Severe postpartum hemorrhage and the risk of adverse maternal outcome: A comparative analysis of two population-based studies in France and the Netherlands.

Objectives: Among women with severe PPH (sPPH) in France and the Netherlands, we compared incidence of adverse maternal outcome (major obstetric hemorrhage (≥2.5L blood loss) and/or hysterectomy and/or mortality) by mode of delivery. Second, we compared use and timing of resuscitation and transfusion management, second-line uterotonics and uterine-sparing interventions (intra-uterine tamponade, compression sutures, vascular ligation, arterial embolization) by mode of delivery. Methods:  Secondary analysis of two population-based studies of women with sPPH in France and the Netherlands. Women were selected by a harmonized definition for sPPH: (total blood loss ≥ 1500 ml) AND (blood transfusion of ≥ 4 units packed red blood cells and/or multicomponent blood transfusion). Findings: Incidence of adverse maternal outcome after vaginal birth was 793/1002, 9.1 % in the Netherlands versus 88/214, 41.1 % in France and 259/342, 76.2% versus 160/270, 59.3% after cesarean. Hemostatic agents such as fibrinogen were administered less frequently (p < 0.001) in the Netherlands (vaginal birth: 83/1002, 8.3% versus 105/2014, 49.5% in France; cesarean: 47/342, 13.7% and 152/270, 55.6%). Second-line uterotonics were started significantly later after PPH-onset in the Netherlands than France (vaginal birth: 46 versus 25 min; cesarean: 45 versus 18 min). Uterine-sparing interventions were less frequently (p < 0.001) applied in the Netherlands after vaginal birth (394/1002,39.3 %, 134/214, 62.6%) and cesarean (133/342, 38.9 % and 155/270, 57.4%), all initiated later after onset of refractory PPH in the Netherlands. Interpretation: Incidence of adverse maternal outcome was higher among women with sPPH in the Netherlands than France regardless mode of birth. Possible explanatory mechanisms are earlier and more frequent use of second-line uterotonics and uterine-sparing interventions in France compared to the Netherlands.

Binational confidential enquiry of maternal deaths due to postpartum hemorrhage in France and the Netherlands: Lessons learned through the perspective of a different context of care.

OBJECTIVE: To learn lessons for maternity care by scrutinizing postpartum hemorrhage management (PPH) in cases of PPH-related maternal deaths in France and the Netherlands. METHODS: In this binational Confidential Enquiry into Maternal Deaths (CEMD), 14 PPH-related maternal deaths were reviewed by six experts from the French and Dutch national maternal death review committees regarding cause and preventability of death, clinical care and healthcare organization. Improvable care factors and lessons learned were identified. CEMD practices and PPH guidelines in France and the Netherlands were compared in the process. RESULTS: For France, new insights were primarily related to organization of healthcare, with lessons learned focusing on medical leadership and implementation of (surgical) checklists. For the Netherlands, insights were mainly related to clinical care, emphasizing hemostatic surgery earlier in the course of PPH and reducing the third stage of labor by prompter manual removal of the placenta. Experts recommended extending PPH guidelines with specific guidance for women refusing blood products and systematic evaluation of risk factors. The quality of CEMD was presumed to benefit from enhanced case finding, also through non-obstetric sources, and electronic reporting of maternal deaths to reduce the administrative burden. CONCLUSION: A binational CEMD revealed opportunities for improvement of care beyond lessons learned at the national level.

Recurrence of hypertensive disorders of pregnancy: results from a nationwide prospective cohort study (CONCEPTION).

OBJECTIVE: To assess the risk of gestational hypertension (GH) and pre-eclampsia (PE) during a second pregnancy after occurrence during a first pregnancy. DESIGN: Prospective cohort study. SETTING: CONCEPTION is a French nationwide cohort study that used data from the National Health Data System (SNDS) database. METHODS: We included all women who gave birth for the first time in France in 2010-2018 and who subsequently gave birth. We identified GH and PE through hospital diagnoses and the dispensing of anti-hypertensive drugs. The incidence rate ratios (IRR) of all hypertensive disorder of pregnancy (HDP) during the second pregnancy were estimated using Poisson models adjusted for confounding. MAIN OUTCOME MEASURES: Incidence rate ratios of HDP during the second pregnancy. RESULTS: Of the 2 829 274 women included, 238 506 (8.4%) were diagnosed with HDP during their first pregnancy. In women with GH during their first pregnancy, 11.3% (IRR 4.5, 95% confidence interval [CI] 4.4-4.7) and 3.4% (IRR 5.0, 95% CI 4.8-5.3) developed GH and PE during their second pregnancy, respectively. In women with PE during their first pregnancy, 7.4% (IRR 2.6, 95% CI 2.5-2.7) and 14.7% (IRR 14.3, 95% CI 13.6-15.0) developed GH and PE during their second pregnancy, respectively. The more severe and earlier the PE during the first pregnancy, the stronger the likelihood of having PE during the second pregnancy. Maternal age, social deprivation, obesity, diabetes and chronic hypertension were all associated with PE recurrence. CONCLUSION: These results can guide policymaking that focuses on improving counselling for women who wish to become pregnant more than once, by identifying those who would benefit more from tailored management of modifiable risk factors, and heightened surveillance during post-first pregnancies.

[Screening and healthcare for pregnant women with psycho-social vulnerability : A French national study]. / Dépistage et parcours de soins en cas de vulnérabilités psycho-sociales maternelles : une enquête nationale française.

INTRODUCTION: Psycho-social vulnerabilities are a medical risk factor for both fetus and mother. Association between socioeconomic status and prenatal follow-up has been well established and inadequate follow-up is associated with higher morbidity and mortality in women in unfavorable situations. OBJECTIVE: The objective is to identify screening strategies and to describe existing systems for pregnant women in psycho-social vulnerability in French maternity hospitals. MATERIAL AND METHODES: This is a national survey conducted by questionnaire in all French maternities. RESULTS: Screening by means of targeted questions is carried out by 96.7% of maternity units. Early prenatal interviews are offered systematically by 64% of maternity units and access to them is still difficult for women in vulnerable situations. In order to organize care pathways, 28.7% of maternities have a structured unit within their establishment and 81% state that they have mobilizable caregivers. Multidisciplinary meetings for the coordination of the various stakeholders are held by 85.8% of maternity units. Collaboration with networks and associations is emphasized. CONCLUSION: A large proportion of maternities seek to identify women in situation of psycho-social vulnerabilities and to organize care paths. However, the resources implemented still appear insufficient for many maternity units. Each maternity hospital has resources and is developing initiatives to deal with the difficulties of care.

[Perinatal maternal suicide: How to prevent?] / Suicide maternel périnatal : comment prévenir ?

The sixth report of the National Confidential Survey on Maternal Deaths provides insights into the frequency, risk factors, causes, adequacy of care, and preventability of maternal deaths occurring in 2013-2015 in France. The method developed ensures an exhaustive identification and a confidential analysis of maternal deaths. It was organized in three steps. 1) All deaths occurring during pregnancy or up to 1 year after its end, whatever the cause or mode of termination, being considered 2) A pair of volunteer assessors (midwives, gyneco-obstetricians, anesthesiologists, psychiatrists) was in charge of collecting the information (history of the woman, course of her pregnancy, circumstances of the event that led to the death and management); 3) Review and classification of deaths by the National Committee of Experts on Maternal Mortality which made a collective judgment on the cause of death, on the adequacy of the care provided, and on what could been done to avoid the death depending on the existence of circumstances that could have prevented the fatal outcome. The operation of the committee has been enriched by new resources to further explore these cases. Specifically, a module of the survey questionnaire, the recruitment of psychiatrists whose contribution allows relevant documentation of the suicides, and the participation of a psychiatrist as an associate expert for the analysis of the appropriateness of the management and the variable determining factors of these cases. Suicide becomes one of the two main causes of maternal mortality, (the other cause being cardiovascular pathologies), with 35 suicides on the triennium among the 262 maternal deaths, that is to say 13.4 % of maternal deaths, about 1 per month. In this population, the average age of women who died by suicide was 31.4years. The majority of the women were born in France, 68 % were prima parous, and in 9 % of cases suicide followed a twin pregnancy. Psychiatric history was known in 33.3 % of the suicidal mothers, and 30.3 % had a history of psychiatric care that was unknown to the maternity team.43 % of the women had psychosocial vulnerability factors, a history of violence, and eviction from the home and/or financial difficulties. In 23 % of the cases, the time of occurrence of these suicides was within the first 42days postpartum, and in 77 % between 43 days and one year after birth with a median delay of 126days. Only one suicide occurred during pregnancy. Maternal suicides were mostly violent deaths. Suboptimal care was present in 72 % of cases, where 91 % of potentially preventable deaths related to a lack of multidisciplinary management and/or inadequate interaction between the patient and the health care system. Among these potentially avoidable deaths, we were able to distinguish: women whose psychiatric pathology was known and for whom multidisciplinary management was not optimal, and women whose psychiatric pathology was not known or was not present - for whom it was rather a matter of a failure to detect and identify the signs, particularly by obstetric care providers or general emergency services. Based on the analysis of the cases, strong messages were identified, with the aim of optimizing management: - The screening by structured questioning of psychiatric history from the moment of registration in the maternity ward, repeated at each consultation throughout the pregnancy. - The reassessment of the psychological and somatic state through an early postnatal interview at one month; - The identification of warning symptoms, with screening tools for depression. If necessary, a further recourse to the psychologist and/or psychiatrist of the maternity hospital, organisation of a home hospitalization, and a private midwife to provide a link in the pre- and postpartum period. This, in addition to the earliest possible care in the PMI (Maternal and Infantile Protection, of the French social care system), appointments with mental health professionals,and the link with the attending physician; - The implementation of a coordinated care pathway in case of a known psychiatric pathology with pre conception counselling. This includes a multidisciplinary collaboration, an adaptation of psychotropic treatment, management of comorbidities referral to specialized perinatal psychopathology teams, prenatal meeting with the pediatrician of the maternity hospital, anticipation of the birth, postpartum and discharge options, liaison sheet established for the organization of the delivery and postpartum, and a regular written transmissions between the intervening parties throughout the care; - The generalization of medico-psycho-social staffs, in maternity wards, for all situations identified as at risk. In addition to the need for training and increased awareness on psychological issues during the perinatal period and on the different pathologies encountered by adult mental health professionals and front-line workers, it is necessary to encourage the development of resources in the country. Particularly, joint child psychiatrist-adult psychiatrist consultations at the territorial level, responsible for being resource contacts for maternity wards and local care professionals, as well as the promotion of case pathway referrals.

Clinical profiles of placenta accreta spectrum: the PACCRETA population-based study.

OBJECTIVE: To describe and compare the characteristics of women with placenta accreta spectrum (PAS) and their pregnancy outcomes according to the presence of placenta praevia and a prior caesarean section. DESIGN: Prospective population-based study. SETTING: All 176 maternity hospitals of eight French regions. POPULATION: Two hundred and forty-nine women with PAS, from a source population of 520 114 deliveries. METHODS: Women with PAS were classified into two risk-profile groups, with or without the high-risk combination of placenta praevia (or an anterior low-lying placenta) and at least one prior caesarean. These two groups were described and compared. MAIN OUTCOME MEASURES: Population-based incidence of PAS, characteristics of women, pregnancies, deliveries and pregnancy outcomes. RESULTS: The PAS population-based incidence was 4.8/10 000 (95% CI 4.2-5.4/10 000). After exclusion of women lost to follow up from the analysis, the group with placenta praevia and a prior caesarean included 115 (48%) women and the group without this combination included 127 (52%). In the group with both factors, PAS was more often suspected antenatally (77% versus 17%; P < 0.001) and more often percreta (38% versus 5%; P < 0.001). This group also had more hysterectomies (53% versus 21%, P < 0.001) and higher rates of blood product transfusions, maternal complications, preterm births and neonatal intensive care unit admissions. Sensitivity analysis showed similar results after exclusion of women who delivered vaginally. CONCLUSION: More than half the cases of PAS occurred in women without the combination of placenta praevia and a prior caesarean delivery, and these women had better maternal and neonatal outcomes. We cannot completely rule out that some of the women who delivered vaginally had placental retention rather than PAS; however, we found similar results among women who delivered by caesarean. TWEETABLE ABSTRACT: Half the women with PAS do not have both placenta praevia and a prior caesarean delivery, and they have better maternal outcomes.

Gestational anaemia and severe acute maternal morbidity: a population-based study.

Anaemia is frequently diagnosed during pregnancy. However, there are few data regarding its incidence, and the association with severe maternal morbidity remains uncertain and potentially biased in high-resource countries. The purpose of this study was to explore the association between gestational anaemia and severe acute maternal morbidity during and after delivery. We performed a cohort-nested case-control analysis from the epidemiology of severe maternal mortality (EPIMOMS) prospective study conducted in six French regions (2012-2013, n = 182,309 deliveries). There were 1669 women with severe acute maternal morbidity during or after delivery, according to a standardised definition obtained by expert consensus. The control group were randomly selected among women without severe morbidity who delivered in the same health centres (n = 3234). We studied the association between gestational anaemia and severe acute maternal morbidity during or after delivery overall, by cause, and by mode of delivery, using multivariable logistic regression and multiple imputation. Gestational anaemia was significantly more frequent in women with severe acute maternal morbidity (25.3%) than in controls (16.3%), p < 0.001, and mostly mild in both groups. After adjustment for confounders, women with gestational anaemia were at increased risk of overall severe acute maternal morbidity during and after delivery (adjusted OR (95%CI) 1.8 (1.5-2.1)). This association was also found for severe postpartum haemorrhage (adjusted OR (95%CI) 1.7 (1.5-2.0)), even after omitting the transfusion criterion (adjusted OR (95%CI) 1.9 (1.6-2.3)), and for severe acute maternal morbidity secondary to causes other than haemorrhage or pregnancy-related hypertensive disorders (adjusted OR (95%CI) 2.7 (1.9-4.0)). These results highlight the importance of optimising the diagnosis and management of anaemia during pregnancy.

An economic evaluation of tranexamic acid to prevent postpartum haemorrhage in women with vaginal delivery: the randomised controlled TRAAP trial.

OBJECTIVE: To estimate the cost-effectiveness of tranexamic acid (TXA) use to prevent postpartum haemorrhage. DESIGN: A trial-based economic evaluation. SETTING: Fifteen French university maternity hospitals. POPULATION: Women enrolled in the TRAAP randomised controlled trial comparing TXA versus placebo in women with vaginal delivery. TRAAP failed to show a reduction in postpartum haemorrhage of at least 500 ml in the intervention arm but evidenced significant lower rates of secondary outcomes related to blood loss. METHODS & MAIN OUTCOME MEASURES: We estimated direct medical costs from within-trial hospital resources collected prospectively from the study report form. All resources were costed at their value to the hospital. We estimated incremental cost per incremental haemorrhage averted. RESULTS: Among the 4079 women in the TRAAP trial, data necessary to calculate costs were available for 3836 (94.0%). The average total costs in the TXA and control groups were €2278 ± 388 and €2288 ± 409 per woman, respectively (P = 0.79). In women with postpartum haemorrhage of at least 500 ml (trial primary endpoint), costs were €2359 ± 354 and €2409 ± 525 (P = 0.14); for provider-assessed clinically significant postpartum haemorrhage and postpartum haemorrhage of at least 1000 ml, costs were respectively €2316 ± 347 versus €2381 ± 521 (P = 0.22) and €2321 ± 318 versus €2411 ± 590 (P = 0.35) in the tranexamic and placebo groups, respectively. The probabilistic sensitivity analysis showed that the use of TXA had a 65-73% probability of saving costs and improving outcome. CONCLUSIONS: Our findings support the use of TXA, as both bleeding events and cost may be reduced three out of four times. TWEETABLE ABSTRACT: Tranexamic acid at vaginal delivery reduces both costs and bleeding events 3 times out of 4.

[Maternal deaths due to suicide in France 2013-2015]. / Mortalité maternelle par suicide en France 2013­2015.

Pregnancy represents a period of significant psychological vulnerability for women. During the perinatal period, twenty percent of them would present with mental disorders ranging from anxiety to depression. In those with pre-existing mental illness, the risk of acute decompensation is significant. For this reason, the World Health Organization recommends classifying suicides occurring during pregnancy and up to one-year post-partum as maternal deaths. Thus, between 2013 and 2015, 35 maternal suicides occurred in France, representing a maternal mortality ratio of 1:4 per 100,000 live births (95% CI: 1.0-2.0). By constituting 13.4% of all maternal deaths for the period, this group is the one of the 2 leading causes of maternal mortality. A total of 23% occurred in the first 42 days post-partum, and 77% between 43 days and one year after birth. 33.3% of the suicidal mothers had a known psychiatric history and 30.3% had a history of psychiatric care, unknown to obstetrical teams. Non-optimal care was present in 72% of cases with 91 % of suicides were potentially preventable, preventability factors beinga lack of multidisciplinary care and inadequate interaction between the patient and the care system. Strong messages were drawn from the analysis of these cases to optimize care: improve knowledge of the psychiatric history from the time of enrolment in maternity units, improve the identification of warning symptoms and the use of the psychologist and/or psychiatrist, set up a specific care pathway and multidisciplinary collaboration in case of known psychiatric disease.

[Maternal Mortality, Frequency, causes, women's profile and preventability of deaths in France, 2013-2015]. / Mortalité Maternelle, Fréquence, causes, profil des femmes et évitabilité des décès en France 2013­2015.

OBJECTIVE: To describe, for the 2013-2015 period, the frequency, causes, risk factors, adequacy of care and preventability of maternal deaths in France. METHOD: Data from the National Confidential Enquiry into Maternal Deaths for 2013-2015. RESULTS: For the period 2013-2015, 262 maternal deaths occurred in France, one every four days, i.e a maternal mortality ratio of 10.8 per 100,000 live births (95 % CI 9.5-12.1), stable compared to 2010-2012. Compared to women aged 25-29, the risk is multiplied by 1.9 for women aged 30-34, by 3 for women aged 35-39 and by 4 for women aged 40 and over. Obese women are twice as frequent among maternal deaths (24 %) than in the general population of parturients (11 %). There are territorial disparities - the maternal mortality ratio in the French overseas departments is 4 times higher than in metropolitan France -, and social disparities - the mortality of migrant women remains higher than that of women born in France, particularly for women born in sub-Saharan Africa whose risk is 2.5 times higher than that native women. A striking result of the 2013-2015 period is the preponderance of suicides and cardiovascular diseases, the two leading causes of maternal mortality, each responsible for approximately one death per month. These two etiologies are not only the most frequent, but also among those with the highest proportion of preventable deaths, 91.3 % and 65.7 % respectively. Another important result is the continued decrease in mortality from obstetric haemorrhage, halved in 15 years, particularly the decrease n hemorrhages due to uterine atony. Overall, 57.8 % of maternal deaths are considered probably or possibly preventable and in 66 % of cases, the care provided was not optimal. CONCLUSION: While the overall maternal mortality ratio remains stable overall, and territorial and social inequalities unchanged, the profile of the causes of maternal mortality is changing. Some developments are a success, such as the continued decrease in maternal mortality due to haemorrhage, the result of the general mobilisation of health actors on this issue. Others point to new priorities for mobilisation, in particular on the mental and cardiovascular health of women during pregnancy or in the year following childbirth. In order to go further in understanding the mechanisms involved, and to identify precise avenues for prevention, it is necessary to analyse in detail the stories of each maternal death in order to identify the opportunities for improvement repeatedly found in the series of deaths. This is what the following articles in this issue propose, with an analysis by cause of death.

[Enhanced system for maternal mortality surveillance in France, context and Methods]. / Enquête Nationale Confidentielle sur les Morts Maternelles en France, contexte et méthode.

Maternal mortality, despite its rarity in rich countries, remains a fundamental indicator of maternal health. It is considered as a "sentinel event", consequence of dysfunctions of the health care system, often cumulative. In addition to the classical epidemiological surveillance outcomes-number of deaths, maternal mortality ratio and identification of the subgroups of women at higher risk-its study allows an accurate analysis of each deceased woman's trajectory to identify opportunities for improvements in the content or organization of care; the correction of which will make it possible to prevent deaths but also upstream morbid events affected by the same dysfunctions. To achieve this dual epidemiological and clinical audit objective, an ad hoc enhanced system is needed. France has had such a system since 1996, the National Confidential enquiry into maternal deaths (ENCMM), coordinated by the Inserm Epopé team. The methodology has been adapted over time to improve completeness and better document cases. The first step is the multi-source identification (direct declaration, death certificate, birth certificates, hospital discharge data) of women who died during pregnancy or within one year of its end, in metropolitan France and overseas departments. The second step is the collection of detailed information for each death by a pair of clinical assessors. Recent evolutions aim to better document the social context of women as well as the background of women who have died of suicide. Psychiatrists have been included among the assessors. The third stage is the review of these anonymized documents by the National Committee of Experts on Maternal Mortality, which judges whether the death is maternal (causal link) and makes a judgment on the adequacy of care and avoidability of death. A psychiatrist is now associated to the CNEMM for the assessment of maternal suicides. The synthesis of the information thus collected for maternal deaths in the period 2013-2015 is presented in these articles of this special issue.

Anaphylaxis in pregnancy: a population-based multinational European study.

Anaphylaxis in pregnancy is a rare but severe complication for both mother and infant. Population-based data on anaphylaxis in pregnancy are lacking from mainland European countries. This multinational study presents the incidence, causative agents, management and maternal and infant outcomes of anaphylaxis in pregnancy. This descriptive multinational study used a combination of retrospective (Finnish medical registries) and prospective population-based studies (UK, France, Belgium and the Netherlands) to identify cases of anaphylaxis. Sixty-five cases were identified among 4,446,120 maternities (1.5 per 100,000 maternities; 95%CI 1.1-1.9). The incidence did not vary between countries. Approximately three-quarters of reactions occurred at the time of delivery. The most common causes were antibiotics in 27 women (43%), and anaesthetic agents in 11 women (17%; including neuromuscular blocking drugs, 7), which varied between countries. Anaphylaxis had very poor outcomes for one in seven mothers and one in seven babies; the maternal case fatality rate was 3.2% (95%CI 0.4-11.0) and the neonatal encephalopathy rate was 14.3% (95%CI 4.8-30.3). Across Europe, anaphylaxis related to pregnancy is rare despite having a multitude of causative agents and different antibiotic prophylaxis protocols.

A population-based analysis of French transfusion practices for women experiencing severe postpartum hemorrhage.

BACKGROUND: Transfusion is a major therapy for severe postpartum hemorrhage but there are few population-based descriptions of practice. The objective of this retrospective French population-based study was to describe transfusion practices in women with severe postpartum hemorrhage and the compliance with guidelines. METHODS: Study data were sourced from a prior prospective population-based study of 182 309 deliveries in France between 2012 and 2013. Transfusion practices and compliance with French national guidelines were described for all women with severe postpartum hemorrhage who had been transfused with red blood cells. RESULTS: In 1495 women with severe postpartum hemorrhage (0.8% of all deliveries), 35.1% were not transfused, 50.0% were transfused during active bleeding and 14.9% exclusively after control of bleeding. Among 697 women with a hemoglobin level <7 g/dL, 21.4% were not transfused. In 747 women transfused during active bleeding, 68.8% also received fresh frozen plasma (fresh frozen plasma to red blood cell ratio between 0.5 and 1 in 80.4%). Forty-four percent received fibrinogen concentrate (including 37.4% with a plasma fibrinogen level >2 g/L) and 8.6% had a massive transfusion. Among 223 women transfused after bleeding was controlled, 5.4% received fresh frozen plasma and 13% had a hemoglobin level >7 g/dL. CONCLUSIONS: One in five women with severe postpartum hemorrhage and a low hemoglobin concentration did not receive blood transfusion, which does not comply with French national recommendations. Over-transfusion occurred in women in whom bleeding had been controlled. The use of tools to help clinicians with transfusion decision-making should be developed.

[CNGOF Guidelines for Clinical Practice: Revision of the Methodology]. / Recommandations pour la pratique clinique du CNGOF : révision méthodologique du processus d'élaboration.

OBJECTIVES: To revise the organization and the methodology of the Practice Clinical Guidelines (PCG) of the French College of Gynecologists and Obstetricians (CNGOF). METHODS: The different available methods of PCG organization and of scientific evidence grading have been consulted after searching in the Medline database. RESULTS: The PCG group of the CNGOF has decided to adopt the AGREE II (for Appraisal of Guidelines for REsearch and Evaluation) methology for PCG organization and the GRADE (for Grading of Recommendation Assessment, Development, and Evaluation) system for grading scientific evidence. CONCLUSION: By adopting the AGREE II consortium criteria and grading scientific evidence according to the GRADE system, the CNGOF will increase the quality of the overall process, will deliver more targeted and easy to assimilate recommendations, to facilitate professional decision making.

Do obstetricians apply the national guidelines? A vignette-based study assessing practices for the prevention of preterm birth.

OBJECTIVE: To describe spontaneous preterm birth prevention practices self-reported before and after the dissemination of relevant guidelines, and to identify personal and organisational factors associated with adherence. DESIGN: A repeated cross-sectional vignette-based survey study. SETTING: French obstetricians. POPULATION: French obstetricians practicing in public or private maternity units. METHODS: Before and after the dissemination of the 2017 French guidelines on the prevention of spontaneous preterm birth, participants were asked to complete a web-based self-administered questionnaire based on two clinical vignettes. Vignette 1 focused on respondents' attitudes towards strict bed rest, cerclage, and progesterone treatment for women with a short cervix in mid-trimester; vignette 2 focused on attitudes towards strict bed rest and maintenance tocolysis after successful tocolysis for preterm labour. A mixed quantitative and qualitative analysis was conducted. MAIN OUTCOME MEASURES: Non-adherence to guidelines for the prevention of spontaneous preterm birth in responses to each vignette. RESULTS: We obtained complete responses from 286 obstetricians before and 282 obstetricians after guideline dissemination, including 145 obstetricians participating in both. After dissemination, 51.4% of obstetricians self-reported non-adherent practices for vignette 1 and 22.3% of obstetricians self-reported non-adherent practices for vignette 2. No improvement was observed after dissemination. The quantitative analysis identified factors associated with non-adherence, including older age and practice in non-university or small hospitals, whereas the qualitative analysis highlighted barriers to implementation, including fear of change, habits, work overload, and lack of time. CONCLUSIONS: Adherence to guidelines was generally low, with practices unmodified by their dissemination. Improvement is required, especially regarding applicability. TWEETABLE ABSTRACT: Adherence to guidelines to prevent spontaneous preterm birth was generally low and remained unmodified after guideline dissemination.

Arterial and venous complications after fertility treatment: A French nationwide cohort study.

OBJECTIVES: To determine whether the risk of thromboembolic complications is higher in women following unsuccessful fertility treatment (FT) and in pregnant women following successful FT, and whether the risk differs according to FT type. STUDY DESIGN: This is an observational prospective cohort study. All French women aged 18-45 years who received FT between 2013 and 2015 were selected from the French health insurance claim database which registers healthcare consumption for the entire French population. All FT reimbursed over a 28-day period from the date of the first FT were considered to constitute one FT cycle. Each FT cycle was classified according to type: either simple ovulation induction (OI) or ovulation stimulation (OS). All hospitalisations with a diagnosis of venous thromboembolism (VTE), arterial thrombosis (AT) or ovarian hyperstimulation syndrome (OHSS) were identified for the selected women in the French hospital discharge database. Poisson regressions were used to estimate incidence rate ratios (IRR) by comparing i) the incidence of thromboembolic complications (i.e., VTE and AT) and OHSS following unsuccessful FT cycles with the incidence of these two diseases in all non-pregnant women of the same age range (i.e. non-pregnant control group), and ii) incidence of thromboembolic complications and OHSS in women who became pregnant following successful FT with the incidence in women of the same age range with spontaneous (i.e., no FT) pregnancies (i.e., pregnant control group (spontaneous pregnancy)). RESULTS: During the study period, 277,913 women underwent FT, for a total of 788,007 FT cycles, with 82,821 FT-related pregnancies. Among unsuccessful FT cycles, 75 VTE and 43 AT were observed. OS treatment cycles but not OI were associated with a higher risk of VTE than in reference group (age-adjusted IRR 1.74, 95%CI [1.30-2.34]). Among FT-related pregnancies, 207 VTE and 35 AT were reported. VTE and AT incidence rates during the first trimester were higher after OS treatment cycles than in the pregnant control group (spontaneous pregnancy) after adjusting for age and twin/multiple pregnancies (IRRVTE = 3.29, 95%CI [2.24-4.81]; IRRAT = 2.63, 95%CI [1.06-6.51]). CONCLUSION: Monitoring women undergoing FT, especially OS, irrespective of pregnancy status is crucial. The risk of thromboembolic complications in the first trimester for FT-related pregnancies seems to be higher than that for spontaneous pregnancies.

Risk of severe maternal morbidity associated with in vitro fertilisation: a population-based study.

OBJECTIVE: To investigate the association between in vitro fertilisation IVF and severe maternal morbidity (SMM) and to explore the role of multiple pregnancy as an intermediate factor. DESIGN: Population-based cohort-nested case-control study. SETTING: Six French regions in 2012/13. POPULATION: Cases were 2540 women with SMM according to the EPIMOMS definition; controls were 3651 randomly selected women who gave birth without SMM. METHODS: Analysis of the associations between IVF and SMM with multivariable logistic regression models, differentiating IVF with autologous oocytes (IVF-AO) from IVF with oocyte donation (IVF-OD). The contribution of multiple pregnancy as an intermediate factor was assessed by path analysis. MAIN OUTCOME MEASURES: Severe maternal morbidity overall and SMM according to its main underlying causal condition and by severity (near misses). RESULTS: The risk of SMM was significantly higher in women with IVF (adjusted OR = 2.5, 95% CI 1.8-3.3). The risk of SMM was significantly higher with IVF-AO, for all-cause SMM (aOR = 2.0, 95% CI 1.5-2.7), for near misses (aOR = 1.9, 95% CI 1.3-2.8), and for intra/postpartum haemorrhages (aOR = 2.3, 95% CI 1.6-3.2). The risk of SMM was significantly higher with IVF-OD, for all-cause SMM (aOR = 18.6, 95% CI 4.4-78.5), for near misses (aOR = 18.1, 95% CI 4.0-82.3), for SMM due to hypertensive disorders (aOR = 16.7, 95% CI 3.3-85.4) and due to intra/postpartum haemorrhages (aOR = 18.0, 95% CI 4.2-77.8). Path-analysis estimated that 21.6% (95% CI 10.1-33.0) of the risk associated with IVF-OD was mediated by multiple pregnancy, and 49.6% (95% CI 24.0-75.1) of the SMM risk associated with IVF-AO. CONCLUSION: The risk of SMM is higher in IVF pregnancies after adjustment for confounders. Exploratory results suggest higher risks among women with IVF-OD; however, confidence intervals were wide, so this finding needs to be confirmed. A large part of the association between IVF-AO and SMM appears to be mediated by multiple pregnancy. TWEETABLE ABSTRACT: The risk of severe maternal morbidity is higher in IVF-conceived pregnancies than in pregnancies conceived by other means.

The International Network of Obstetric Survey Systems study of uterine rupture: a descriptive multi-country population-based study.

OBJECTIVE: International comparison of complete uterine rupture. DESIGN: Descriptive multi-country population-based study. SETTING: International. POPULATION: International Network of Obstetric Survey Systems (INOSS). METHODS: We merged individual data, collected prospectively in nine population-based studies, of women with complete uterine rupture, defined as complete disruption of the uterine muscle and the uterine serosa, regardless of symptoms and rupture of fetal membranes. MAIN OUTCOME MEASURES: Prevalence of complete uterine rupture, regional variation and correlation with rates of caesarean section (CS) and trial of labour after CS (TOLAC). Severe maternal and perinatal morbidity and mortality. RESULTS: We identified 864 complete uterine ruptures in 2 625 017 deliveries. Overall prevalence was 3.3 (95% CI 3.1-3.5) per 10 000 deliveries, 22 (95% CI 21-24) in women with and 0.6 (95% CI 0.5-0.7) in women without previous CS. Prevalence in women with previous CS was negatively correlated with previous CS rate (ρ = -0.917) and positively correlated with TOLAC rate of the background population (ρ = 0.600). Uterine rupture resulted in peripartum hysterectomy in 87 of 864 women (10%, 95% CI 8-12%) and in a perinatal death in 116 of 874 infants (13.3%, 95% CI 11.2-15.7) whose mother had uterine rupture. Overall rate of neonatal asphyxia was 28% in neonates who survived. CONCLUSIONS: Higher prevalence of complete uterine ruptures per TOLAC was observed in countries with low previous CS and high TOLAC rates. Rates of hysterectomy and perinatal death are about 10% following complete uterine rupture, but in women undergoing TOLAC the rates are extremely low (only 2.2 and 3.2 per 10 000 TOLACs, respectively.) TWEETABLE ABSTRACT: Prevalence of complete uterine rupture is higher in countries with low previous CS and high TOLAC rates.