[Lessons and impact of two audits on postpartum hemorrhages in 24 maternity hospitals of the network "Sécurité Naissance - Naître Ensemble" in "Pays-de-la-Loire" area]

[Retrospective study of the impact of training on the management of immediate post-partum hemorrhage]

OBJECTIVE

The aim of the study was to assess the impact of the introduction of training workshops on the quality of prevention and management of Post-Partum Hemorrhage (PPH) in a type III university center.

METHODS

A clinical audit was carried out in our type III university center before and after the introduction of training workshops on the prevention and management of PPH, in two periods between January 1st to December 31st 2011 and March 1st and August 1st, 2015. Training workshops were according to the recommendations for clinical practice of the National College of Gynecologists-Obstetricians French published in 2014, and included a theoretical portion and a simulation of low fidelity manikin. Data on the management of patients presenting with PPH after vaginal birth of a singleton were retrospectively collected consecutively from medical records. Data were collected using a standardized analytical grid. Between the two data collections, some improvement actions were implemented.

RESULTS

After implementation of training workshops, the proportion of patients with active management of the third stage of labor (prophylactic uterotonic after delivery) has significantly improved (72% before, vs. 92% after, P=0.001); time to PPH diagnosis has been significantly higher notified (40% before, vs. 94% after, P<0.001), as well as the quantification of bleeding at diagnosis (46% before, vs. 72% after, P<0.003) and total bleeding (68% before, vs. 92%, P<0.001). PPH-specific monitoring sheet was found to be used significantly more frequently (3 before, vs. 30 after, P=0.00015). Additionally, the Physician Anesthesiologist has been contacted significantly more often (34% before, vs. 53% after, P=0.002).

CONCLUSION

Our study highlights a significant improvement in professional practices between 2011 and 2015 on PPH prevention and management in our type III university center.

[Clinical audit of screening for gestational diabetes among 848 pregnant women in 23 maternity units of the Pays de la Loire, 2014]

INTRODUCTION

Guidelines for screening for gestational diabetes mellitus (GDM) were published in 2010. An audit of the maternity units of the Pays de la Loire network sought to determine the adherence rate and to study the factors affecting it in order to propose corrective measures to improve it.

METHODS

The perinatal network in Pays de la Loire provided obstetricians of the 23 participating maternity units with a set of criteria to be collected from the files of women giving birth. The methodology of the audit was designed to enable calculation of the adherence rate overall and according to indications (risk factors, hyperglycemia, and macrosomia): adherence, non-adherence, and over-adherence (screening in the absence of an indication). To obtain around 900 pregnancies, the audit was planned to cover a week of deliveries in June 2014.

RESULTS

The analysis included 848 pregnancies and 872 newborns. Risk factors were found for 46.6% of the women (43.2 to 49.9): 13.2% for maternal age≥35years and 30.8% for BMI≥25kg/m². GDM was diagnosed for 14.6% (12.4 to 17.2). The adherence rate for screening was 45.5% (42.2 to 49.9), the non-adherence rate 27.6% (24.7 to 30.7), and the over-adherence rate 26.9% (24.0 to 30.0). Among the factors potentially associated with adherence, we observed only the second-trimester factor (macrosomia); there was no "professional" effect on adherence criteria. No evidence of overmanagement was observed for the pregnancies/deliveries/newborns with overdiagnosis. Oral glucose tolerance tests were performed in accordance with the guidelines (95.9%). Follow-up of women with GDM by specialists was satisfactory (84.6%).

DISCUSSION

This audit showed that adherence to the guidelines was insufficient in the Pays de la Loire network. The reasons for this are numerous: ignorance of the guidelines, in part due to their relative recency, the change in the blood sugar levels defining GDM (perceived as too low), and the absence of strong evidence about these thresholds from publications and practices in other countries, the need to select women for risk factors, and sometimes the late onset of prenatal care at the maternity unit.

CONCLUSION

In view of this audit, the Perinatal Network of Pays de la Loire must work to improve the knowledge and screening practices for GDM among its professionals, by the repeated dissemination of these guidelines and chart review sessions.

Policy of high-dose tranexamic acid for treating postpartum hemorrhage after vaginal delivery

OBJECTIVE

To assess whether a policy of routine administration of high-dose tranexamic acid (TA) at the diagnosis of postpartum hemorrhage (PPH) reduces blood loss after vaginal birth.

METHODS

This controlled single-center before-and-after study of all women with PPH ≥ 500 ml after vaginal birth took place from January 2011 through March 2012; the control group included those seen from January 2011 through August 2011, and the case patients those from September 2011 through March 2012. Our protocol for the management of PPH was modified effective September 2011 to include administration of high-dose TA (4 g of TA intravenously then 1 g/h for 6 h) once blood loss reached 800 ml. Our primary objective was to assess the efficacy of this policy in reducing blood loss in PPH.

RESULTS

Maternal characteristics did not differ between the two groups. Mean estimated blood loss was not significantly lower in the TA group (n = 138) than in the control group (n = 151) (respectively, 915.7 ± 321 ml versus 944.8 ± 313.8 ml; p = 0.47). The difference between pre- and post-delivery hemoglobin levels were lower in the TA group (-2.6 g/dl ± 1.2 versus -2.9 g/dl ± 1.3; p = 0.09), but it was not significant. Postpartum iron sucrose injections were significantly less frequent in the TA than the control group (2.2% versus 9.9%; p < 0.05).

CONCLUSIONS

A policy of high-dose TA in PPH after vaginal deliveries was not associated with a significant reduction of blood loss.

Mitochondrial data are not suitable for resolving placental mammal phylogeny

Mitochondrial data have traditionally been used in reconstructing a variety of species phylogenies. The low rates of recombination and thorough characterization of mitochondrial data across vertebrate species make it a particularly attractive phylogenetic marker. The relatively low number of fully sequenced mammal genomes and the lack of extensive sampling within Superorders have posed a serious problem for reaching agreement on the placement mammal species. The use of mitochondrial data sequences from large numbers of mammals could serve to circumvent the taxon-sampling deficit. Here we assess the suitability of mitochondrial data as a phylogenetic marker in mammal phylogenetics. MtDNA datasets of mammal origin have been filtered as follows: (i) we have sampled sparsely across the phylogenetic tree, (ii) we have constrained our sampling to genes with high taxon coverage, (iii) we have categorised rates across sites in a phylogeny independent manner and have removed fast evolving sites, and (iv), we have sampled from very shallow divergence times to reduce phylogenetic conflict. However, topologies obtained using these filters are not consistent with previous studies and are discordant across different genes. Individual mitochondrial genes, and indeed all mitochondrial genes analysed as a supermatrix, resulted in poor resolution of the species phylogeny. Overall, our study highlights the limitations of mitochondrial data, not only for resolving deep divergences and but also for shallow divergences in the mammal phylogeny.

[Declarative survey about postpartum haemorrhage management by anaesthesiologists in Pays de la Loire area (France): what's the adherence to clinical practice guidelines?]

OBJECTIVE

To assess the management of postpartum hemorrhage (PPH) by anaesthesiologists in Pays de la Loire area.

METHODS

A declarative survey was conducted from November 2011 to January 2012 with an online questionnaire to assess prevention and PPH specific care and to clarify the PPH transfusion practices and interest of new therapies. Nine indicators of adherence to clinical practice guidelines were selected to distinguish two groups: one group "adhering to the RCP" and another "not adhering to the RCP".

RESULTS

Response rate 53%. One hundred and one responses were analyzed. Use of a collection bag graded blood receipt pockets 93%, start time of PPH noted: 76%, leaf specific monitoring: 67%, management of the third part of the work: 78%. The evacuation of the placenta is performed within 30minutes in 75% of cases. The transfusion strategy happens early (92% before the biological assessment results) and "aggressive" (ratio RCB/FFP is 1/1 for 72%). The use of tranexamic acid is not systematic (53%). Seventy-nine percent of respondents adhere to the RCP. Practitioners in maternity level 1 (with few deliveries) don't follow these RCP as much.

CONCLUSION

Some inappropriate practices remain in structures not used to support them. The use of new therapies remain controversial. The priority at this time is the implementation and enforcement of the current RCP, not their modifications.

[Evaluation of the respect of the clinical practice guidelines in maternal transfer for postpartum haemorrhage in 2011: about 84 cases]

OBJECTIVES

Guidelines for the management of post-partum haemorrhage (PPH) were defined by the "Collège National des Gynécologues Obstétriciens Français (CNGOF)" since 2004. The aim of this work was to assess whether the management of PPH before and during the transfer was in accordance with national recommendations.

PATIENTS AND METHODS

This is an observational monocentric prospective study concerning 84 patients transferred for PPH in a referent centre in 2011.

RESULTS

In 62 cases (73.8%), transfusionnal files were found. Time noted PPH for 60 (71.4%) and amount of blood loss in 55 cases (65.5%) were notified. Evacuation of retained placenta was always performed; the broad-spectrum antibiotic prophylaxis covered only 21 cases of intra uterine procedures. Less than 5% of the patients received intravenous sulprostone before the transfer; 72.6% (n=61) of the patients were transfused before transfer 25% of the patients (n=21) had a very high risk of PPH in ante partum and were not addressed to a centre with appropriate medical and technical facilities.

DISCUSSION AND CONCLUSION

Thus improvement can be made in the communication between the health care centre during transfer for PPH and the ante partum transfer of patients with high risk of PPH.