AND METHOD: A retrospective analysis was performed on 137 cases of forceps deliver (n = 63) and cesarean section (n = 74) indicated for abnormal fetal heart rhythm. All cases were observed in a level 3 maternity unit between October 2003 and August 2004. RESULTS: The mean decision-to-delivery interval was significantly shorter in the forceps group (14.84 min +/- 6.54 versus 29.31 min +/- 11.79 p < 0.0001). Maternal and neonatal morbidity were comparable. CONCLUSION: This study suggest that once the fetal head is engaged, forceps delivery can significantly reduced the decision-to-delivery interval.

Amniotic fluid embolism during caesarean section.

Amniotic fluid embolism occurs rarely but is a leading cause of maternal mortality. A high index of clinical suspicion is necessary to make an early diagnosis to reduce morbidity and mortality. We report a non-fatal case of amniotic fluid embolism occurring during a caesarean section, with special emphasis on the mode of development and diagnosis. The initial presentation of this syndrome was a coagulopathy, followed by the usual complications of massive bleeding. Although non-specific, the diagnosis of amniotic fluid embolism was supported by the observation of amniotic fluid in the central venous blood as well as in the broncho-alveolar fluid.

Evaluating the decision--to--delivery interval in emergency caesarean sections.

OBJECTIVE: To assess the interval between the decision to carry out an emergency caesarean section and delivery, and to determine whether this interval can be shortened. STUDY DESIGN: A retrospective study was performed in a French maternity hospital over a 6-month period. All caesarean sections performed during labour were included. These caesarean sections were divided into two groups according to Lucas's classification: (1) emergency and urgent caesarean sections and (2) scheduled caesarean sections. RESULTS: The mean decision--to--delivery interval was 39.5 min in the first group and 55.9 min in the second group. It was mainly influenced by the time taken to get the patient into theatre. The mean decision-to-operating theatre interval accounted for 45.6 and 53.8% of the mean decision-to delivery-interval, respectively. CONCLUSION: The recommended interval of 30 min is not routinely achieved. Improving communication within the perinatal team could decrease the decision--to--operating theatre interval and should be promoted.

[An unusual case of post partum haemorrhage: leptospirosis infection]. / Une cause inhabituelle d'hémorragie de la délivrance: la leptospirose.

We report the case of a 30-year-old woman with a post-partum haemorrhage and foetal death caused by a leptospirosis infection. This disease could induce a coagulopathy associated with foetal death and potential hazard for epidural analgesia.

Epidural analgesia with 0.15% ropivacaine plus sufentanil 0.5 microgram ml-1 versus 0.10% bupivacaine plus sufentanil 0.5 microgram ml-1: a double-blind comparison during labour.

BACKGROUND: Ropivacaine has been claimed to produce less motor block than bupivacaine during epidural analgesia. However, this advantage has not been clearly confirmed in obstetric studies using low analgesic concentrations in a ratio close to that suggested to be equianalgesic. METHODS: This double-blind, randomized, prospective study was performed in 140 parturients who requested epidural analgesia. After a lumbar epidural catheter had been placed, patients received either 0.10% bupivacaine plus sufentanil 0.5 microgram ml-1 or 0.15% ropivacaine plus sufentanil 0.5 microgram ml-1 followed by a continuous infusion. Additional boluses were used for inadequate levels of analgesia. Visual analogue pain scores, motor block, level of sensory block, supplementary boluses and main characteristics of labour were recorded. RESULTS: No differences were observed between the two groups for pain scores, total volume of anaesthetic solution used [59 (23) and 57 (24) ml in the bupivacaine and ropivacaine groups respectively], duration of labour, mode of delivery, side-effects or satisfaction score. The incidence of motor block was not statistically different between the groups (54 and 69% in the bupivacaine and ropivacaine groups respectively, P = 0.07). However, when motor block occurred, survival analysis showed that it occurred sooner in the course of labour with ropivacaine compared with bupivacaine (log rank test, P = 0.012). CONCLUSION: Combined with sufentanil 0.5 microgram ml-1, 0.10% bupivacaine and 0.15% ropivacaine produce effective and equivalent analgesia during labour, with similar incidences of motor block.

[Cerebral vascular malformations and pregnancy: obstetrical and anesthetic management]. / Malformations vasculaires cérébrales et grossesse: conduite à tenir obstétricale et anesthésique.

Obstetrical management of women known to have a cerebral vascular malformation is controversial. The risk of cerebral hemorrhage during pregnancy is difficult to assess. We report thirteen cases of pregnancy in women with known cerebral vascular malformations who had or had not undergone surgical treatment. The effect of pregnancy on these malformations and corresponding obstetrical care described in the literature were studied. Our conclusion is that the risk of bleeding from cerebral arteriovenous malformations is not significantly increased during pregnancy whereas the risk of cerebral hemorrhage is slightly increased at the end of pregnancy, but unchanged during labor and delivery, in women with arterial aneurysms. There is no reason to advise against pregnancy in most cases and vaginal delivery is often possible unless there is a risk of dystocia.

[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.

[Pregnancy and cystic fibrosis. A case history]. / Grossesse et mucoviscidose. A propos d'une observation.

The authors report a case of pregnancy in a patient suffering from moderately severe cystic fibrosis (the syndrome consisted of diffused obstruction in respiratory function with a vital capacity of 79% and the lowered blood oxygen level with arterial blood gas estimations; oxygen saturation was 94%). The condition was marked by temporary worsening during the pregnancy in which infective bronchitis supervened). She also threatened to go into early labour and did in fact deliver at 36 1/2 weeks of an infant which was normal for the duration of the maturity. The authors review previous known facts about cystic fibrosis. A study of the literature has made it possible to be more accurate in describing methods of ante natal diagnosis of the condition and ways of following the pregnancy and the illness as well as the woman's fertility and her ability to breast feed.

[Protein C deficiency and pregnancy. Apropos of 2 case reports]. / Déficit en protéine C et grossesse. A propos de deux observations.

Protein C is a protein found in the serum, dependent on vitamin K. It is a strong protection against venous thrombosis. Deficiency in protein C, whether constitutional or acquired, can give rise to thrombo-embolic accidents in young patients without any obvious triggering factor. The authors start by describing the physiological features of protein C. Deficiencies of this protein are transferred through a dominant autosome. Two cases are described where protein C deficiency occurred in pregnancy. This association has not been previously described. They then discuss the kinetics of protein C in pregnancy, at delivery and in the newborn. They then point out how important it is to treat with anticoagulants in prophylactic doses during the pregnancy. They use repeated doses of Heparin as an anticoagulant and for its antivitamin K action following the delivery. They give a list of precautions that have to be observed in this relay system which should be slow and carefully worked out later. Obstetrical observation has to look for the onset of pre-eclampsia and intra-uterine growth retardation due to placental microthrombi. The authors conclude, after pointing out the frequency and the seriousness of this condition, by proposing that it should systematically be looked for in families where there have been cases of thrombo-embolic accidents.

[Use of epidural and intrathecal opiates in obstetrics]. / Emploi des opiacés par voie périmédullaire en obstétrique.

The discovery of opiate receptors and naturally occurring opiate-like substances in the central nervous system started a new era in pain control. Epidural and spinal opiates have been increasingly used since 1979. However, applying these analgesic techniques in obstetrics has been criticized because of possible side-effects on the mother and foetus. In this literature survey, their advantages and disadvantages are analyzed. Maternal side-effects include pruritus, nausea, urinary retention, and, most of all, respiratory depression. As a general rule, these side-effects are greater with the intrathecal route, high doses, and the use of morphine. The effects on the course of labour are small, and neonatal status is not altered. Spinal and epidural opiates are efficient analgesic techniques for labour and caesarean section. They provide a dose-related, but not surgical, analgesia. Currently, there is a great deal of interest in mixtures of a diluted local anaesthetic agent and a lipophilic drug for use during labour or caesarean section. An opiate alone may not consistently provide satisfactory analgesia during labour, and it cannot be recommended for routine use, except for patients in whom the cardiovascular effects of routine regional anaesthesia are to be avoided. The choice of a lipid-soluble opiate like fentanyl is safe. However, when considering new drugs, great care must be taken to avoid unforeseen problems. A good knowledge of the problem and a cautious approach combined with careful monitoring of the respiratory rate and adequacy of ventilation are the keys to the safe use of spinal and epidural opiates.