Publications by authors named "Marie-Pierre Bonnet"

37 Publications

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

Anesth Analg 2021 May 14. Epub 2021 May 14.

From the Centre for Epidemiology and Statistics Sorbonne Paris Cité (CRESS), Paris University, Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, Institut National de la Santé et de la Recherche Médicale (INSERM), Institut National de la Recherche Agronomique (INRA), Paris, France.

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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1213/ANE.0000000000005578DOI Listing
May 2021

Vitamin C in severe preeclampsia: a promising therapeutic option against peripartum pulmonary oedema?

Anaesth Crit Care Pain Med 2021 02 11;40(1):100814. Epub 2021 Feb 11.

Département d'Anesthésie, Hôpital Antoine Béclère, APHP, Université Paris-Saclay, 157, rue de la Porte de Trivaux, 92140 Clamart, France. Electronic address:

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.accpm.2021.100814DOI Listing
February 2021

A total blood volume or more transfused during pregnancy or after childbirth: Individual patient data from six international population-based observational studies.

PLoS One 2021 22;16(1):e0244933. Epub 2021 Jan 22.

National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Headington, Oxford, United Kingdom.

Background: This study aimed to compare incidence, management and outcomes of women transfused their blood volume or more within 24 hours during pregnancy or following childbirth.

Methods: Combined analysis of individual patient data, prospectively collected in six international population-based studies (France, United Kingdom, Italy, Australia, the Netherlands and Denmark). Massive transfusion in major obstetric haemorrhage was defined as transfusion of eight or more units of red blood cells within 24 hours in a pregnant or postpartum woman. Causes, management and outcomes of women with massive transfusion were compared across countries using descriptive statistics.

Findings: The incidence of massive transfusion was approximately 21 women per 100,000 maternities for the United Kingdom, Australia and Italy; by contrast Denmark, the Netherlands and France had incidences of 82, 66 and 69 per 100,000 maternities, respectively. There was large variation in obstetric and haematological management across countries. Fibrinogen products were used in 86% of women in Australia, while the Netherlands and Italy reported lower use at 35-37% of women. Tranexamic acid was used in 75% of women in the Netherlands, but in less than half of women in the UK, Australia and Italy. In all countries, women received large quantities of colloid/crystalloid fluids during resuscitation (>3·5 litres). There was large variation in the use of compression sutures, embolisation and hysterectomy across countries. There was no difference in maternal mortality; however, variable proportions of women had cardiac arrests, renal failure and thrombotic events from 0-16%.

Interpretation: There was considerable variation in the incidence of massive transfusion associated with major obstetric haemorrhage across six high-income countries. There were also large disparities in both transfusion and obstetric management between these countries. There is a requirement for detailed evaluation of evidence underlying current guidance. Furthermore, cross-country comparison may empower countries to reference their clinical care against that of other countries.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0244933PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7822517PMC
May 2021

Unexpected benefits of the COVID challenge: When critically ill adult patients are managed in a pediatric PACU.

Paediatr Anaesth 2020 08;30(8):957-959

Department of Anesthesiology and Intensive Care, Armand Trousseau University Hospital, GRC 29, APHP, Sorbonne University, Paris, France.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/pan.13980DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7537080PMC
August 2020

[Obstetric anaesthesia during the COVID-19 pandemic].

Prat Anesth Reanim 2020 Sep 10;24(4):196-201. Epub 2020 Jul 10.

DMU DREAM, service d'anesthésie réanimation, hôpital Armand-Trousseau, Sorbonne université, AP-HP, 26, avenue du Dr Arnold-Netter, 75012 Paris, France.

Pregnant women and parturients have also been concerned by the COVID-19 pandemic. However, they are not especially at risk for severe forms of the disease prone to induce prematurity but without transmission to the fœtus. Obstetrical management of parturients have changed with an extensive use of teleconsultation and a limitation of relatives in the delivery room and in the ward. The choice of the mode of delivery remains determined by obstetrical reasons, and use of regional anaesthesia remains recommended for labour and caesarean section provided there is not haemostasis disorders. The pandemic issue has not change management of fever and hypertension. The post-partum period is more impacted due to an increased risk of thromboembolic events justifying an extended use of anticoagulants. On the other hand, the use of non-steroidal anti-inflammatory drugs is restricted. The key point was cooperation between obstetricians, anaesthesiologists, intensivists and pediatrician.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.pratan.2020.07.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7351395PMC
September 2020

Determinants of the use of nonpharmacological analgesia for labor pain management: a national population-based study.

Pain 2020 11;161(11):2571-2580

Université de Paris, Center of Research in Epidemiology and StatisticS/CRESS/Obstetrical Perinatal and Pediatric Epidemiology Research Team (EPOPé), INSERM, INRA, Paris, France.

Besides neuraxial analgesia, nonpharmacological methods are also proposed to help women coping with pain during labor. We aimed to identify the individual and organizational factors associated with the use of nonpharmacological analgesia for labor pain management. Women who attempted vaginal delivery with labor analgesia were selected among participants included in the 2016 National Perinatal Survey, a population-based cross-sectional study. Labor analgesia was studied as neuraxial analgesia alone, nonpharmacological analgesia alone, and neuraxial and nonpharmacological analgesia combined. The associations were studied using multilevel multinomial logistic regression. Among the 9231 women included, 62.4% had neuraxial analgesia alone, 6.4% had nonpharmacological analgesia alone, and 31.2% had both. Nonpharmacological analgesia alone or combined with neuraxial analgesia were both associated with high educational level (adjusted odds ratio 1.55; 95% confidence interval [CI], 1.08-2.23 and 1.39; 95% CI, 1.18-1.63), antenatal preference to deliver without neuraxial analgesia, and public maternity unit status. Nonpharmacological analgesia alone was more frequent among multiparous women, and in maternity units with an anesthesiologist not dedicated to delivery unit (1.57; 95% CI, 1.16-2.12) and with the lowest midwife workload (2.15; 95% CI, 1.43-3.22). Neuraxial and nonpharmacological analgesia combined was negatively associated with inadequate prenatal care (0.70; 95% CI, 0.53-0.94). In France, most women who had nonpharmacological analgesia during labor used it as a complementary method to neuraxial analgesia. The use of nonpharmacological analgesia combined with neuraxial analgesia mainly depends on the woman's preference, but also on socioeconomic factors, quality of prenatal care, and care organization.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/j.pain.0000000000001956DOI Listing
November 2020

Guidelines: Anaesthesia in the context of COVID-19 pandemic.

Anaesth Crit Care Pain Med 2020 06 5;39(3):395-415. Epub 2020 Jun 5.

Department of Anaesthesiology and Intensive Care, DMU DREAM, AP-HP, 6 Sorbonne Université, Paris, France; Clinique Remusat, 75016 Paris, France; Clinique Jouvenet, 75016 Paris, France.

Objectives: The world is currently facing an unprecedented healthcare crisis caused by the COVID-19 pandemic. The objective of these guidelines is to produce a framework to facilitate the partial and gradual resumption of intervention activity in the context of the COVID-19 pandemic.

Methods: The group has endeavoured to produce a minimum number of recommendations to highlight the strengths to be retained in the 7 predefined areas: (1) protection of staff and patients; (2) benefit/risk and patient information; (3) preoperative assessment and decision on intervention; (4) modalities of the preanaesthesia consultation; (5) specificity of anaesthesia and analgesia; (6) dedicated circuits and (7) containment exit type of interventions.

Results: The SFAR Guideline panel provides 51 statements on anaesthesia management in the context of COVID-19 pandemic. After one round of discussion and various amendments, a strong agreement was reached for 100% of the recommendations and algorithms.

Conclusion: We present suggestions for how the risk of transmission by and to anaesthetists can be minimised and how personal protective equipment policies relate to COVID-19 pandemic context.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.accpm.2020.05.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7274119PMC
June 2020

Anaesthesia and intensive care in obstetrics during the COVID-19 pandemic.

Anaesth Crit Care Pain Med 2020 06 13;39(3):345-349. Epub 2020 May 13.

Service d'Anesthésie Réanimation Médecine Péri Opératoire, AP-HP, Université Paris Saclay, Hôpital Bicêtre, 78, rue du Général Leclerc, 94275 Le Kremlin Bicêtre Cedex, France.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.accpm.2020.05.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7219381PMC
June 2020

Incidence and risk factors for maternal hypoxaemia during induction of general anaesthesia for non-elective Caesarean section: a prospective multicentre study.

Br J Anaesth 2020 07 14;125(1):e81-e87. Epub 2020 Apr 14.

Department of Anaesthesiology and Critical Care, Cochin-Port Royal University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France. Electronic address:

Background: Pregnant women are at increased risk of hypoxaemia during general anaesthesia. Our aim was to determine the incidence and the risk factors that contribute to hypoxaemia in this setting.

Methods: Every woman 18 yr or older who underwent a non-elective Caesarean section under general anaesthesia was eligible to participate in this multicentre observational study. The primary endpoint was the incidence of hypoxaemia defined as the SpO ≤95%. The secondary endpoint was the incidence of difficult intubation defined as more than two attempts or failed intubation.

Results: During the study period, 895 women were prospectively included in 17 maternity hospitals, accounting for 79% of women who had general anaesthesia for non-elective Caesarean section. Maternal hypoxaemia was observed in 172 women (19%; confidence interval [CI], 17-22%). Risk factors associated with hypoxaemia in the multivariate analysis were difficult or failed intubation (adjusted odds ratio [aOR]=19.1 [8.6-42.7], P<0.0001) and BMI >35 kg m (aOR=0.53 [0.28-0.998], P=0.0495). Intubation was difficult in 40 women (4.5%; CI, 3.3-6%) and failed intubation occurred in five women (0.56%; CI, 0.1-1%). In the multivariate analysis, use of a hypnotic drug other than propofol was associated with difficult or failed intubation (aOR=25 [2-391], P=0.02). A propensity score confirmed that propofol was associated with a significant decreased risk of difficulty or failure to intubate (P<0.001).

Conclusions: Hypoxaemia during Caesarean sections was observed in 19% of women and was significantly associated with difficult or failed intubation. The use of propofol may protect against the occurrence of difficult intubation.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.bja.2020.03.010DOI Listing
July 2020

Delivery Hospital Characteristics and Postpartum Maternal Mortality: A National Case-Control Study in France.

Anesth Analg 2020 01;130(1):52-62

From the Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé), Centre for Epidemiology and Statistics Sorbonne Paris Cité (CRESS), DHU Risks in Pregnancy, Paris Descartes University, Paris, France.

Background: The variability in resources for managing critical events among maternity hospitals may impact maternal safety. Our main objective was to assess the risk of postpartum maternal death according to hospitals' organizational characteristics. A secondary objective aimed to assess the specific risk of death due to postpartum hemorrhage (PPH).

Methods: This national population-based case-control study included all 2007-2009 postpartum maternal deaths from the national confidential enquiry (n = 147 cases) and a 2010 national representative sample of parturients (n = 14,639 controls). To adjust for referral bias, cases were classified by time when the condition/complication responsible for the death occurred: postpartum maternal deaths due to conditions present before delivery (n = 66) or during or after delivery (n = 81). Characteristics of delivery hospitals included 24/7 on-site availability of an anesthesiologist and an obstetrician, level of perinatal care, number of deliveries annually, and their teaching and profit status. In teaching and other nonprofit hospitals in France, obstetric care is organized on the principle of collective team-based management, while in for-profit hospitals, this organization is based mostly on that of "one woman-one doctor." Logistic regression models were used to estimate adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for postpartum maternal death.

Results: The risk of maternal death from prepartum conditions was lower for women who gave birth in for-profit compared with teaching hospitals (aOR, 0.3; 95% CI, 0.1-0.8; P = .02) and in hospitals with <1500 vs ≥1500 annual deliveries (aOR, 0.4; 95% CI, 0.1-0.9; P = .02). Conversely, the risk of postpartum maternal death from complications occurring during or after delivery was higher for women who delivered in for-profit compared with teaching hospitals (aOR, 2.8; 95% CI, 1.3-6.0; P = .009), as was the risk of death from PPH in for-profit versus nonprofit hospitals (aOR, 2.8; 95% CI, 1.2-6.5; P = .019).

Conclusions: After adjustment for the referral bias related to prepartum morbidity, the risk of postpartum maternal mortality in France differs according to the hospital's organizational characteristics.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1213/ANE.0000000000004290DOI Listing
January 2020

Pain management after laparoscopic hysterectomy: systematic review of literature and PROSPECT recommendations.

Reg Anesth Pain Med 2019 04 3;44(4):425-436. Epub 2019 Feb 3.

Department of Anesthesiology and Intensive Care Hôpital Tenon, Groupe Hospitalier Universitaire Est Parisien, Assistance Publique Hôpitaux de Paris, Université Pierre & Marie, Paris, France.

Background And Objectives: Laparoscopic hysterectomy is increasingly performed because it is associated with less postoperative pain and earlier recovery as compared with open abdominal hysterectomy. The aim of this systematic review was to evaluate the available literature regarding the management of pain after laparoscopic hysterectomy.

Strategy And Selection Criteria: Randomized controlled trials evaluating postoperative pain after laparoscopic hysterectomy published between January 1996 and May 2018 were retrieved, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, from the EMBASE and MEDLINE databases and the Cochrane Register of Controlled Trials. Efficacy and adverse effects of analgesic techniques were assessed.

Results: Of the 281 studies initially identified, 56 were included. Of these, 31 assessed analgesic or anesthetic interventions and 25 assessed surgical interventions. Acetaminophen, non-steroidal anti-inflammatory drugs, and dexamethasone reduced opioid consumption. Limited evidence hindered recommendations on alpha-2-agonists. Inconsistent evidence was found in the studies investigating pregabalin and transversus abdominis plane block, and no evidence was found for intraperitoneal local anesthetics, port site infiltration, or single-port laparoscopy. Measures to lower peritoneal insufflation pressure or humidify or heat insufflated gas seem to reduce the incidence of shoulder pain, but not abdominal pain.

Conclusions: The baseline analgesic regimen for laparoscopic hysterectomy should include acetaminophen, a non-steroidal anti-inflammatory drug, dexamethasone, and opioids as rescue analgesics.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1136/rapm-2018-100024DOI Listing
April 2019

Patient blood management in obstetrics: prevention and treatment of postpartum haemorrhage. A NATA consensus statement.

Blood Transfus 2019 03 6;17(2):112-136. Epub 2019 Feb 6.

Department of Anaesthesiology, Université de Montréal, Montreal, QC, Canada.

Patient blood management (PBM) is the timely application of evidence-informed medical and surgical concepts designed to maintain haemoglobin concentration, optimise haemostasis, and minimise blood loss in an effort to improve patient outcomes. The aim of this consensus statement is to provide recommendations on the prevention and treatment of postpartum haemorrhage as part of PBM in obstetrics. A multidisciplinary panel of physicians with expertise in obstetrics, anaesthesia, haematology, and transfusion medicine was convened by the Network for the Advancement of Patient Blood Management, Haemostasis and Thrombosis (NATA) in collaboration with the International Federation of Gynaecology and Obstetrics (FIGO), the European Board and College of Obstetrics and Gynaecology (EBCOG), and the European Society of Anaesthesiology (ESA). Members of the task force assessed the quantity, quality and consistency of the published evidence, and formulated recommendations using the system developed by the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) working group. The recommendations in this consensus statement are intended for use by clinical practitioners managing perinatal care of women in all settings, and by policy-makers in charge of decision making for the update of clinical practice in health care establishments.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.2450/2019.0245-18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6476742PMC
March 2019

Placenta percreta is associated with more frequent severe maternal morbidity than placenta accreta.

Am J Obstet Gynecol 2018 08 5;219(2):193.e1-193.e9. Epub 2018 May 5.

Port-Royal Maternity Unit, Department of Obstetrics Paris, Hôpitaux Universitaires Paris Centre, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France; Sorbonne Paris Cité, Université Paris Descartes, Faculté de Médecine, Paris, France.

Background: Abnormally invasive placentation is the leading cause of obstetric hysterectomy and can cause poor to disastrous maternal outcomes. Most previous studies of peripartum management and maternal morbidity have included variable proportions of severe and less severe cases.

Objective: The aim of this study was to compare maternal morbidity from placenta percreta and accreta.

Study Design: This retrospective study at a referral center in Paris includes all women with abnormally invasive placentation from 2003 through 2017. Placenta percreta and accreta were diagnosed histologically or clinically. When placenta percreta was suspected before birth, a conservative approach leaving the placenta in situ was proposed because of the intraoperative risk of cesarean delivery. When placenta accreta was suspected, parents were offered a choice of a conservative approach or an attempt to remove the placenta, to be followed in case of failure by hysterectomy. Maternal outcomes were compared between women with placenta percreta and those with placenta accreta/increta. The primary outcome measure was a composite criterion of severe acute maternal morbidity including at least 1 of the following: hysterectomy during cesarean delivery, delayed hysterectomy, transfusion of ≥10 U of packed red blood cells, septic shock, acute kidney injury, cardiovascular failure, maternal transfer to intensive care, or death.

Results: Of the 156 women included, 51 had placenta percreta and 105 placenta accreta. Abnormally invasive placentation was suspected antenatally nearly 4 times more frequently in the percreta than the accreta group (96.1% [49/51] vs 25.7% [27/105], P < .01). Among the 76 women with antenatally suspected abnormally invasive placentation (48.7%), the rate of antenatal decisions for conservative management was higher in the percreta than the accreta group (100% [49/49] vs 40.7% [11/27], P < .01). The composite maternal morbidity rate was significantly higher in the percreta than the accreta group (86.3% [44/51] vs 28/105 [26.7%], P < .001). A secondary analysis restricted to women with an abnormally invasive placentation diameter >6 cm showed similar results (86.0% [43/50) vs 48.7% [19/38), P < .01). The rate of hysterectomy during cesareans was significantly higher in the percreta than the accreta group (52.9% [27/51] vs 20.9% [22/105], P < .01) as was the total hysterectomy rate (43/51 [84.3%] vs 23.8% [25/105], P < .01).

Conclusion: Severe maternal morbidity is much more frequent in women with placenta percreta than with placenta accreta, despite multidisciplinary planning, management in a referral center, and better antenatal suspicion.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ajog.2018.04.049DOI Listing
August 2018

Effective concentration of levobupivacaine and ropivacaine in 80% of patients receiving epidural analgesia (EC80) in the first stage of labour: A study using the Continual Reassessment Method.

Anaesth Crit Care Pain Med 2018 10 30;37(5):429-434. Epub 2017 Dec 30.

Anaesthesia and critical care department, hôpital Antoine-Béclère, Assistance publique-Hôpitaux de Paris, 157, rue de la Porte-de-Trivaux, BP 405, 92141 Clamart, France.

Background: A comparison of the effective dose in 50% of patients (ED50) has suggested that the potency of levobupivacaine lies between that of bupivacaine and ropivacaine. However, for clinical purposes, knowledge and use of doses close to the ED95 are more relevant. This study was designed to determine the EC80 (effective concentration) for both epidural levobupivacaine and ropivacaine using the Continual Reassessment Method (CRM) during obstetric analgesia.

Methods: In this double-blind randomised study, term parturients were included by cohorts of 6 if cervical dilatation was≤5cm and visual analogue pain score (VAPS)>30mm. Efficacy was defined by a decrease of VAPS to a value≤10, thirty minutes after epidural injection of 20mL of levobupivacaine or ropivacaine. The first cohort received the lowest dose. Every next cohort received a dose according to the response's probability calculated using a Bayesian method, incorporating data from all consecutive previous patients. In addition, a logistic equation was fitted a posteriori to the whole data set to determine the whole dose-probability curve.

Results: Fifty-four patients were enrolled. Levobupivacaine 0.17% and ropivacaine 0.2% gave probabilities of success of 82% and 72% respectively. By fitting the logistic model to the data, the concentration leading to a probability of 0.8 (EC80) was 0.14% for levobupivacaine and 0.24% for ropivacaine while the EC50 were 0.09% for levobupivacaine and 0.17% for ropivacaine, respectively.

Conclusion: This study suggests that epidural levobupivacaine used as the sole drug for labour analgesia has an EC80 lower than that of ropivacaine.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.accpm.2017.12.009DOI Listing
October 2018

Lower limbs venous compression reduces the incidence of maternal hypotension following epidural analgesia during term labor.

Eur J Obstet Gynecol Reprod Biol 2017 Dec 16;219:94-99. Epub 2017 Oct 16.

APHP, Maternité Port Royal, GH Broca-Cochin-Hôtel Dieu, 123 boulevard de Port Royal, 75014 Paris, France; PRES Sorbonne Paris Cité, France; DHU Risques et Grossesse, Université Paris Descartes, France; PremUP Foundation, France; INSERM, UMR-S 1139, Paris, France.

Objective(s): Every year in France, 10% to 20% of the 600 000 women given epidural analgesia during labor experience hypotension, which in 15% of cases is associated with fetal heart rate abnormalities. The efficiency of lower limbs venous compression in preventing the occurrence of maternal hypotension after neuraxial anesthesia has already been demonstrated, but only in the context of scheduled cesarean section. We assessed the preventive effect of medical lower limbs venous compression on the incidence of maternal hypotension after epidural analgesia during spontaneous term labor.

Study Design: This before/after, single-center study in a university hospital included 93 women in spontaneous labor at term who between 1 January and 31 March 2015 with epidural analgesia plus lower limbs compression and 202 women in spontaneous labor at term who delivered between 1 and 31 December 2014 with epidural analgesia without lower limbs compression (control group). The main outcome was maternal hypotension (systolic blood pressure <90mmHg and/or delta >20%) in the 15min after epidural analgesia.

Results: In the lower limbs compression group the incidence of hypotension 15min after epidural analgesia was significantly lower than in the control group (3.23% versus 23.3%, adjusted odds ratio=0.1 [0.03; 0.35]). The incidence of fetal heart rate abnormalities was unsignificantly lower in the lower limbs compression group than in the control group (10.7% versus 16.34%, p=0.22).

Conclusion: The results suggest that medical lower limbs compression (20-36mmHg) in women in spontaneous labor at term, could significantly reduce the incidence of maternal hypotension following epidural analgesia. A prospective, randomized, open trial would allow confirmation of these preliminary results.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ejogrb.2017.10.016DOI Listing
December 2017

Maternal Death Due to Amniotic Fluid Embolism: A National Study in France.

Anesth Analg 2018 01;126(1):175-182

From the Inserm UMR 1153 Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé), Centre for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Paris, France.

Background: A structured definition of amniotic fluid embolism (AFE) based on 4 criteria was recently proposed for use in research by the Society for Maternal-Fetal Medicine (SMFM) and the Amniotic Fluid Embolism Foundation. The main objective of this study was to review all AFE-related maternal deaths in France during 2007-2011 according to the presence or not of all these 4 diagnostic criteria.

Methods: Maternal deaths due to AFE were identified by the national experts committee of the French Confidential Enquiry into Maternal Deaths during 2007-2011 (n = 39). The maternal mortality ratio for AFE was calculated. We applied the structured definition proposed by the Society for Maternal-Fetal Medicine and the Amniotic Fluid Embolism Foundation to AFE-related maternal deaths identified by the national experts committee. Characteristics of women, pregnancies and deliveries; clinical and biological features of AFE; and specific laboratory tests used were described by the presence or not of all 4 diagnostic criteria. Management of obstetric hemorrhage and quality of care according to the experts were also described.

Results: The maternal mortality ratio from AFE was 0.95/100,000 live births (95% confidence interval, 0.67-1.3). Detailed clinical data were collected for 36 women who died from AFE: 21 (58%) had all 4 proposed diagnostic criteria and 15 (42%) had 1 or more missing criterion. Documented early disseminated intravascular coagulopathy was missing for 14 women, and 2 women exhibited more than 1 missing criterion. Ten of the 15 women with missing criteria had clinical coagulopathy, with standard hemostasis tests performed in only 3. Specific diagnostic examinations for AFE were performed in similar proportions by the presence or not of all diagnostic criteria. Opportunities to improve care included timely performance of indicated hysterectomy (n = 13) and improved transfusion practices (n = 9). In the context of maternal cardiac arrest, for 5 of 13 women, fetal extraction was performed within 5 minutes.

Conclusions: The structured definition of AFE for research studies would exclude more than one-third of AFE-related maternal deaths identified by the national experts committee. Inclusion of clinical coagulopathy as a diagnostic criterion for AFE would reduce this proportion to 14%. There is still room for improvement in the management of obstetric hemorrhage and timely fetal extraction in the context of maternal cardiac arrest, frequently observed in AFE-related maternal death.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1213/ANE.0000000000002511DOI Listing
January 2018

Anesthetic and Obstetrical Factors Associated With the Effectiveness of Epidural Analgesia for Labor Pain Relief: An Observational Population-Based Study.

Reg Anesth Pain Med 2017 Jan/Feb;42(1):109-116

From the *Department of Anesthesia and Intensive Care, Hôpital Cochin, Hôpitaux Universitaires Paris Centre, AP-HP, Paris Descartes University, Paris, France; †Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, Paris, France; ‡DHU Risks in Pregnancy, Paris, France; and §Port Royal Maternity, Hôpitaux Universitaires Paris Centre, AP-HP, Paris Descartes University, Paris, France.

Background And Objectives: The effectiveness of labor epidural analgesia is difficult to explore, as it includes the maternal satisfaction with analgesia as well as the overall childbirth experience. In this population-based study, we sought to identify factors associated with the effectiveness of epidural analgesia for labor pain relief.

Methods: We performed a secondary analysis of the 2010 French National Perinatal Survey, a cross-sectional study of a representative sample of births in France. All participants who gave birth with an epidural analgesia were included. Effectiveness of epidural analgesia was assessed 2 to 3 days after delivery and intended to include analgesic efficacy and maternal satisfaction together. The factors analyzed were anesthetic management and maternal, obstetrical, and organizational characteristics, using a logistic regression with random effects model.

Results: Among the 9337 women who gave birth with an epidural analgesia and were included, 8377 (89.3%; 95% confidence interval [CI] = 88.7-89.9) considered their epidural to be very or fairly effective. In the multivariate analysis, effectiveness was significantly associated with the use of patient-controlled epidural analgesia (adjusted odds ratio [aOR] = 1.2 [1.0-1.5]; P = 0.02) and delivery in private maternity facilities (aOR = 1.3 [1.1-1.6]); it was significantly less effective in obese women (aOR = 0.6 [0.5-0.8]) and multiparous women not receiving oxytocin during labor (aOR = 0.4 [0.4-0.6]) as compared with nonobese and nulliparous women with oxytocin, respectively.

Conclusions: At the population level, most women found epidural analgesia effective for labor pain relief, but specific attention should be paid to obese parturients and multiparous women not receiving oxytocin. High epidural effectiveness with patient-controlled analgesia should promote an increased use of this method.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/AAP.0000000000000517DOI Listing
October 2017

Management of postpartum haemorrhage.

F1000Res 2016 27;5. Epub 2016 Jun 27.

Department of Anaesthesia and Intensive Care Medicine, Paris Sud University, Paris, France.

Postpartum Haemorrhage (PPH) is a major cause of maternal morbidity and mortality. Treatment of acquired coagulopathy observed in severe PPH is an important part of PPH management, but is mainly based on literature in trauma patients, and data thus should be interpreted with caution. This review describes recent advances in transfusion strategy and in the use of tranexamic acid and fibrinogen concentrates in women with PPH.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.12688/f1000research.7836.1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4926727PMC
July 2016

Sedation and anaesthesia for non-obstetric surgery.

Anaesth Crit Care Pain Med 2016 Oct 2;35 Suppl 1:S35-S41. Epub 2016 Jul 2.

Department of Anaesthesia and Intensive Care, Hôpital Cochin, Hôpitaux Universitaires Paris Centre, AP-HP, Paris Descartes University, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France; Inserm UMR 1153, Obstetrical, Perinatal and Paediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, 53, avenue de l'Observatoire, 75014 Paris, France; DHU Risks in pregnancy, 53, avenue de l'Observatoire, 75014 Paris, France. Electronic address:

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.accpm.2016.06.009DOI Listing
October 2016

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).

Eur J Obstet Gynecol Reprod Biol 2016 Mar 21;198:12-21. Epub 2015 Dec 21.

INSERM U1153, Equipe de recherche en Epidémiologie Obstétricale, Périnatale et Pédiatrique (EPOPé), Paris, France; DHU Risques et Grossesse, 53 avenue de l'observatoire, Paris, France; Maternité Port-Royal, Université Paris Descartes, Groupe hospitalier Cochin Broca Hôtel-Dieu, Assistance Publique-Hôpitaux de Paris, Paris, France.

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).
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ejogrb.2015.12.012DOI Listing
March 2016

What Is the True Incidence of Postpartum Hemorrhage?

Anesth Analg 2015 Nov;121(5):1397

Department of Anesthesia and Intensive Care, Hôpitaux Universitaires Paris Centre, AP-HP, Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Paris, France, Department of Anesthesia and Intensive Care, Hôpitaux Universitaires Paris Sud, AP-HP, Paris Sud University, Paris, France Obstetrical, Perinatal and Pediatric Epidemiology, Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, Descartes University, Paris, France Department of Obstetrics and Gynecology, Hôpital Universitaire Robert-Debré, Université Paris Diderot Sorbonne Paris Cité, Paris, France.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1213/ANE.0000000000000845DOI Listing
November 2015

Initial Preference for Labor Without Neuraxial Analgesia and Actual Use: Results from a National Survey in France.

Anesth Analg 2015 Sep;121(3):759-66

From the *INSERM (U1153), Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Center for Epidemiology and Biostatistics, Paris, France; †DHU Risks in Pregnancy, Paris-Descartes University, Paris, France; ‡Service d'Anesthésie-Réanimation Chirurgicale, Hôpital Cochin, Hôpitaux Universitaires Paris Centre, Assistance Publique Hôpitaux de Paris, Paris, France; §Maternité Port Royal, Hôpital Cochin Saint-Vincent-de-Paul, Assistance Publique Hôpitaux de Paris, Paris, France; and ∥Pôle Anesthésie Réanimation, Maternité Jeanne de Flandre, CHRU Lille, Lille, France.

Background: The rate of neuraxial analgesia during labor in France is one of the highest among high-income countries: 77% of vaginal deliveries in 2010. In this context, the question of how women's preferences for delivering without neuraxial analgesia relate to actual use is of interest. Our objective was to study the factors associated with women's initial preference for labor without neuraxial analgesia and those associated with its use in women who initially preferred not to have it.

Methods: We used data from the 2010 French National Perinatal Survey, a cross-sectional study of a representative sample of all births in France. Data were collected from interviews with mothers in the postpartum ward and from medical records. Our sample included 7123 women who had vaginal deliveries and were at low risk for cesarean delivery. The factors analyzed were maternal sociodemographic characteristics, prenatal care, childbirth class attendance, labor management, and organization of maternity units. Multilevel Poisson regression models were used to study factors associated with women's initial preference in the overall population and to study factors associated with actual use of neuraxial analgesia in the group of women who initially preferred not to have it.

Results: Initially, 26% of our population (n = 1835) preferred to deliver without neuraxial analgesia; this preference was associated with high parity, unfavorable social conditions, and delivery in a public maternity unit. Among these women, 52% (n = 961) delivered with neuraxial analgesia. This discrepancy between initial preference and actual use was significantly associated with nulliparity (adjusted relative risk [aRR] = 1.4; 95% confidence interval [CI], 1.3-1.6), oxytocin augmentation of labor (aRR = 2.4; 95% CI, 2.1-2.7), presence of an anesthesiologist in the unit 24/7 (aRR = 1.4; 95% CI, 1.2-1.6; compared with delivery in hospitals without an anesthesiologist on site 24/7), and high midwife workload (aRR = 1.1; 95% CI, 1.0-1.2). There was no clear association with maternal educational level.

Conclusions: Our results suggest that parity, the management of labor, and availability of anesthesiologists play a major role in the intrapartum decision to use neuraxial analgesia for women who initially preferred not to have it. Further research is necessary in the clinical circumstances leading to this decision and the role of women's demands and medical staff attitudes throughout labor.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1213/ANE.0000000000000832DOI Listing
September 2015

Pregnancy-related ICU admissions in France: trends in rate and severity, 2006-2009.

Crit Care Med 2015 Jan;43(1):78-86

1Institut National de la Santé et de la Recherche Médicale 1153, Obstetrical, Perinatal and Pediatric Epidemiology Resear team (Epopé), Center for Epidemiology and Biostatistics Sorbonne Paris Cité, DHU Risks in pregnancy, Paris Descartes University, Paris, France. 2Baudelocque Midwifery School, Assistance Publique des Hôpitaux de Paris, Paris, France. 3Departments of Anaesthesia and Critical Care, Hôpital Cochin, Hôpitaux Universitaires Paris Centre, Assistance Publique-Hôpitaux de Paris, Paris, France.

Objective: To determine the national rate per delivery of pregnancy-related ICU admissions of women in France, the characteristics and severity of these cases, and their trends over the 4-year study period.

Design: Descriptive study from the national hospital discharge database.

Setting: All ICUs in France.

Patients: All women admitted to an ICU during the pregnancy, the delivery, or the postpartum period from January 1, 2006, to December 31, 2009.

Interventions: None.

Measurements And Main Results: Of 3,262,526 deliveries, 11,824 women had pregnancy-related ICU admissions, for an overall rate of 3.6 per 1,000 deliveries. The conditions reported most frequently were obstetric hemorrhages (34.2%) and hypertensive disorders of pregnancy (22.3%). Case severity was assessed with four markers: case-fatality rate (1.3%), length of ICU stay (mean, 3.0 ± 0.1 d), Simplified Acute Physiology Score II score (mean: 19.7 ± 0.1), and a SUP REA code, which indicates the combination of a Simplified Acute Physiology Score II score more than or equal to 15 and at least one specific procedure related to life support or organ failure (23.0%). The most frequent causes of ICU admission were those associated with the least severity in the ICU. During the study period, the rate of pregnancy-related ICU admissions decreased from 3.9 to 3.4 per 1,000 deliveries (p < 0.001), whereas the overall severity of cases increased with longer stays, higher Simplified Acute Physiology Score II scores, and a greater proportion of SUP REA codes (all p < 0.001). Analysis by principal diagnosis showed that the severity of the condition of women admitted to ICU significantly increased over time for hemorrhages and hypertensive complications.

Conclusions: The rate of women with pregnancy-related ICU admissions decreased and the severity of their cases increased. Most ICU admissions remained related to the least severe conditions. This raises the issue of the most appropriate organization of care for women with pregnancy-related conditions who require continuous surveillance but not necessarily intensive care.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/CCM.0000000000000601DOI Listing
January 2015

Postpartum haemorrhage in Canada and France: a population-based comparison.

PLoS One 2013 24;8(6):e66882. Epub 2013 Jun 24.

INSERM, U953, Epidemiological Research Unit on Perinatal Health and Women's and Children's Health, Université Pierre et Marie Curie Paris 6, Paris, France.

Objective: Maternal mortality ratio due to postpartum haemorrhage (PPH) is higher in France than in Canada. We explored this difference by comparing PPH features between these two countries.

Methods: Using data between 2004 and 2006, we compared the incidence, risk factors, causes and use of second-line treatments, of PPH between France (N = 6,660 PPH) and Canada (N = 9,838 PPH). We assessed factors associated with PPH through multivariate logistic models.

Results: PPH incidence, overall (4.8% (95% CI 4.7-4.9) in Canada and 4.5% (95% CI 4.4-4.7) in France), and after vaginal delivery (5.3% (95%CI 5.2-5.4) in Canada and 4.8 (95%CI 4.7-4.9) in France), were significantly higher in Canada than in France, but not after caesarean delivery. Women delivering without PPH were similar between the two populations, except for macrosomia (11% in Canada, 7% in France, p<0.001), caesarean delivery (27% in Canada, 18% in France, p<0.001), and episiotomy (17% in Canada, 34% in France, p<0.001). After vaginal delivery, factors strongly associated with PPH were multiple pregnancy, operative delivery and macrosomia in both populations, and episiotomy only in France (Odds Ratio 1.39 (95% CI 1.23-1.57)). The use of second-line treatments for PPH management was significantly more frequent in France than in Canada after both vaginal and caesarean delivery.

Conclusion: PPH incidence was not higher in France than in Canada and there was no substantial difference in PPH risk factors between the 2 countries. Greater use of second-line treatments in PPH management in France suggests a more frequent failure of first-line treatments and a higher rate of severe PPH, which may be involved in the higher maternal mortality ratio due to PPH.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0066882PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3691240PMC
February 2014

Transfusion practices in postpartum hemorrhage: a population-based study.

Acta Obstet Gynecol Scand 2013 Apr 16;92(4):404-13. Epub 2013 Jan 16.

INSERM, UMR S953, Epidemiological Research Unit on Perinatal Health and Women's and Children's Health, Port Royal Maternity Unit, Cochin Teaching Hospital, Paris, France.

Objective: To describe transfusion practices and anemia in women with postpartum hemorrhage (PPH), according to the clinical context.

Design: Population-based cohort study.

Setting: A total of 106 French maternity units (146 781 deliveries, December 2004 to November 2006).

Population: All women with PPH (n = 9365).

Methods: Description of the rate of red blood cell (RBC) transfusion in PPH overall and compared with transfusion guidelines.

Main Outcome Measures: Transfusion practices and postpartum anemia by mode of delivery and cause of PPH in women given RBCs within 12 h after PPH.

Results: A total of 701 women received RBCs (0.48 ± 0.04% of all women and 7.5 ± 0.5% of women with PPH). Half the women with clinical PPH and hemoglobin lower than 7.0 g/dL received no RBCs. In the group with clinical PPH and transfusion within 12 h (n = 426), operative vaginal delivery was associated with a larger maximal hemoglobin drop, more frequent administration of fresh-frozen plasma (FFP) and pro-hemostatic agents [odds ratio (OR) 3.54, 95% confidence interval (95% CI) 1.12-11.18], transfusion of larger volumes of RBCs and FFP, a higher rate of massive RBCs transfusion (OR 5.22, 95% CI 2.12-12.82), and more frequent use of conservative surgery (OR 3.2, 95% CI 1.34-7.76), compared with spontaneous vaginal delivery.

Conclusions: The RBC transfusion for PPH was not given in a large proportion of women with very low hemoglobin levels despite guidelines to the contrary. Operative vaginal delivery is characterized by higher blood loss and more transfusions than spontaneous vaginal delivery.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/aogs.12063DOI Listing
April 2013

Prohemostatic interventions in obstetric hemorrhage.

Semin Thromb Hemost 2012 Apr 18;38(3):259-64. Epub 2012 Feb 18.

Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada.

Obstetric hemorrhage is a major cause of maternal morbidity and mortality. Pregnancy is associated with substantial hemostatic changes, resulting in a relatively hypercoagulable state. Acquired coagulopathy can, however, develop rapidly in severe obstetric hemorrhage. Therefore, prohemostatic treatments based on high fresh frozen plasma and red blood cell (FFP:RBC) ratio transfusion and procoagulant agents (fibrinogen concentrates, recombinant activated factor VII, and tranexamic acid) are crucial aspects of management. Often, evidence from trauma patients is applied to obstetric hemorrhage management, although distinct differences exist between the two situations. Therefore, until efficacy and safety are demonstrated in obstetric hemorrhage, clinicians should be cautious about wholesale adoption of high FFP:RBC ratio products. Applications of transfusion protocols, dedicated to massive obstetric hemorrhage and multidisciplinarily developed, currently remain the best available option. Similarly, while procoagulant agents appear promising in treatment of obstetric hemorrhage, caution is nonetheless warranted as long as clear evidence in the context of obstetric hemorrhage is lacking.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1055/s-0032-1302441DOI Listing
April 2012

Critical care and transfusion management in maternal deaths from postpartum haemorrhage.

Eur J Obstet Gynecol Reprod Biol 2011 Oct 31;158(2):183-8. Epub 2011 May 31.

INSERM, UMR S953, Epidemiological Research Unit on Perinatal Health and Women's and Children's Health, Hôpital Tenon, Paris, France.

Objectives: In postpartum haemorrhage (PPH), as for other causes of acute haemorrhage, management can have a major impact on patient outcomes. The aim of this study was to describe critical care management, particularly transfusion practices, in cases of maternal deaths from PPH.

Study Design: This retrospective study provided a descriptive analysis of all cases of maternal death from PPH in France identified through the systematic French Confidential Enquiry into Maternal Death in 2000-2003.

Results: Thirty-eight cases of maternal death from PPH were analysed. Twenty-six women (68%) had a caesarean section [21 (55%) emergency, five (13%) elective]. Uterine atony was the most common cause of PPH (n=13, 34%). Women received a median of 9 (range 2-64) units of red blood cells (RBCs) and 9 (range 2-67) units of fresh frozen plasma (FFP). The median delay in starting blood transfusion was 82 (range 0-320)min. RBC and FFP transfusions peaked 2-4h and 12-24h after PPH diagnosis, respectively. The median FFP:RBC ratio was 0.6 (range 0-2). Fibrinogen concentrates and platelets were administered to 18 (47%) and 16 (42%) women, respectively. Three women received no blood products. Coagulation tests were performed in 20 women. The haemoglobin concentration was only measured once in seven of the 22 women who survived for more than 6h. Twenty-four women received vasopressors, a central venous access was placed in 11 women, and an invasive blood pressure device was placed in two women. General anaesthesia was administered in 37 cases, with five patients being extubated during active PPH.

Conclusions: This descriptive analysis of maternal deaths from PPH suggests that there may be room for improvement of specific aspects of critical care management, including: transfusion procedures, especially administration delays and FFP:RBC ratio; repeated laboratory assessments of haemostasis and haemoglobin concentration; invasive haemodynamic monitoring; and protocols for general anaesthesia.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ejogrb.2011.04.042DOI Listing
October 2011

Analgesic efficacy and adverse effects of epidural morphine compared to parenteral opioids after elective caesarean section: a systematic review.

Eur J Pain 2010 Oct 8;14(9):894.e1-9. Epub 2010 Apr 8.

Département d'Anesthésie-Réanimation, Groupe Hospitalier Cochin Port Royal, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Université René Descartes, Paris, France.

Background: The optimal effective dose of epidural morphine that provides postoperative analgesia after caesarean section with minimal side effects remains debated.

Aims: We performed a systematic review to assess the analgesic efficacy and the incidence of adverse effects of epidural morphine after caesarean section compared to systemic analgesia with opioids.

Methods: We searched Medline, Embase and Cochrane Collaboration Library databases. Studies were evaluated with the Modified Oxford Scale. Prospective randomized studies comparing analgesic efficacy and/or adverse effects of a single epidural morphine administration versus systemic opioids after elective caesarean section were included.

Results: Ten studies (n=431) were selected. Epidural morphine increases the time until the first request for a rescue analgesic (Emax, 29.7 h; 95% confidence interval, 25.2-33.9) and decreases pain scores and postoperative morphine request during the first 24 h compared to systemic opioid analgesia. However, epidural morphine increases the incidence of pruritus (relative risk, 2.7; 95% CI, 2.1-3.6) and nausea (relative risk, 2.0; 95% CI, 1.2-3.3).

Conclusions: A single bolus of epidural morphine provides better analgesia than parenteral opioids but with an effect limited to the first postoperative day after caesarean section and with an increase in morphine side effects.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ejpain.2010.03.003DOI Listing
October 2010

Use of clotting factors and other prohemostatic drugs for obstetric hemorrhage.

Curr Opin Anaesthesiol 2010 Jun;23(3):310-6

Département d'Anesthésie Réanimation, Hôpital Antoine Béclère, Groupe Hospitalier Universitaire Paris Sud, Assistance Publique-Hôpitaux de Paris, Université Paris XI, Clamart, France.

Purpose Of Review: To guide the optimal use of blood products and to clarify the indications for prohemostatic drugs in obstetric hemorrhage.

Recent Findings: The literature emphasizes the usefulness of transfusing packed red blood cells, fresh frozen plasma and platelets earlier and in defined ratios to prevent dilutional coagulopathy during obstetric hemorrhage. The value of fibrinogen concentrate and prohemostatic drugs such as tranexamic acid and recombinant factor VIIa is also pointed out.

Summary: It seems reasonable to use blood products for transfusion earlier and in a 1: 1 fresh frozen plasma: red blood cell ratio during acute obstetric hemorrhage; however, this analysis is mainly based on trauma literature. Fibrinogen concentrate should be added if the fibrinogen plasma level remains below 1.0 g l(-1) and perhaps even as soon as it falls below 1.5-2.0 g l(-1); the addition of tranexamic acid (1 g) is cheap, likely to be useful and appears safe. Data on the proactive administration of platelets are insufficient to recommend this practice routinely. Presently, recombinant factor VIIa (60-90 microg kg(-1)) is advocated only after failure of other conventional therapies, including embolization or conservative surgery, but prior to obstetric hysterectomy. Prospective randomized controlled trials are highly desirable.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/ACO.0b013e32833835a2DOI Listing
June 2010