1
|
Froeliger A, Deneux-Tharaux C, Loussert L, Bouchghoul H, Madar H, Sentilhes L. Prevalence and risk factors for postpartum depression 2 months after a vaginal delivery: a prospective multicenter study. Am J Obstet Gynecol 2024; 230:S1128-S1137.6. [PMID: 38193879 DOI: 10.1016/j.ajog.2023.08.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 08/25/2023] [Accepted: 08/25/2023] [Indexed: 01/10/2024]
Abstract
BACKGROUND Very little is known about the prevalence and risk factors of postpartum depression among women with vaginal births without major pregnancy complications. OBJECTIVE This study aimed to assess the prevalence of postpartum depression and identify its characteristics 2 months after singleton vaginal delivery at or near term. STUDY DESIGN This was an ancillary cohort study of the TRanexamic Acid for Preventing Postpartum Hemorrhage After Vaginal Delivery randomized controlled trial, which was conducted in 15 French hospitals in 2015-2016 and enrolled women with singleton vaginal deliveries after 35 weeks of gestation. After randomization, the characteristics of labor, delivery, and the immediate postpartum experience, including the experience of childbirth, were prospectively collected. Medical records provided women's other characteristics, particularly any psychiatric history. Of note, 2 months after childbirth, provisional postpartum depression diagnosis was defined as a score of ≥13 on the Edinburgh Postnatal Depression Scale, a validated self-administered questionnaire. The corrected prevalence of postpartum depression was calculated with the inverse probability weighting method to take nonrespondents into account. Associations between potential risk factors and postpartum depression were analyzed by multivariate logistic regression. Moreover, an Edinburgh Postnatal Depression Scale cutoff value of ≥11 was selected to perform a sensitivity analysis. RESULTS The questionnaire was returned by 2811 of 3891 women (72.2% response rate). The prevalence rates of the provisional diagnosis were 9.9% (95% confidence interval, 8.6%-11.3%) defined by an Edinburgh Postnatal Depression Scale score of ≥13 and 15.5% (95% confidence interval, 14.0%-17.1%) with a cutoff value of ≥11. The characteristics associated with higher risks of postpartum depression in multivariate analysis were mostly related to prepregnancy characteristics, specifically age of <25 years (adjusted odds ratio, 1.8; 95% confidence interval, 1.1-2.9) and advanced age (adjusted odds ratio, 1.8; 95% confidence interval, 1.2-2.6), migration from North Africa (adjusted odds ratio, 2.9; 95% confidence interval, 1.9-4.4), previous abortion (adjusted odds ratio, 1.4; 95% confidence interval, 1.0-2.0), and psychiatric history (adjusted odds ratio, 2.9; 95% confidence interval, 1.8-4.8). Some characteristics of labor and delivery, such as induced labor (adjusted odds ratio, 1.5; 95% confidence interval, 1.1-2.0) and operative vaginal delivery (adjusted odds ratio, 1.4; 95% confidence interval, 1.0-2.0), seemed to be associated with postpartum depression. In addition, bad memories of childbirth in the immediate postpartum were strongly associated with postpartum depression symptoms at 2 months after giving birth (adjusted odds ratio, 2.4; 95% confidence interval, 1.3-4.2). CONCLUSION Approximately 10% of women with vaginal deliveries have postpartum depression symptoms, assessed by a score of ≥13 on the depression scale that was used at 2 months. Prepregnancy vulnerability factors; obstetrical characteristics, such as induced labor and operative vaginal delivery; and bad memories of childbirth 2 days after delivery were the main factors associated with this provisional diagnosis. A screening approach that targets risk factors may help to identify women at risk of postpartum depression who could benefit from early intervention.
Collapse
Affiliation(s)
- Alizée Froeliger
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux, France; Perinatal Obstetrical and Pediatric Epidemiology Research Team, Center for Research on Epidemiology and Statistics, National Institute of Health and Medical Research, Université Paris Cité, Paris, France
| | - Catherine Deneux-Tharaux
- Perinatal Obstetrical and Pediatric Epidemiology Research Team, Center for Research on Epidemiology and Statistics, National Institute of Health and Medical Research, Université Paris Cité, Paris, France
| | - Lola Loussert
- Perinatal Obstetrical and Pediatric Epidemiology Research Team, Center for Research on Epidemiology and Statistics, National Institute of Health and Medical Research, Université Paris Cité, Paris, France; Department of Obstetrics and Gynecology, Toulouse University Hospital, Toulouse, France
| | - Hanane Bouchghoul
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux, France
| | - Hugo Madar
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux, France
| | - Loïc Sentilhes
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux, France.
| |
Collapse
|
2
|
Froeliger A, Deneux-Tharaux C, Madar H, Bouchghoul H, Le Ray C, Sentilhes L. Closed- or open-glottis pushing for vaginal delivery: a planned secondary analysis of the TRAnexamic Acid for Preventing postpartum hemorrhage after vaginal delivery study. Am J Obstet Gynecol 2024; 230:S879-S889.e4. [PMID: 37633725 DOI: 10.1016/j.ajog.2023.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 07/11/2023] [Indexed: 08/28/2023]
Abstract
BACKGROUND The effect on obstetrical outcomes of closed- or open-glottis pushing is uncertain among both nulliparous and parous women. OBJECTIVE This study aimed to assess the association between open- or closed-glottis pushing and mode of delivery after an attempted singleton vaginal birth at or near term. STUDY DESIGN This was an ancillary planned cohort study of the TRAAP (TRAnexamic Acid for Preventing postpartum hemorrhage after vaginal delivery) randomized controlled trial, conducted in 15 French maternity units from 2015 to 2016 that enrolled women with an attempted singleton vaginal delivery after 35 weeks' gestation. After randomization, characteristics of labor and delivery were prospectively collected, with special attention to active second-stage pushing and a specific planned questionnaire completed immediately after birth by the attending care provider. The exposure was the mode of pushing, classified into 2 groups: closed- or open-glottis. The main endpoint was operative vaginal delivery. Secondary endpoints were items of maternal morbidity, including severe perineal laceration, episiotomy, postpartum hemorrhage, duration of the second stage of labor, and a composite severe neonatal morbidity outcome. We also assessed immediate maternal satisfaction, experience of delivery, and psychological status 2 months after delivery. The associations between mode of pushing and outcome were analyzed by multivariate logistic regression to control for confounding bias, with multilevel mixed-effects analysis, and a random intercept for center. RESULTS Among 3041 women included in our main analysis, 2463 (81.0%) used closed-glottis pushing and 578 (19.0%) open-glottis pushing; their respective operative vaginal delivery rates were 19.1% (n=471; 95% confidence interval, 17.6-20.7) and 12.5% (n=72; 95% confidence interval, 9.9-15.4; P<.001). In an analysis stratified according to parity and after controlling for available confounders, the rate of operative vaginal delivery did not differ between the groups among nulliparous women: 28.7% (n=399) for the closed-glottis and 27.5% (n=64) for the open-glottis group (adjusted odds ratio, 0.93; 95% confidence interval, 0.65-1.33; P=.7). The operative vaginal delivery rate was significantly lower for women using open- compared with closed-glottis pushing in the parous population: 2.3% (n=8) for the open- and 6.7% (n=72) for the closed-glottis groups (adjusted odds ratio, 0.43; 95% confidence interval, 0.19-0.90; P=.03). Other maternal and neonatal outcomes did not differ between the 2 modes of pushing among either the nulliparous or parous groups. CONCLUSION Among nulliparous women with singleton pregnancies at term, the risk of operative vaginal birth did not differ according to mode of pushing. These results will inform shared decision-making about the mode of pushing during the second stage of labor.
Collapse
Affiliation(s)
- Alizée Froeliger
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux, France
| | - Catherine Deneux-Tharaux
- Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Centre of Research in Epidemiology and Statistics, Institut National de la Sante et de la Recherche Medicale, Université Paris Cité, Paris, France
| | - Hugo Madar
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux, France
| | - Hanane Bouchghoul
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux, France
| | - Camille Le Ray
- Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Centre of Research in Epidemiology and Statistics, Institut National de la Sante et de la Recherche Medicale, Université Paris Cité, Paris, France; Assistance Publique - Hôpitaux de Paris, Maternity Port Royal, Paris, France
| | - Loïc Sentilhes
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux, France.
| |
Collapse
|
3
|
Madar H, Deneux-Tharaux C, Sentilhes L. Shock index as a predictor of postpartum haemorrhage after vaginal delivery: Secondary analysis of a multicentre randomised controlled trial. BJOG 2024; 131:343-352. [PMID: 37555480 DOI: 10.1111/1471-0528.17634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 06/09/2023] [Accepted: 07/22/2023] [Indexed: 08/10/2023]
Abstract
OBJECTIVE To describe the shock index (SI) distribution during the first 2 hours after delivery and to evaluate its performance when measured 15 and 30 minutes after delivery for predicting postpartum haemorrhage (PPH) occurrence in the general population of parturients after vaginal delivery. DESIGN Secondary analysis of a multicentre randomised controlled trial testing prophylactic administration of tranexamic acid versus placebo in addition to prophylactic oxytocin to prevent PPH. SETTING 15 French maternity units in 2015-2016. SAMPLE 3891 women with a singleton live fetus ≥35 weeks, born vaginally. METHODS For each PPH-related predicted outcome, we calculated the area under the receiver operating characteristic curve (AUROC) values of the SI at 15 and 30 minutes after delivery and its predictive performance for SI cut-off values of 0.7, 0.9 and 1.1. MAIN OUTCOME MEASURES Quantitative blood loss ≥1000 ml (QBL ≥1000 ml) measured in a graduated collector bag and provider-assessed clinically significant PPH (cPPH). RESULTS Prevalence of QBL ≥1000 ml and cPPH was respectively 2.7% (104/3839) and 9.1% (354/3891). The distributions of the SI at 15 and 30 minutes after delivery were similar with a median value of 0.73 and 97th percentile of 1.11 for both. The AUROC values of the 15-minute SI for discriminating QBL ≥1000 ml and cPPH were respectively 0.66 (lower limit of the 95% confidence interval [LCI] 0.60) and 0.56 (LCI 0.52); and for the 30-minute SI 0.68 (LCI 0.61) and 0.49 (LCI 0.43). CONCLUSIONS The shock index at 15 and 30 minutes after delivery did not satisfactorily predict either QBL ≥1000 ml or clinical PPH.
Collapse
Affiliation(s)
- Hugo Madar
- Université Paris Cité, Women's Health IHM, U1153, Centre of Research In Epidemiology and Statistics, Obstetrical, Perinatal and Paediatric Epidemiology EPOPé Research Team, INSERM, INRAE, Paris, France
- Department of Obstetrics and Gynaecology, Bordeaux University Hospital, Bordeaux, France
| | - Catherine Deneux-Tharaux
- Université Paris Cité, Women's Health IHM, U1153, Centre of Research In Epidemiology and Statistics, Obstetrical, Perinatal and Paediatric Epidemiology EPOPé Research Team, INSERM, INRAE, Paris, France
| | - Loïc Sentilhes
- Department of Obstetrics and Gynaecology, Bordeaux University Hospital, Bordeaux, France
| |
Collapse
|
4
|
Braund S, Deneux-Tharaux C, Sentilhes L, Seco A, Rozenberg P, Goffinet F. Induction of labor and risk of postpartum hemorrhage in women with vaginal delivery: A propensity score analysis. Int J Gynaecol Obstet 2024; 164:732-740. [PMID: 37568268 DOI: 10.1002/ijgo.15043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 07/13/2023] [Accepted: 07/25/2023] [Indexed: 08/13/2023]
Abstract
OBJECTIVE To explore the association between induction of labor (IOL) and postpartum hemorrhage (PPH) after vaginal delivery. METHODS We included women from the merged database of three randomized prospective trials (TRACOR, CYTOCINON, and TRAAP) that measured postpartum blood loss precisely, with standardized methods. IOL was considered overall and according to its method. The association between IOL and PPH was tested by multivariate logistic regression modeling, adjusted for confounders, and by propensity score matching. The role of potential intermediate factors, i.e. estimated quantity of oxytocin administered during labor and operative vaginal delivery, was assessed with structural equation modeling. RESULTS Labor was induced for 1809 of the 9209 (19.6%) women. IOL was associated with a significantly higher risk of PPH of 500 mL or more (adjusted odds ratio 1.56, 95% confidence interval 1.42-1.70) and PPH of 1000 mL or more (adjusted odds ratio 1.51, 95% confidence interval 1.16-1.96). The risk of PPH increased similarly regardless of the method of induction. The results were similar after propensity score matching (odds ratio for PPH ≥500 mL 1.57, 95% confidence interval 1.33-1.87, odds ratio for PPH ≥1000 mL 1.57, 95% confidence interval 1.06-2.07). Structural equation modeling showed that 34% of this association was mediated by the quantity of oxytocin administered during labor and 1.3% by women who underwent operative vaginal delivery. CONCLUSION Among women with vaginal delivery, the risk of PPH is higher in those with IOL, regardless of its method, and after accounting for indication bias. The quantity of oxytocin administered during labor may explain one third of this association.
Collapse
Affiliation(s)
- Sophia Braund
- Université Paris Cité, INSERM U1153, Obstetrical, Perinatal and Pediatric Epidemiology (EPOPé) Research Team, Center for Research in Epidemiology and Statistics (CRESS), Paris, France
- Department of Obstetrics and Gynecology, Charles Nicolle University Hospital, Rouen, France
| | - Catherine Deneux-Tharaux
- Université Paris Cité, INSERM U1153, Obstetrical, Perinatal and Pediatric Epidemiology (EPOPé) Research Team, Center for Research in Epidemiology and Statistics (CRESS), Paris, France
| | - Loïc Sentilhes
- Department of Obstetrics and Gynecology, Pellegrin University Hospital, Bordeaux, France
| | - Aurélien Seco
- Clinical Research Unit of Paris Descartes Necker Cochin, APHP, Paris, France
| | | | - François Goffinet
- Université Paris Cité, INSERM U1153, Obstetrical, Perinatal and Pediatric Epidemiology (EPOPé) Research Team, Center for Research in Epidemiology and Statistics (CRESS), Paris, France
- Department of Obstetrics and Gynecology, Cochin Port-Royal Hospital, APHP, Paris, France
| |
Collapse
|
5
|
Li P, Li Y, Zhang Y, Zhao L, Li X, Bao J, Guo J, Yan J, Zhou K, Sun M. Incidence, temporal trends and risk factors of puerperal infection in Mainland China: a meta-analysis of epidemiological studies from recent decade (2010-2020). BMC Pregnancy Childbirth 2023; 23:815. [PMID: 37996780 PMCID: PMC10666378 DOI: 10.1186/s12884-023-06135-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 11/17/2023] [Indexed: 11/25/2023] Open
Abstract
BACKGROUND Puerperal infection (PI) is a severe threat to maternal health. The incidence and risk of PI should be accurately quantified and conveyed for prior decision-making. This study aims to assess the quality of the published literature on the epidemiology of PI, and synthesize them to identify the temporal trends and risk factors of PI occurring in Mainland China. METHODS This review was registered in PROSPERO (CRD42021267399). Putting a time frame on 2010 to March 2022, we searched Cochrane library, Embase, Google Scholar, MEDLINE, Web of Science, China biology medicine, China national knowledge infrastructure and Chinese medical current contents, and performed a meta-analysis and meta-regression to pool the incidence of PI and the effects of risk factors on PI. RESULTS A total of 49 eligible studies with 133,938 participants from 17 provinces were included. The pooled incidence of PI was 4.95% (95%CIs, 4.46-5.43), and there was a statistical association between the incidence of PI following caesarean section and the median year of data collection. Gestational hypertension (OR = 2.14), Gestational diabetes mellitus (OR = 1.82), primipara (OR = 0.81), genital tract inflammation (OR = 2.51), anemia during pregnancy (OR = 2.28), caesarean section (OR = 2.03), episiotomy (OR = 2.64), premature rupture of membrane (OR = 2.54), prolonged labor (OR = 1.32), placenta remnant (OR = 2.59) and postpartum hemorrhage (OR = 2.43) have significant association with PI. CONCLUSIONS Maternal infection remains a crucial complication during puerperium in Mainland China, which showed a nationwide temporal rising following caesarean section in the past decade. The opportunity to prevent unnecessary PI exists in several simple but necessary measures and it's urgent for clinicians and policymakers to focus joint efforts on promoting the bundle of evidence-based practices.
Collapse
Affiliation(s)
- Peng Li
- Department of Hospital Infection Control, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Zhengzhou, China
| | - Yan Li
- Department of Hospital Infection Control, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Zhengzhou, China
| | - Youjian Zhang
- Department of Hospital Infection Control, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Zhengzhou, China
| | - Lina Zhao
- Department of Obstetrics, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Zhengzhou, China
| | - Xiaohong Li
- Department of Obstetrics, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Zhengzhou, China
| | - Junzhe Bao
- College of Public Health, Zhengzhou University, Zhengzhou, China
| | - Jianing Guo
- Department of Hospital Infection Control, Henan Province Women and Children's Hospital, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jun Yan
- Department of Obstetrics, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Zhengzhou, China
| | - Ke Zhou
- Department of Obstetrics, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Zhengzhou, China
| | - Mingjie Sun
- Department of Hospital Infection Control, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Zhengzhou, China.
| |
Collapse
|
6
|
Rozenberg P, Sentilhes L, Goffinet F, Vayssiere C, Senat MV, Haddad B, Morel O, Garabedian C, Vivanti A, Perrotin F, Kayem G, Azria E, Raynal P, Verspyck E, Sananes N, Gallot D, Bretelle F, Seco A, Winer N, Deneux-Tharaux C. Efficacy of early intrauterine balloon tamponade for immediate postpartum hemorrhage after vaginal delivery: a randomized clinical trial. Am J Obstet Gynecol 2023; 229:542.e1-542.e14. [PMID: 37209893 DOI: 10.1016/j.ajog.2023.05.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 05/08/2023] [Accepted: 05/14/2023] [Indexed: 05/22/2023]
Abstract
BACKGROUND Many questions remain about the appropriate use of intrauterine balloon devices in postpartum hemorrhage after vaginal delivery refractory to first-line uterotonics. Available data suggest that early use of intrauterine balloon tamponade might be beneficial. OBJECTIVE This study aimed to compare the effect of intrauterine balloon tamponade used in combination with second-line uterotonics vs intrauterine balloon tamponade used after the failure of second-line uterotonic treatment on the rate of severe postpartum hemorrhage in women with postpartum hemorrhage after vaginal delivery refractory to first-line uterotonics. STUDY DESIGN This multicenter, randomized, controlled, parallel-group, nonblinded trial was conducted at 18 hospitals and enrolled 403 women who had just given birth vaginally at 35 to 42 weeks of gestation. The inclusion criteria were a postpartum hemorrhage refractory to first-line uterotonics (oxytocin) and requiring a second-line uterotonic treatment with sulprostone (E1 prostaglandin). In the study group, the sulprostone infusion was combined with intrauterine tamponade by an ebb balloon performed within 15 minutes of randomization. In the control group, the sulprostone infusion was started alone within 15 minutes of randomization, and if bleeding persisted 30 minutes after the start of sulprostone infusion, intrauterine tamponade using the ebb balloon was performed. In both groups, if the bleeding persisted 30 minutes after the insertion of the balloon, an emergency radiological or surgical invasive procedure was performed. The primary outcome was the proportion of women who either received ≥3 units of packed red blood cells or had a calculated peripartum blood loss of >1000 mL. The prespecified secondary outcomes were the proportions of women who had a calculated blood loss of ≥1500 mL, any transfusion, an invasive procedure and women who were transferred to the intensive care unit. The analysis of the primary outcome with the triangular test was performed sequentially throughout the trial period. RESULTS At the eighth interim analysis, the independent data monitoring committee concluded that the incidence of the primary outcome did not differ between the 2 groups and stopped inclusions. After 11 women were excluded because they met an exclusion criterion or withdrew their consent, 199 and 193 women remained in the study and control groups, respectively, for the intention-to-treat analysis. The women's baseline characteristics were similar in both groups. Peripartum hematocrit level change, which was needed for the calculation of the primary outcome, was missing for 4 women in the study group and 2 women in the control group. The primary outcome occurred in 131 of 195 women (67.2%) in the study group and 142 of 191 women (74.3%) in the control group (risk ratio, 0.90; 95% confidence interval, 0.79-1.03). The groups did not differ substantially for rates of calculated peripartum blood loss pf ≥1500 mL, any transfusion, invasive procedure, and admission to an intensive care unit. Endometritis occurred in 5 women (2.7%) in the study group and none in the control group (P=.06). CONCLUSION The early use of intrauterine balloon tamponade did not reduce the incidence of severe postpartum hemorrhage compared with its use after the failure of second-line uterotonic treatment and before recourse to invasive procedures.
Collapse
Affiliation(s)
- Patrick Rozenberg
- Department of Obstetrics and Gynecology, American Hospital of Paris, Neuilly-sur-Seine, France; Université Paris-Saclay, UVSQ, Inserm, Equipe U1018, Epidémiologie clinique, CESP, Montigny-le-Bretonneux, France.
| | - Loïc Sentilhes
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux, France
| | - François Goffinet
- Department of Obstetrics and Gynecology, Hôpital Cochin-Port Royal, AP-HP, Paris, France
| | - Christophe Vayssiere
- Department of Obstetrics and Gynecology, Hôpital Paule de Viguier, CHU, Toulouse, France
| | - Marie-Victoire Senat
- Department of Obstetrics and Gynecology, Hôpital Bicêtre AP-HP, Le Kremlin-Bicêtre, France
| | - Bassam Haddad
- Department of Obstetrics and Gynecology, Hôpital Intercommunal de Créteil, Créteil, France
| | - Olivier Morel
- Department of Obstetrics and Gynecology, Centre Hospitalier Régional Universitaire de Nancy, Nancy, France
| | - Charles Garabedian
- Department of Obstetrics and Gynecology, Hôpital Jeanne de Flandre, Lille, France
| | - Alexandre Vivanti
- Department of Obstetrics and Gynecology, Hôpital Antoine-Béclère AP-HP, Clamart, France
| | - Franck Perrotin
- Department of Obstetrics and Gynecology, Hôpital Bretonneau, Tours, France
| | - Gilles Kayem
- Department of Obstetrics and Gynecology, Hôpital Armand Trousseau AP-HP, Paris, France
| | - Elie Azria
- Department of Obstetrics and Gynecology, Hôpital Saint Joseph, Paris, France
| | - Pierre Raynal
- Department of Obstetrics and Gynecology, Hôpital André Mignot, Le Chesnay-Rocquencourt, France
| | - Eric Verspyck
- Department of Obstetrics and Gynecology, Centre Hospitalier Universitaire de Rouen, Rouen, France
| | - Nicolas Sananes
- Department of Obstetrics and Gynecology, Centre Médico-Chirurgical et Obstétrical, Schiltigheim, France
| | - Denis Gallot
- Department of Obstetrics and Gynecology, CHU Clermont-Ferrand Site Estaing, Clermont Ferrand, France
| | - Florence Bretelle
- Department of Obstetrics and Gynecology, Hôpital Nord, Marseille, France
| | - Aurélien Seco
- Clinical Research Unit Necker Cochin, APHP, Paris, France
| | - Norbert Winer
- Department of Obstetrics and Gynecology, Hôpital Mère-Enfant, Nantes, France; NUN INRAE UMR 1280, PhAN Nantes University, Nantes, France
| | - Catherine Deneux-Tharaux
- Obstetrical Perinatal and Paediatric Epidemiology Research Team, Université de Paris Cité, CRESS, INSERM, INRA, Paris, France
| |
Collapse
|
7
|
Erkaya R, Karabulutlu Ö, Çalik KY. Uterine massage to reduce blood loss after vaginal delivery. Health Care Women Int 2023; 44:1346-1362. [PMID: 34369853 DOI: 10.1080/07399332.2021.1940184] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Accepted: 06/03/2021] [Indexed: 10/20/2022]
Abstract
Postpartum hemorrhage (PPH) is a major cause of maternal mortality and disability. A need for simple, inexpensive techniques to prevent PPH and provide treatment exists, particularly in cases where uterotonics cannot be accessed. Uterine massage is recommended as part of the routine active management of the third stage of labor. This study was conducted to determine the effectiveness of uterine massage after delivery of the placenta in reducing postpartum blood loss. Thus, a randomized controlled trial was conducted in Turkey between March 2018 and September 2018. A total of 176 pregnant women (88 in the control and 88 in the uterine massage groups) were randomly allocated to the two groups: one group receiving sustained uterine massage, while the other comprising the control group. The uterine massage group was administered transabdominal uterine massage, starting immediately after delivery of the placenta and continuing every 15 min for a duration of 2 h until the uterus hardened. The blood loss within 2 h of delivery was recorded. Level of significance was taken as p < 0.05, and the chi-square, t, and Mann-Whitney U tests as well as Spearman's correlation and linear regression were employed in the analysis of the data. The average amount blood loss within 2 h of the delivery was significantly higher in the control group than in the massage group (X = 170.49 ± 61.46 and X = 186.20 ± 47.59, p < 0.05). A statistically significant difference was present between the uterine massage and control groups in terms of hemoglobin, hematocrit, WBC, and RCB pre-delivery and pre-discharge (first 24 h) values and in the use of additional uterotonics and the amount of blood loss (p < 0.05). The results of the analysis show that postpartum uterine massage has a reducing effect on the amount of PPH.
Collapse
Affiliation(s)
- Reyhan Erkaya
- Faculty of Health Science, Obstetrics and Gynaecology Nursing Department, Karadeniz Technical University, Trabzon, Turkey
| | - Özlem Karabulutlu
- Faculty of Health Sciences, Department of Midwifery, Kafkas University, Kars, Turkey
| | - Kıymet Yeşilçiçek Çalik
- Faculty of HealthScience, Obstetrics and Gynaecology Nursing Department, Karadeniz Technical University, Trabzon, Turkey
| |
Collapse
|
8
|
Madar H, Sentilhes L, Goffinet F, Bonnet MP, Rozenberg P, Deneux-Tharaux C. Comparison of quantitative and calculated postpartum blood loss after vaginal delivery. Am J Obstet Gynecol MFM 2023; 5:101065. [PMID: 37356572 DOI: 10.1016/j.ajogmf.2023.101065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 06/09/2023] [Accepted: 06/19/2023] [Indexed: 06/27/2023]
Abstract
BACKGROUND Because there is no consensus on the method of assessing postpartum blood loss, the comparability and relevance of the postpartum hemorrhage-related literature are questionable. Quantitative blood loss assessment using a volumetric technique with a graduated collector bag has been proposed to overcome limitations of intervention-based outcomes but remains partly subjective and potentially biased by amniotic fluid or missed out-of-bag losses. Calculated blood loss based on laboratory parameters has been studied and used as an objective method expected to reflect total blood loss. However, few studies have compared quantitative with calculated blood loss. OBJECTIVE This study aimed to compare the distribution of postpartum blood loss after vaginal delivery assessed by 2 methods-quantitative and calculated blood loss-and the incidence of abnormal blood loss with each method. STUDY DESIGN Data were obtained from the merged database of 3 multicenter, randomized controlled trials, all testing different interventions to prevent postpartum blood loss in individuals with a singleton live fetus at ≥35 weeks of gestation, born vaginally. All 3 trials measured blood loss volume by using a graduated collector bag. Hematocrit was measured in the eighth or ninth month of gestation and on day 2 postpartum. The 2 primary outcomes were: quantitative blood loss, defined by the total volume of blood loss measured in a graduated collector bag, and calculated blood loss, mathematically defined from the peripartum hematocrit change (estimated blood volume × [(antepartum hematocrit-postpartum hematocrit)/antepartum hematocrit], where estimated blood volume [mL]=booking weight [kg] × 85). We modeled the association between positive quantitative blood loss and positive calculated blood loss with polynomial regression and calculated the Spearman correlation coefficient. RESULTS Among the 8341 individuals included in this analysis, the median quantitative blood loss (100 mL; interquartile range, 50-275) was significantly lower than the median calculated blood loss (260 mL; interquartile range, 0-630) (P<.05). The incidence of abnormal blood loss was lower with quantitative blood loss than calculated blood loss for all 3 thresholds: for ≥500 mL, it was 9.6% (799/8341) and 32.3% (2691/8341), respectively; for ≥1000 mL, 2.1% (176/8341) and 11.5% (959/8341); and for ≥2000 mL, 0.1% (10/8341) and 1.4% (117/8341) (P<.05). Quantitative blood loss and calculated blood loss were significantly but moderately correlated (Spearman coefficient=0.44; P<.05). The association between them was not linear, and their difference tended to increase with blood loss. Negative calculated blood loss values occurred in 23% (1958/8341) of individuals; among them, >99% (1939/1958) had quantitative blood loss ≤500 mL. CONCLUSION Quantitative and calculated blood loss were significantly but moderately correlated after vaginal delivery. However, clinicians should be aware that quantitative blood loss is lower than calculated blood loss, with a difference that tended to rise as blood loss increased.
Collapse
Affiliation(s)
- Hugo Madar
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux, France (Drs Madar and Sentilhes).
| | - Loïc Sentilhes
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux, France (Drs Madar and Sentilhes)
| | - François Goffinet
- Université Paris Cité, Women's Health IHM, U1153, Centre of Research In Epidemiology and Statistics, Obstetrical, Perinatal and Pediatric Epidemiology EPOPé Research Team, INSERM, INRAE, Paris, France (Drs Madar, Goffinet, Bonnet, and Deneux-Tharaux); Maternité Port-Royal, Department of Obstetrics and Gynecology, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, FHU PREMA, Paris, France (Dr Goffinet)
| | - Marie-Pierre Bonnet
- Université Paris Cité, Women's Health IHM, U1153, Centre of Research In Epidemiology and Statistics, Obstetrical, Perinatal and Pediatric Epidemiology EPOPé Research Team, INSERM, INRAE, Paris, France (Drs Madar, Goffinet, Bonnet, and Deneux-Tharaux); Sorbonne Université, Department of Anesthesia and Intensive Care, Armand Trousseau Hospital, DMU DREAM, GRC 29, Assistance Publique-Hôpitaux de Paris, Paris, France (Dr Bonnet)
| | - Patrick Rozenberg
- Department of Obstetrics and Gynecology, American Hospital of Paris, Neuilly-sur-Seine, France (Dr Rozenberg); Department of Obstetrics and Gynecology, Poissy-Saint Germain Hospital, Poissy, France (Dr Rozenberg); Paris Saclay University, UVSQ, INSERM, Team U1018, Clinical Epidemiology, CESP, Montigny-le-Bretonneux, France (Dr Rozenberg)
| | - Catherine Deneux-Tharaux
- Université Paris Cité, Women's Health IHM, U1153, Centre of Research In Epidemiology and Statistics, Obstetrical, Perinatal and Pediatric Epidemiology EPOPé Research Team, INSERM, INRAE, Paris, France (Drs Madar, Goffinet, Bonnet, and Deneux-Tharaux)
| |
Collapse
|
9
|
Bouchghoul H, Hamel JF, Mattuizzi A, Ducarme G, Froeliger A, Madar H, Sentilhes L. Predictors of shoulder dystocia at the time of operative vaginal delivery: a prospective cohort study. Sci Rep 2023; 13:2658. [PMID: 36792626 PMCID: PMC9931691 DOI: 10.1038/s41598-023-29109-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 01/30/2023] [Indexed: 02/17/2023] Open
Abstract
Our aim was to identify factors associated with shoulder dystocia following an attempted operative vaginal delivery (aOVD) in a prospective cohort study and to evaluate whether these factors can be used to accurately predict shoulder dystocia by building a score of shoulder dystocia risk. This was a planned secondary analysis of a prospective cohort study of deliveries with aOVD at term from 2008-2013. Cases were defined as women with shoulder dystocia following an aOVD defined as a delivery that requires additional obstetric maneuvers following failure of gentle downward traction on the fetal head to effect delivery of the shoulders. Multivariate logistic regression analyses were performed to determine risk factors for shoulder dystocia. Shoulder dystocia occurred in 57 (2.7%) of the 2118 women included. In the whole cohort, women with shoulder dystocia more often had a history of shoulder dystocia (3.5% vs. 0.2%, p = 0.01), and there was a significant interaction between aOVD and gestational age and the duration of the second stage of labor: women with shoulder dystocia more often had a gestational age > 40 weeks and a second stage of labor longer than 3 h specifically for midpelvic aOVD. In multivariable analysis, a history of shoulder dystocia was the only factor independently associated with shoulder dystocia following aOVD (aOR 27.00, 95% CI 4.10-178.00). The AUC for the receiver operating characteristic curve generated using a multivariate model with term interaction with head station was 0.70 (95% CI 0.62-0.77). The model failed to accurately predict shoulder dystocia.
Collapse
Affiliation(s)
- Hanane Bouchghoul
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, Place Amélie Raba Léon, 33076, Bordeaux, France.
| | - Jean-François Hamel
- grid.411147.60000 0004 0472 0283Clinical Research Center, Angers University Hospital, Angers, France
| | - Aurélien Mattuizzi
- grid.42399.350000 0004 0593 7118Department of Obstetrics and Gynecology, Bordeaux University Hospital, Place Amélie Raba Léon, 33076 Bordeaux, France
| | - Guillaume Ducarme
- Department of Obstetrics and Gynecology, General Hospital, La Roche Sur Yon, France
| | - Alizée Froeliger
- grid.42399.350000 0004 0593 7118Department of Obstetrics and Gynecology, Bordeaux University Hospital, Place Amélie Raba Léon, 33076 Bordeaux, France
| | - Hugo Madar
- grid.42399.350000 0004 0593 7118Department of Obstetrics and Gynecology, Bordeaux University Hospital, Place Amélie Raba Léon, 33076 Bordeaux, France
| | - Loïc Sentilhes
- grid.42399.350000 0004 0593 7118Department of Obstetrics and Gynecology, Bordeaux University Hospital, Place Amélie Raba Léon, 33076 Bordeaux, France
| |
Collapse
|
10
|
Li J, Chen J, Wang Y, Hu L, Zhang R, Chen W. Doppler Imaging Assessment of Changes of Blood Flow in Adenomyosis After Higher-Dose Oxytocin: A Randomized Controlled Trial. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2022; 41:2413-2421. [PMID: 35005793 DOI: 10.1002/jum.15923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 11/19/2021] [Accepted: 11/29/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVES To assess the changes of blood flow in adenomyosis (AM) after higher-dose oxytocin (OT) in different doses, and to evaluate the safety for patients. METHODS A total of 124 patients with AM were randomly divided into 4 groups with continuous intravenous infusion of OT as 0.06, 0.12, 0.24 and 0.36 U/min, respectively. The changes of arteries of AM before and after intravenous infusion of OT were observed by color Doppler ultrasound. The changes of blood flow volume of the artery of AM before and after intravenous infusion of OT were compared among the 4 groups, and the vital signs and adverse drug reactions were monitored during intravenous drip. RESULTS During the trial, no severe adverse reactions occurred and the vital signs of all the patients were stable. Among the 4 groups, it was found that there was a significant difference in the change of blood flow volume of blood artery in AM lesions between 0.06 U/min OT group and the other three groups after intravenous drip of OT (P < .05), but there was no significant difference in blood flow volume among the three groups (P > .05), and the difference of adverse drug reactions was statistically significant with the increase of OT dose (P < .05). CONCLUSION OT can effectively reduce the blood flow volume of AM lesions, and continuous intravenous infusion of 0.12 U/min OT is an appropriate dose that can not only minimize the blood flow volume but also reduce the incidence of adverse drug reactions.
Collapse
Affiliation(s)
- JunShu Li
- State Key Laboratory of Ultrasound in Medicine and Engineering, College of Biomedical Engineering, Chongqing Medical University, Chongqing, China
- Department of Obstetrics and Gynecology, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, China
| | - JinYun Chen
- State Key Laboratory of Ultrasound in Medicine and Engineering, College of Biomedical Engineering, Chongqing Medical University, Chongqing, China
- Ultrasound Ablation Center, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yong Wang
- State Key Laboratory of Ultrasound in Medicine and Engineering, College of Biomedical Engineering, Chongqing Medical University, Chongqing, China
- Department of Ultrasound Diagnosis, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, China
| | - Liang Hu
- State Key Laboratory of Ultrasound in Medicine and Engineering, College of Biomedical Engineering, Chongqing Medical University, Chongqing, China
- Ultrasound Ablation Center, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Rong Zhang
- State Key Laboratory of Ultrasound in Medicine and Engineering, College of Biomedical Engineering, Chongqing Medical University, Chongqing, China
- Ultrasound Ablation Center, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - WenZhi Chen
- State Key Laboratory of Ultrasound in Medicine and Engineering, College of Biomedical Engineering, Chongqing Medical University, Chongqing, China
- Department of Obsterics and Gynecology, Chongqing Haifu Hospital, Chongqing, China
| |
Collapse
|
11
|
Trial of Labor Compared With Elective Cesarean Delivery for Low-Lying Placenta. Obstet Gynecol 2022; 140:429-438. [PMID: 35926200 DOI: 10.1097/aog.0000000000004890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 05/26/2022] [Indexed: 01/05/2023]
Abstract
OBJECTIVE To compare outcomes of women with low-lying placenta by planned mode of delivery and distance from the internal os distance. METHODS Six tertiary maternity hospitals in France participated in this retrospective multicenter study of births from 2007-2012. Women with low-lying placenta , defined as an internal os distance of 20 mm or less, who gave birth after 35 weeks of gestation were included and classified in the planned trial-of-labor or elective cesarean delivery groups. The primary endpoint was severe postpartum hemorrhage (PPH) defined as blood loss exceeding 1,000 mL. Secondary outcomes were composite variables of severe maternal and neonatal morbidity. We used multivariable logistic regression and propensity scores to compare outcomes by planned mode of delivery. RESULTS Among 128,233 births during the study period, 171 (0.13%) women had low-lying placenta: 70 (40.9%) in the trial-of-labor group and 101 (59.1%) who underwent elective cesarean delivery. The rate of severe PPH was 22.9% (16/70, 95% CI 13.7-34.4) for the trial-of-labor group and 23.0% (23/101, 95% CI 15.2-32.5) for the cesarean delivery group ( P =.9); severe maternal and neonatal morbidity rates were likewise similar (2.9% vs 2.0% [ P =.7] and 12.9% vs 9.9% [ P =.5], respectively). Trial-of-labor was not significantly associated with a higher rate of severe PPH after multivariable logistic regression and propensity score-weighted analysis (adjusted odds ratio [aOR] 1.42, 95% CI 0.62-3.24 [ P =.4]; and aOR 1.34, 95% CI 0.53-3.38 [ P =.5], respectively). The vaginal delivery rate in the trial-of-labor group was 50.0% (19/38) in those with an internal os distance of 11-20 mm and 18.5% (5/27) in those with a distance of 1-10 mm. CONCLUSION Our results support a policy of offering a trial of labor to women with low-lying placenta after 35 weeks of gestation and an internal os distance of 11-20 mm. An internal os distance of 1-10 mm reduces the likelihood of vaginal birth considerably, compared with 11-20 mm, but without increasing the incidence of severe PPH or severe maternal morbidity.
Collapse
|
12
|
Maternal and Neonatal Morbidity After Attempted Operative Vaginal Delivery. Obstet Gynecol 2022; 139:833-845. [DOI: 10.1097/aog.0000000000004746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 01/27/2022] [Indexed: 11/26/2022]
|
13
|
Igboke FN, Obi VO, Dimejesi BI, Lawani LO. Tranexamic acid for reducing blood loss following vaginal delivery: a double-blind randomized controlled trial. BMC Pregnancy Childbirth 2022; 22:178. [PMID: 35241023 PMCID: PMC8896099 DOI: 10.1186/s12884-022-04462-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 12/29/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Postpartum haemorrhage (PPH) is a major cause of maternal morbidity and mortality worldwide. Tranexamic acid (TXA) is a useful drug for prevention of PPH and merits evaluation in Nigeria, where PPH is the leading cause of maternal death (25%) and severe maternal morbidity. This study evaluates the efficacy of TXA in reducing blood loss following vaginal delivery. METHODS This was a double-blind randomized placebo-controlled study on the efficacy and safety of intravenous TXA in reducing blood loss in women undergoing vaginal delivery in a tertiary hospital. Data analysis was conducted with IBM SPSS software (version 20, Chicago II, USA). P-value < 0.05 was considered statistically significant. RESULTS The mean estimated blood loss was lower in TXA compared with the placebo group. (174.87 ± 119.83 ml versus 341.07 ± 67.97 ml respectively; P < 0.0001). PPH (blood loss > 500 ml) was 5.13% in the study arm compared to the control arm 7.14%- risk ratio (RR) 0.71; 95% CI: 0.38-1.79, p = 0.5956]. Additional uterotonics was required more in the control group compared to the treatment group 14(16.67%) versus 3(3.85%), p-value= 0.007. There were no major complications noticed in the treatment group. CONCLUSION This study demonstrated that intravenous administration of TXA reduced blood loss following vaginal delivery. It also reduced the need for additional uterotonics. However, blood loss greater than 500 was not significantly reduced. TRIAL REGISTRATION This trial was registered retrospectively. Pan African Clinical Trial Registry: PACTR202010828881019 on 12/10/2020.
Collapse
Affiliation(s)
| | | | | | - Lucky Osaheni Lawani
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, M5T 3M6, Canada
| |
Collapse
|
14
|
Isacson M, Thies-Lagergren L, Oras P, Hellström-Westas L, Andersson O. Umbilical cord clamping and management of the third stage of labor: A telephone-survey describing Swedish midwives’ clinical practice. Eur J Midwifery 2022; 6:6. [PMID: 35274089 PMCID: PMC8832505 DOI: 10.18332/ejm/145697] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Revised: 05/29/2021] [Accepted: 01/10/2022] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION The timing of cord clamping impacts children’s short- and long-term well-being. When making clinical decisions, midwives incorporate their tacit and professional knowledge, experience and current evidence. There appears to be a lack of knowledge regarding Swedish midwives’ management of the third stage of labor and cord clamping practice. The aim of this study was to explore Swedish midwives’ clinical practice concerning umbilical cord clamping and the third stage of labor in spontaneous vaginal births. METHODS The study was designed as a cross-sectional telephone survey including 13 questions. Midwives were randomly selected from 48 births units in Sweden. Two midwives from each unit were interviewed. The primary outcome was timing of umbilical cord clamping practice in full-term infants. Secondary outcomes were the management of the third stage of labor including prophylactic use of synthetic oxytocin, the timing of cord clamping in preterm infants, controlled cord traction, uterine massage, and cord milking. RESULTS Altogether, 95 midwives were interviewed. In full-term infants, all midwives preferred late cord clamping. Considerable heterogeneity was seen regarding the practices of synthetic oxytocin administration postpartum, controlled cord traction, uterine massage or cord milking, and cord clamping in preterm infants. CONCLUSIONS Midwives in Sweden modify recommendations regarding delayed cord clamping in a way they might perceive as more natural and practical in their daily, clinical work. The study revealed a reluctance toward the administration of prophylactic oxytocin due to fear that the drug could pass to the infant. An overall large variation of the management of the third stage of labor was seen.
Collapse
Affiliation(s)
- Manuela Isacson
- Neonatology research group, Section of Pediatrics, Department of Clinical Sciences Lund, Faculty of Medicine, Lund University, Lund, Sweden
- Sachs' Children and Youth Hospital, Södersjukhuset, Stockholm, Sweden
| | - Li Thies-Lagergren
- Midwifery research, reproductive, perinatal and sexual health, Department of Health Sciences, Faculty of Medicine, Lund University, Lund, Sweden
- Department of Obstetrics and Gynaecology, Helsingborg Hospital, Helsingborg, Sweden
| | - Paola Oras
- Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden
| | | | - Ola Andersson
- Neonatology research group, Section of Pediatrics, Department of Clinical Sciences Lund, Faculty of Medicine, Lund University, Lund, Sweden
| |
Collapse
|
15
|
Striebich S, Mattern E, Oganowski T, Schäfers R, Ayerle G. Methodological challenges and solution strategies during implementation of a midwife-led multicenter randomized controlled trial (RCT) in maternity hospitals. BMC Med Res Methodol 2021; 21:222. [PMID: 34689745 PMCID: PMC8542460 DOI: 10.1186/s12874-021-01429-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 10/05/2021] [Indexed: 11/10/2022] Open
Abstract
Background Randomized controlled trials (RCTs), especially multicentric, with complex interventions are methodically challenging. Careful planning under everyday conditions in compliance with the relevant international quality standard (Good Clinical Practice [GCP] guideline) is crucial. Specific challenges exist for RCTs conducted in delivery rooms due to various factors that cannot be planned beforehand. Few published RCTs report challenges and problems in implementing complex interventions in maternity wards. In Germany as well as in other countries, midwives and obstetricians have frequently little experience as investigators in clinical trials. Methods The aim is to describe the key methodological and organizational challenges in conducting a multicenter study in maternity wards and the solution strategies applied to them. In particular, project-related and process-oriented challenges for hospital staff are considered. The exemplarily presented randomized controlled trial “BE-UP” investigates the effectiveness of an alternative design of a birthing room on the rate of vaginal births and women-specific outcomes. Results The results are presented in five sectors: 1) Selection of and support for cooperating hospitals: they are to be selected according to predefined criteria, and strategies to offer continuous support in trial implementation must be mapped out. 2) Establishing a process of requesting informed consent: a quality-assured process to inform pregnant women early on must be feasible and effective. 3) Individual digital real-time randomization: In addition to instructing maternity teams, appropriate measures for technical failure must be provided. 4) The standardized birthing room: The complex intervention is to be implemented according to the study protocol yet adapted to the prevailing conditions in the delivery rooms. 5) GCP-compliant documentation: midwives and obstetricians will be instructed in high-quality data collection, supported by external monitoring throughout the trial. Conclusion Since not all potential challenges can be anticipated in the planning of a trial, study teams need to be flexible and react promptly to any problems that threaten recruitment or the implementation of the complex intervention. Thought should be given to the perspectives of midwives and obstetricians as recruiters and how clinic-intern processes could be adapted to correspond with the trial’s requirements. Trial registration The BE-UP study was registered on 07/03/ 2018 in the German Register for Clinical Trials under Reference No. DRKS00012854 and can also be found on the International Clinical Trials Registry Platform (ICTRP) (see https://apps.who.int/trialsearch/Trial2.aspx?TrialID=DRKS0001285).
Collapse
Affiliation(s)
- Sabine Striebich
- Martin Luther University Halle-Wittenberg, Institute of Health and Nursing Science, Magdeburger Str. 8, 06112, Halle (Saale), Germany.
| | - Elke Mattern
- Hochschule für Gesundheit Bochum - University of Applied Sciences, Gesundheitscampus 6 - 8, 44801, Bochum, Germany
| | - Theresa Oganowski
- Hochschule für Gesundheit Bochum - University of Applied Sciences, Gesundheitscampus 6 - 8, 44801, Bochum, Germany
| | - Rainhild Schäfers
- Hochschule für Gesundheit Bochum - University of Applied Sciences, Gesundheitscampus 6 - 8, 44801, Bochum, Germany
| | - Gertrud Ayerle
- Martin Luther University Halle-Wittenberg, Institute of Health and Nursing Science, Magdeburger Str. 8, 06112, Halle (Saale), Germany
| |
Collapse
|
16
|
Hawker L, Weeks A. Postpartum haemorrhage (PPH) rates in randomized trials of PPH prophylactic interventions and the effect of underlying participant PPH risk: a meta-analysis. BMC Pregnancy Childbirth 2020; 20:107. [PMID: 32054453 PMCID: PMC7020586 DOI: 10.1186/s12884-020-2719-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 01/03/2020] [Indexed: 09/18/2023] Open
Abstract
Background Postpartum haemorrhage (PPH) remains a leading cause of maternal mortality. Many trials assessing interventions to prevent PPH base their data on low risk women. It is important to consider the impact data collection methods may have on these results. This review aims to assess trials of PPH prophylaxis by grading trials according to the degree of risk status of the population enrolled in these trials and identify differences in the PPH rates of low risk and high risk populations. Methods Systematic review and meta-analysis using a random-effects model. Trials were identified through CENTRAL. Trials were assessed for eligibility then graded according to antenatal risk factors and method of birth into five grades. The main outcomes were overall trial rate of minor PPH (blood loss ≥500 ml) and major PPH (> 1000 ml) and method of determining blood loss (estimated/measured). Results There was no relationship between minor or major PPH rate and risk grade (Kruskal-Wallis: minor - T = 0.92, p = 0.82; major - T = 0.91, p = 0.92). There was no difference in minor or major PPH rates when comparing estimation or measurement methods (Mann-Whitney: minor - U = 67, p = 0.75; major - U = 35, p = 0.72). There was however a correlation between % operative births and minor PPH rate, but not major PPH (Spearman r = 0.32 v. Spearman r = 0.098). Conclusions Using data from trials using low risk women to generalise best practice guidelines might not be appropriate for all births, particularly complex births. Although complex births contribute disproportionately to PPH rates, this review showed they are often underrepresented in trials. Despite this, there was no difference in reported PPH rates between studies conducted in high and low risk groups. Method of birth was shown to be an important risk factor for minor PPH and may be a better predictor of PPH than antenatal risk factors. Women with operative births are often excluded from trials meaning a lack of data supporting interventions in these women. More focus on complex births is needed to ensure the evidence base is relevant to the target population.
Collapse
Affiliation(s)
- Lydia Hawker
- Sanyu Research Unit, Department of Women's and Children's Health, University of Liverpool, Liverpool, UK.
| | - Andrew Weeks
- Sanyu Research Unit, Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
| |
Collapse
|
17
|
Sentilhes L, Daniel V, Deneux-Tharaux C. TRAAP2 - TRAnexamic Acid for Preventing postpartum hemorrhage after cesarean delivery: a multicenter randomized, doubleblind, placebo- controlled trial - a study protocol. BMC Pregnancy Childbirth 2020; 20:63. [PMID: 32005192 PMCID: PMC6995226 DOI: 10.1186/s12884-019-2718-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 12/30/2019] [Indexed: 12/28/2022] Open
Abstract
Background An antifibrinolytic agent that blocks lysine-binding sites on plasminogen molecules, tranexamic acid reduces bleeding-related mortality in women with postpartum hemorrhage (PPH), especially administered fairly soon after delivery. According to the randomized controlled trials thus far reported for PPH prevention after cesarean deliveries (n = 16), women who received tranexamic acid had significantly less postpartum blood loss and no increase in severe adverse effects. These were, however, primarily small single-center studies that had fundamental methodological flaws. Multicenter randomized controlled trials with adequate power are necessary to demonstrate its value persuasively before tranexamic acid goes into widespread use for the prevention of PPH after cesarean deliveries. Methods/design This study will be a multicenter, double-blind, randomized controlled trial with two parallel groups including 4524 women with cesarean deliveries before or during labor, at a term ≥34 weeks, modeled on our previous study of tranexamic acid administered after vaginal deliveries. Treatment (either tranexamic acid 1 g or placebo) will be administered intravenously just after birth. All women will also receive a prophylactic uterotonic agent. The primary outcome will be the incidence of PPH, defined by a calculated estimated blood loss > 1000 mL or a red blood cell transfusion before day 2 postpartum. This study will have 80% power to show a 20% reduction in the incidence of PPH, from 15.0 to 12.0%. Discussion As an, inexpensive, easy to administer drug that can be add to the routine management of cesarean births in delivery rooms, tranexamic acid is a promising candidate for preventing PPH after these births. This large, adequately powered, multicenter randomized placebo-controlled trial seeks to determine if the benefits of the routine prophylactic use of tranexamic acid after cesarean delivery significantly outweigh its risks. Trial registration ClinicalTrials.gov NCT03431805 (February 12, 2018).
Collapse
Affiliation(s)
- Loïc Sentilhes
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, Place Amélie Raba Léon, 33076, Bordeaux, France. .,Production Pharmaceutique pour la Recherche Institutionnelle du Grand Ouest (PPRIGO), Brest, France.
| | - Valérie Daniel
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, Place Amélie Raba Léon, 33076, Bordeaux, France.,Department of pharmacy, Angers University Hospital, Angers, France
| | - Catherine Deneux-Tharaux
- INSERM U1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Center for Epidemiology and Statistics, Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Paris, France
| | | |
Collapse
|
18
|
van Ast M, Goedhart MM, Luttmer R, Orelio C, Deurloo KL, Veerbeek J. The duration of the third stage in relation to postpartum hemorrhage. Birth 2019; 46:602-607. [PMID: 31216383 DOI: 10.1111/birt.12441] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 05/13/2019] [Accepted: 05/16/2019] [Indexed: 11/29/2022]
Abstract
INTRODUCTION In this study, we describe the distribution of placenta delivery and the incidence of postpartum hemorrhage in both spontaneous placental delivery and manual removal of the placenta. METHODS A retrospective study was performed of 7603 singleton vaginal deliveries of a gestational age over 32 weeks, registered between September 2011 and 2016. We calculated the incidence of postpartum hemorrhage (≥1000 mL blood loss) per 10-minute duration of the third stage. The odds ratio for developing postpartum hemorrhage was assessed, adjusted for risk factors. The incidence of postpartum hemorrhage was compared between women that did and did not receive manual removal of placenta. RESULTS The median duration of the third stage was 10 minutes (interquartile range 7-16 minutes). The median amount of blood loss was 300 mL (200-400 mL). The overall incidence of postpartum hemorrhage was 8.5%. With every additional 10 minutes of third-stage duration, the risk of developing postpartum hemorrhage significantly increased. In a third stage longer than 60 minutes, the incidence of postpartum hemorrhage was 21.2% without manual removal of the placenta and 70.3% with manual removal. CONCLUSIONS The incidence of postpartum hemorrhage increases significantly from 10 to 19 minutes into the third stage. Women with the removal of the placenta had a significantly higher percentage of postpartum hemorrhage. The optimal timing for manual removal of the placenta should be investigated in a carefully designed randomized controlled trial to examine whether earlier manual removal of placenta lowers the incidence and limits the severity of postpartum hemorrhage.
Collapse
Affiliation(s)
- Manon van Ast
- Department of Obstetrics and Gynecology, Diakonessenhuis Utrecht, Utrecht, The Netherlands
| | - Martijn M Goedhart
- Department of Obstetrics and Gynecology, Diakonessenhuis Utrecht, Utrecht, The Netherlands
| | - Roosmarijn Luttmer
- Department of Obstetrics and Gynecology, Diakonessenhuis Utrecht, Utrecht, The Netherlands
| | - Claudia Orelio
- Research Support, Diakademie, Diakonessenhuis Utrecht, Utrecht, The Netherlands
| | - Koen L Deurloo
- Department of Obstetrics and Gynecology, Diakonessenhuis Utrecht, Utrecht, The Netherlands
| | - Jan Veerbeek
- Department of Obstetrics and Gynecology, Diakonessenhuis Utrecht, Utrecht, The Netherlands
| |
Collapse
|
19
|
Sentilhes L, Madar H, Ducarme G, Hamel JF, Mattuizzi A, Hanf M. Outcomes of operative vaginal delivery managed by residents under supervision and attending obstetricians: a prospective cross-sectional study. Am J Obstet Gynecol 2019; 221:59.e1-59.e15. [PMID: 30807764 DOI: 10.1016/j.ajog.2019.02.044] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 02/14/2019] [Accepted: 02/19/2019] [Indexed: 01/28/2023]
Abstract
BACKGROUND To assess both severe maternal and neonatal mortality and morbidity after attempted operative vaginal deliveries by residents under supervision and by attending obstetricians. STUDY DESIGN Secondary analysis of a 5-year prospective study with cross-sectional analysis including 2192 women with live singleton term fetuses in vertex presentation who underwent an attempted operative vaginal delivery in a tertiary care university hospital. Obstetricians who attempted or performed an operative vaginal delivery were classified into 2 groups according to their level of experience: attending obstetricians (who had 5 years or more of experience) and obstetric residents (who had less than 5 years of experience) under the supervision of an attending obstetrician. We used multivariate logistic regression and propensity score methods to compare outcomes associated with attending obstetricians and obstetric residents. Severe maternal morbidity was defined as third- or fourth-degree perineal laceration, perineal hematoma, cervical laceration, extended uterine incision for cesareans, postpartum hemorrhage >1500 mL, surgical hemostatic procedures, uterine artery embolization, blood transfusion, infection, thromboembolic events, admission to the intensive care unit, or maternal death; severe neonatal morbidity was defined as a 5-minute Apgar score <7, umbilical artery pH <7.00, need for resuscitation or intubation, neonatal trauma, intraventricular hemorrhage greater than grade 2, neonatal intensive care unit admission for more than 24 hours, convulsions, sepsis, or neonatal death. RESULTS High prepregnancy body mass index, high dose of oxytocin, manual rotation, persistent occiput posterior or transverse positions, operating room delivery, midpelvic delivery, forceps, and spatulas were significantly more frequent in deliveries managed by attending obstetricians than residents whereas a second-stage pushing phase longer than 30 minutes was significantly more frequent in deliveries managed by residents. The rate of severe maternal morbidity was 7.8% (115/1475) for residents vs 9.9% (48/484) for attending obstetricians; for severe neonatal morbidity, the rates were 8.3% (123/1475) vs 15.1% (73/484), respectively. In the univariate, multivariable, and sensitivity analyses, attempted operative vaginal delivery managed by a resident was significantly and inversely associated with severe neonatal but not maternal morbidity. After propensity score matching, delivery managed by a resident was not significantly associated with severe maternal morbidity (adjusted odds ratio, 0.74; 95% confidence interval, 0.39-1.38) and was no longer associated with neonatal morbidity (adjusted odds ratio, 0.51; 95% confidence interval, 0.25-1.04). CONCLUSION Management of attempted operative vaginal deliveries by residents under the supervision of attending obstetricians, compared with by the attending obstetricians themselves, does not appear to be associated with either maternal or neonatal morbidity. These reassuring results support the continued use of residency programs for training in operative vaginal deliveries under the supervision of attending obstetricians.
Collapse
|
20
|
Begley CM, Gyte GML, Devane D, McGuire W, Weeks A, Biesty LM. Active versus expectant management for women in the third stage of labour. Cochrane Database Syst Rev 2019; 2:CD007412. [PMID: 30754073 PMCID: PMC6372362 DOI: 10.1002/14651858.cd007412.pub5] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Active management of the third stage of labour involves giving a prophylactic uterotonic, early cord clamping and controlled cord traction to deliver the placenta. With expectant management, signs of placental separation are awaited and the placenta is delivered spontaneously. Active management was introduced to try to reduce haemorrhage, a major contributor to maternal mortality in low-income countries. This is an update of a review last published in 2015. OBJECTIVES To compare the effects of active versus expectant management of the third stage of labour on severe primary postpartum haemorrhage (PPH) and other maternal and infant outcomes.To compare the effects of variations in the packages of active and expectant management of the third stage of labour on severe primary PPH and other maternal and infant outcomes. SEARCH METHODS For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov and the World health Organization International Clinical Trials Registry Platform (ICTRP), on 22 January 2018, and reference lists of retrieved studies. SELECTION CRITERIA Randomised and quasi-randomised controlled trials comparing active versus expectant management of the third stage of labour. Cluster-randomised trials were eligible for inclusion, but none were identified. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the studies for inclusion, assessed risk of bias, carried out data extraction and assessed the quality of the evidence using the GRADE approach. MAIN RESULTS We included eight studies, involving analysis of data from 8892 women. The studies were all undertaken in hospitals, seven in higher-income countries and one in a lower-income country. Four studies compared active versus expectant management, and four compared active versus a mixture of managements. We used a random-effects model in the analyses because of clinical heterogeneity. Of the eight studies included, we considered three studies as having low risk of bias in the main aspects of sequence generation, allocation concealment and completeness of data collection. There was an absence of high-quality evidence according to GRADE assessments for our primary outcomes, which is reflected in the cautious language below.The evidence suggested that, for women at mixed levels of risk of bleeding, it is uncertain whether active management reduces the average risk of maternal severe primary PPH (more than 1000 mL) at time of birth (average risk ratio (RR) 0.34, 95% confidence interval (CI) 0.14 to 0.87, 3 studies, 4636 women, I2 = 60%; GRADE: very low quality). For incidence of maternal haemoglobin (Hb) less than 9 g/dL following birth, active management of the third stage may reduce the number of women with anaemia after birth (average RR 0.50, 95% CI 0.30 to 0.83, 2 studies, 1572 women; GRADE: low quality). We also found that active management of the third stage may make little or no difference to the number of babies admitted to neonatal units (average RR 0.81, 95% CI 0.60 to 1.11, 2 studies, 3207 infants; GRADE: low quality). It is uncertain whether active management of the third stage reduces the number of babies with jaundice requiring treatment (RR 0.96, 95% CI 0.55 to 1.68, 2 studies, 3142 infants, I2 = 66%; GRADE: very low quality). There were no data on our other primary outcomes of very severe PPH at the time of birth (more than 2500 mL), maternal mortality, or neonatal polycythaemia needing treatment.Active management reduces mean maternal blood loss at birth and probably reduces the rate of primary blood loss greater than 500 mL, and the use of therapeutic uterotonics. Active management also probably reduces the mean birthweight of the baby, reflecting the lower blood volume from interference with placental transfusion. In addition, it may reduce the need for maternal blood transfusion. However, active management may increase maternal diastolic blood pressure, vomiting after birth, afterpains, use of analgesia from birth up to discharge from the labour ward, and more women returning to hospital with bleeding (outcome not pre-specified).In the comparison of women at low risk of excessive bleeding, there were similar findings, except it was uncertain whether there was a difference identified between groups for severe primary PPH (average RR 0.31, 95% CI 0.05 to 2.17; 2 studies, 2941 women, I2 = 71%), maternal Hb less than 9 g/dL at 24 to 72 hours (average RR 0.17, 95% CI 0.02 to 1.47; 1 study, 193 women) or the need for neonatal admission (average RR 1.02, 95% CI 0.55 to 1.88; 1 study, 1512 women). In this group, active management may make little difference to the rate of neonatal jaundice requiring phototherapy (average RR 1.31, 95% CI 0.78 to 2.18; 1 study, 1447 women).Hypertension and interference with placental transfusion might be avoided by using modifications to the active management package, for example, omitting ergot and deferring cord clamping, but we have no direct evidence of this here. AUTHORS' CONCLUSIONS Although the data appeared to show that active management reduced the risk of severe primary PPH greater than 1000 mL at the time of birth, we are uncertain of this finding because of the very low-quality evidence. Active management may reduce the incidence of maternal anaemia (Hb less than 9 g/dL) following birth, but harms such as postnatal hypertension, pain and return to hospital due to bleeding were identified.In women at low risk of excessive bleeding, it is uncertain whether there was a difference between active and expectant management for severe PPH or maternal Hb less than 9 g/dL (at 24 to 72 hours). Women could be given information on the benefits and harms of both methods to support informed choice. Given the concerns about early cord clamping and the potential adverse effects of some uterotonics, it is critical now to look at the individual components of third-stage management. Data are also required from low-income countries.It must be emphasised that this review includes only a small number of studies with relatively small numbers of participants, and the quality of evidence for primary outcomes is low or very low.
Collapse
Affiliation(s)
- Cecily M Begley
- Trinity College DublinSchool of Nursing and Midwifery24 D'Olier StreetDublinIreland
| | - Gillian ML Gyte
- University of LiverpoolCochrane Pregnancy and Childbirth Group, Department of Women's and Children's HealthFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
| | - Declan Devane
- National University of Ireland GalwaySchool of Nursing and MidwiferyUniversity RoadGalwayIreland
| | - William McGuire
- University of YorkCentre for Reviews and DisseminationYorkY010 5DDUK
| | - Andrew Weeks
- The University of LiverpoolDepartment of Women's and Children's HealthFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
| | - Linda M Biesty
- National University of Ireland GalwaySchool of Nursing and MidwiferyUniversity RoadGalwayIreland
| | | |
Collapse
|
21
|
Grange J, Chatellier M, Chevé MT, Paumier A, Launay-Bourillon C, Legendre G, Olivier M, Ducarme G. Predictors of failed intrauterine balloon tamponade for persistent postpartum hemorrhage after vaginal delivery. PLoS One 2018; 13:e0206663. [PMID: 30365539 PMCID: PMC6203390 DOI: 10.1371/journal.pone.0206663] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Accepted: 10/17/2018] [Indexed: 11/18/2022] Open
Abstract
Objective To identify the predictors of intrauterine balloon tamponade (IUBT) failure for persistent postpartum hemorrhage (PPH) after vaginal delivery. Design Retrospective case-series in five maternity units in a perinatal network. Setting All women who underwent IUBT for persistent PPH after vaginal delivery from January 2011 to December 2015 in these hospitals. Methods All maternity apply the same management policy for PPH. IUBT, using a Bakri balloon, was used as a second line therapy for persistent PPH after failure of bimanual uterine massage and uterotonics to stop bleeding after vaginal delivery. Women who required another second line therapy (embolization or surgical procedures) to stop bleeding after IUBT were defined as cases, and women whom IUBT stopped bleeding were defined as control group. We determined independent predictors for failed IUBT using multiple regression and adjusting for demographics with adjusted odds ratios (aORs) and 95% confidence intervals (95% CI). Results During the study period, there were 91,880 deliveries in the five hospitals and IUBT was used in 108 women to control bleeding. The success rate was 74.1% (80/108). In 28 women, invasive procedures were required (19 embolization and 9 surgical procedures with 5 peripartum hysterectomies). Women with failed IUBT were more often obese (25.9% vs. 8.1%; p = 0.03), duration of labor was shorter (363.9 min vs. 549.7min; p = 0.04), and major PPH (≥1,500 mL) before IUBT was more frequent (64% vs. 40%; p = 0.04). Obesity was a predictive factor of failed IUBT (aOR 4.40, 95% CI 1.06–18.31). Major PPH before IUBT seemed to be another predictor of failure (aOR 1.001, 95% CI 1.000–1.002), but our result did not reach statistical significativity. Conclusion Intrauterine balloon tamponade is an effective second line therapy for persistent primary PPH after vaginal delivery. Pre-pregnancy obesity is a risk factor of IUBT failure.
Collapse
Affiliation(s)
- Joséphine Grange
- Department of Obstetrics and Gynecology, Centre Hospitalier Départemental, La Roche sur Yon, France
| | | | - Marie-Thérèse Chevé
- Department of Obstetrics and Gynecology, Le Mans General Hospital, Le Mans, France
| | - Anne Paumier
- Department of Obstetrics and Gynecology, Atlantic Polyclinic, Saint-Herblain, France
| | | | - Guillaume Legendre
- Department of Obstetrics and Gynecology, Angers University Hospital, Angers, France
| | - Marion Olivier
- Réseau Sécurité Naissance des Pays de la Loire, Nantes, France
| | - Guillaume Ducarme
- Department of Obstetrics and Gynecology, Centre Hospitalier Départemental, La Roche sur Yon, France
- * E-mail:
| |
Collapse
|
22
|
Sentilhes L, Winer N, Azria E, Sénat MV, Le Ray C, Vardon D, Perrotin F, Desbrière R, Fuchs F, Kayem G, Ducarme G, Doret-Dion M, Huissoud C, Bohec C, Deruelle P, Darsonval A, Chrétien JM, Seco A, Daniel V, Deneux-Tharaux C. Tranexamic Acid for the Prevention of Blood Loss after Vaginal Delivery. N Engl J Med 2018; 379:731-742. [PMID: 30134136 DOI: 10.1056/nejmoa1800942] [Citation(s) in RCA: 136] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND The use of tranexamic acid reduces mortality due to postpartum hemorrhage. We investigated whether the prophylactic administration of tranexamic acid in addition to prophylactic oxytocin in women with vaginal delivery would decrease the incidence of postpartum hemorrhage. METHODS In a multicenter, double-blind, randomized, controlled trial, we randomly assigned women in labor who had a planned vaginal delivery of a singleton live fetus at 35 or more weeks of gestation to receive 1 g of tranexamic acid or placebo, administered intravenously, in addition to prophylactic oxytocin after delivery. The primary outcome was postpartum hemorrhage, defined as blood loss of at least 500 ml, measured with a collector bag. RESULTS Of the 4079 women who underwent randomization, 3891 had a vaginal delivery. The primary outcome occurred in 156 of 1921 women (8.1%) in the tranexamic acid group and in 188 of 1918 (9.8%) in the placebo group (relative risk, 0.83; 95% confidence interval [CI], 0.68 to 1.01; P=0.07). Women in the tranexamic acid group had a lower rate of provider-assessed clinically significant postpartum hemorrhage than those in the placebo group (7.8% vs. 10.4%; relative risk, 0.74; 95% CI, 0.61 to 0.91; P=0.004; P=0.04 after adjustment for multiple comparisons post hoc) and also received additional uterotonic agents less often (7.2% vs. 9.7%; relative risk, 0.75; 95% CI, 0.61 to 0.92; P=0.006; adjusted P=0.04). Other secondary outcomes did not differ significantly between the two groups. The incidence of thromboembolic events in the 3 months after delivery did not differ significantly between the tranexamic acid group and the placebo group (0.1% and 0.2%, respectively; relative risk, 0.25; 95% CI, 0.03 to 2.24). CONCLUSIONS Among women with vaginal delivery who received prophylactic oxytocin, the use of tranexamic acid did not result in a rate of postpartum hemorrhage of at least 500 ml that was significantly lower than the rate with placebo. (Funded by the French Ministry of Health; TRAAP ClinicalTrials.gov number, NCT02302456 .).
Collapse
Affiliation(s)
- Loïc Sentilhes
- From the Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux (L.S.), the Departments of Obstetrics and Gynecology (L.S.), Pharmacy (A.D., V.D.), and Clinical Research (J.-M.C.), Angers University Hospital, Angers, the Department of Obstetrics and Gynecology, University Medical Center of Nantes and the Centre d'Investigation Clinique Mère Enfant, University Hospital, the National Institute of Agricultural Research, Physiology of Nutritional Adaptations, University of Nantes, the Institute of Digestive Disease and Centre de Recherche en Nutrition Humaine Ouest, Nantes (N.W.), the Maternity Unit, Paris Saint Joseph Hospital (E.A.), INSERM Unité 1153, Obstetrical, Perinatal, and Pediatric Epidemiology Research Team, the Center for Epidemiology and Statistics, Sorbonne Paris Cité, University Hospital Department of Risks in Pregnancy (E.A., C.L.R., G.K., A.S., C.D.-T.), the Port Royal Maternity Unit, Cochin Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University Hospital Department of Risks in Pregnancy (C.L.R.), Paris Descartes University, the Department of Obstetrics and Gynecology, Bicêtre University Hospital, AP-HP (M.-V.S.), and the Department of Obstetrics and Gynecology, Trousseau Hospital, AP-HP (G.K.), Paris, the Department of Obstetrics and Gynecology, Caen University Hospital, Caen (D.V.), the Department of Obstetrics and Gynecology, Tours University Hospital, Tours (F.P.), the Department of Obstetrics and Gynecology, Saint Joseph Hospital, Marseille (R.D.), the Department of Obstetrics and Gynecology, Montpellier University Hospital, Montpellier (F.F.), the Center for Research in Epidemiology and Population Health, INSERM Unité 1018, Reproduction and Child Development, Villejuif (F.F.), the Department of Obstetrics and Gynecology, Centre Hospitalier Departemental, La Roche-sur-Yon (G.D.), the Hospices Civils de Lyon, Hôpital Femme Mère Enfant, Department of Obstetrics and Gynecology, University Lyon 1 (M.D.-D.), and the Department of Obstetrics and Gynecology, Croix Rousse University Hospital (C.H.), Lyon, the Department of Obstetrics and Gynecology, François Mitterrand Hospital, Pau (C.B.), the Department of Obstetrics and Gynecology, Jeanne de Flandre University Hospital, Lille (P.D.), and the Production Pharmaceutique pour la Recherche Institutionnelle du Grand Ouest, Brest University Hospital, Brest (A.D., V.D.) - all in France
| | - Norbert Winer
- From the Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux (L.S.), the Departments of Obstetrics and Gynecology (L.S.), Pharmacy (A.D., V.D.), and Clinical Research (J.-M.C.), Angers University Hospital, Angers, the Department of Obstetrics and Gynecology, University Medical Center of Nantes and the Centre d'Investigation Clinique Mère Enfant, University Hospital, the National Institute of Agricultural Research, Physiology of Nutritional Adaptations, University of Nantes, the Institute of Digestive Disease and Centre de Recherche en Nutrition Humaine Ouest, Nantes (N.W.), the Maternity Unit, Paris Saint Joseph Hospital (E.A.), INSERM Unité 1153, Obstetrical, Perinatal, and Pediatric Epidemiology Research Team, the Center for Epidemiology and Statistics, Sorbonne Paris Cité, University Hospital Department of Risks in Pregnancy (E.A., C.L.R., G.K., A.S., C.D.-T.), the Port Royal Maternity Unit, Cochin Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University Hospital Department of Risks in Pregnancy (C.L.R.), Paris Descartes University, the Department of Obstetrics and Gynecology, Bicêtre University Hospital, AP-HP (M.-V.S.), and the Department of Obstetrics and Gynecology, Trousseau Hospital, AP-HP (G.K.), Paris, the Department of Obstetrics and Gynecology, Caen University Hospital, Caen (D.V.), the Department of Obstetrics and Gynecology, Tours University Hospital, Tours (F.P.), the Department of Obstetrics and Gynecology, Saint Joseph Hospital, Marseille (R.D.), the Department of Obstetrics and Gynecology, Montpellier University Hospital, Montpellier (F.F.), the Center for Research in Epidemiology and Population Health, INSERM Unité 1018, Reproduction and Child Development, Villejuif (F.F.), the Department of Obstetrics and Gynecology, Centre Hospitalier Departemental, La Roche-sur-Yon (G.D.), the Hospices Civils de Lyon, Hôpital Femme Mère Enfant, Department of Obstetrics and Gynecology, University Lyon 1 (M.D.-D.), and the Department of Obstetrics and Gynecology, Croix Rousse University Hospital (C.H.), Lyon, the Department of Obstetrics and Gynecology, François Mitterrand Hospital, Pau (C.B.), the Department of Obstetrics and Gynecology, Jeanne de Flandre University Hospital, Lille (P.D.), and the Production Pharmaceutique pour la Recherche Institutionnelle du Grand Ouest, Brest University Hospital, Brest (A.D., V.D.) - all in France
| | - Elie Azria
- From the Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux (L.S.), the Departments of Obstetrics and Gynecology (L.S.), Pharmacy (A.D., V.D.), and Clinical Research (J.-M.C.), Angers University Hospital, Angers, the Department of Obstetrics and Gynecology, University Medical Center of Nantes and the Centre d'Investigation Clinique Mère Enfant, University Hospital, the National Institute of Agricultural Research, Physiology of Nutritional Adaptations, University of Nantes, the Institute of Digestive Disease and Centre de Recherche en Nutrition Humaine Ouest, Nantes (N.W.), the Maternity Unit, Paris Saint Joseph Hospital (E.A.), INSERM Unité 1153, Obstetrical, Perinatal, and Pediatric Epidemiology Research Team, the Center for Epidemiology and Statistics, Sorbonne Paris Cité, University Hospital Department of Risks in Pregnancy (E.A., C.L.R., G.K., A.S., C.D.-T.), the Port Royal Maternity Unit, Cochin Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University Hospital Department of Risks in Pregnancy (C.L.R.), Paris Descartes University, the Department of Obstetrics and Gynecology, Bicêtre University Hospital, AP-HP (M.-V.S.), and the Department of Obstetrics and Gynecology, Trousseau Hospital, AP-HP (G.K.), Paris, the Department of Obstetrics and Gynecology, Caen University Hospital, Caen (D.V.), the Department of Obstetrics and Gynecology, Tours University Hospital, Tours (F.P.), the Department of Obstetrics and Gynecology, Saint Joseph Hospital, Marseille (R.D.), the Department of Obstetrics and Gynecology, Montpellier University Hospital, Montpellier (F.F.), the Center for Research in Epidemiology and Population Health, INSERM Unité 1018, Reproduction and Child Development, Villejuif (F.F.), the Department of Obstetrics and Gynecology, Centre Hospitalier Departemental, La Roche-sur-Yon (G.D.), the Hospices Civils de Lyon, Hôpital Femme Mère Enfant, Department of Obstetrics and Gynecology, University Lyon 1 (M.D.-D.), and the Department of Obstetrics and Gynecology, Croix Rousse University Hospital (C.H.), Lyon, the Department of Obstetrics and Gynecology, François Mitterrand Hospital, Pau (C.B.), the Department of Obstetrics and Gynecology, Jeanne de Flandre University Hospital, Lille (P.D.), and the Production Pharmaceutique pour la Recherche Institutionnelle du Grand Ouest, Brest University Hospital, Brest (A.D., V.D.) - all in France
| | - Marie-Victoire Sénat
- From the Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux (L.S.), the Departments of Obstetrics and Gynecology (L.S.), Pharmacy (A.D., V.D.), and Clinical Research (J.-M.C.), Angers University Hospital, Angers, the Department of Obstetrics and Gynecology, University Medical Center of Nantes and the Centre d'Investigation Clinique Mère Enfant, University Hospital, the National Institute of Agricultural Research, Physiology of Nutritional Adaptations, University of Nantes, the Institute of Digestive Disease and Centre de Recherche en Nutrition Humaine Ouest, Nantes (N.W.), the Maternity Unit, Paris Saint Joseph Hospital (E.A.), INSERM Unité 1153, Obstetrical, Perinatal, and Pediatric Epidemiology Research Team, the Center for Epidemiology and Statistics, Sorbonne Paris Cité, University Hospital Department of Risks in Pregnancy (E.A., C.L.R., G.K., A.S., C.D.-T.), the Port Royal Maternity Unit, Cochin Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University Hospital Department of Risks in Pregnancy (C.L.R.), Paris Descartes University, the Department of Obstetrics and Gynecology, Bicêtre University Hospital, AP-HP (M.-V.S.), and the Department of Obstetrics and Gynecology, Trousseau Hospital, AP-HP (G.K.), Paris, the Department of Obstetrics and Gynecology, Caen University Hospital, Caen (D.V.), the Department of Obstetrics and Gynecology, Tours University Hospital, Tours (F.P.), the Department of Obstetrics and Gynecology, Saint Joseph Hospital, Marseille (R.D.), the Department of Obstetrics and Gynecology, Montpellier University Hospital, Montpellier (F.F.), the Center for Research in Epidemiology and Population Health, INSERM Unité 1018, Reproduction and Child Development, Villejuif (F.F.), the Department of Obstetrics and Gynecology, Centre Hospitalier Departemental, La Roche-sur-Yon (G.D.), the Hospices Civils de Lyon, Hôpital Femme Mère Enfant, Department of Obstetrics and Gynecology, University Lyon 1 (M.D.-D.), and the Department of Obstetrics and Gynecology, Croix Rousse University Hospital (C.H.), Lyon, the Department of Obstetrics and Gynecology, François Mitterrand Hospital, Pau (C.B.), the Department of Obstetrics and Gynecology, Jeanne de Flandre University Hospital, Lille (P.D.), and the Production Pharmaceutique pour la Recherche Institutionnelle du Grand Ouest, Brest University Hospital, Brest (A.D., V.D.) - all in France
| | - Camille Le Ray
- From the Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux (L.S.), the Departments of Obstetrics and Gynecology (L.S.), Pharmacy (A.D., V.D.), and Clinical Research (J.-M.C.), Angers University Hospital, Angers, the Department of Obstetrics and Gynecology, University Medical Center of Nantes and the Centre d'Investigation Clinique Mère Enfant, University Hospital, the National Institute of Agricultural Research, Physiology of Nutritional Adaptations, University of Nantes, the Institute of Digestive Disease and Centre de Recherche en Nutrition Humaine Ouest, Nantes (N.W.), the Maternity Unit, Paris Saint Joseph Hospital (E.A.), INSERM Unité 1153, Obstetrical, Perinatal, and Pediatric Epidemiology Research Team, the Center for Epidemiology and Statistics, Sorbonne Paris Cité, University Hospital Department of Risks in Pregnancy (E.A., C.L.R., G.K., A.S., C.D.-T.), the Port Royal Maternity Unit, Cochin Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University Hospital Department of Risks in Pregnancy (C.L.R.), Paris Descartes University, the Department of Obstetrics and Gynecology, Bicêtre University Hospital, AP-HP (M.-V.S.), and the Department of Obstetrics and Gynecology, Trousseau Hospital, AP-HP (G.K.), Paris, the Department of Obstetrics and Gynecology, Caen University Hospital, Caen (D.V.), the Department of Obstetrics and Gynecology, Tours University Hospital, Tours (F.P.), the Department of Obstetrics and Gynecology, Saint Joseph Hospital, Marseille (R.D.), the Department of Obstetrics and Gynecology, Montpellier University Hospital, Montpellier (F.F.), the Center for Research in Epidemiology and Population Health, INSERM Unité 1018, Reproduction and Child Development, Villejuif (F.F.), the Department of Obstetrics and Gynecology, Centre Hospitalier Departemental, La Roche-sur-Yon (G.D.), the Hospices Civils de Lyon, Hôpital Femme Mère Enfant, Department of Obstetrics and Gynecology, University Lyon 1 (M.D.-D.), and the Department of Obstetrics and Gynecology, Croix Rousse University Hospital (C.H.), Lyon, the Department of Obstetrics and Gynecology, François Mitterrand Hospital, Pau (C.B.), the Department of Obstetrics and Gynecology, Jeanne de Flandre University Hospital, Lille (P.D.), and the Production Pharmaceutique pour la Recherche Institutionnelle du Grand Ouest, Brest University Hospital, Brest (A.D., V.D.) - all in France
| | - Delphine Vardon
- From the Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux (L.S.), the Departments of Obstetrics and Gynecology (L.S.), Pharmacy (A.D., V.D.), and Clinical Research (J.-M.C.), Angers University Hospital, Angers, the Department of Obstetrics and Gynecology, University Medical Center of Nantes and the Centre d'Investigation Clinique Mère Enfant, University Hospital, the National Institute of Agricultural Research, Physiology of Nutritional Adaptations, University of Nantes, the Institute of Digestive Disease and Centre de Recherche en Nutrition Humaine Ouest, Nantes (N.W.), the Maternity Unit, Paris Saint Joseph Hospital (E.A.), INSERM Unité 1153, Obstetrical, Perinatal, and Pediatric Epidemiology Research Team, the Center for Epidemiology and Statistics, Sorbonne Paris Cité, University Hospital Department of Risks in Pregnancy (E.A., C.L.R., G.K., A.S., C.D.-T.), the Port Royal Maternity Unit, Cochin Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University Hospital Department of Risks in Pregnancy (C.L.R.), Paris Descartes University, the Department of Obstetrics and Gynecology, Bicêtre University Hospital, AP-HP (M.-V.S.), and the Department of Obstetrics and Gynecology, Trousseau Hospital, AP-HP (G.K.), Paris, the Department of Obstetrics and Gynecology, Caen University Hospital, Caen (D.V.), the Department of Obstetrics and Gynecology, Tours University Hospital, Tours (F.P.), the Department of Obstetrics and Gynecology, Saint Joseph Hospital, Marseille (R.D.), the Department of Obstetrics and Gynecology, Montpellier University Hospital, Montpellier (F.F.), the Center for Research in Epidemiology and Population Health, INSERM Unité 1018, Reproduction and Child Development, Villejuif (F.F.), the Department of Obstetrics and Gynecology, Centre Hospitalier Departemental, La Roche-sur-Yon (G.D.), the Hospices Civils de Lyon, Hôpital Femme Mère Enfant, Department of Obstetrics and Gynecology, University Lyon 1 (M.D.-D.), and the Department of Obstetrics and Gynecology, Croix Rousse University Hospital (C.H.), Lyon, the Department of Obstetrics and Gynecology, François Mitterrand Hospital, Pau (C.B.), the Department of Obstetrics and Gynecology, Jeanne de Flandre University Hospital, Lille (P.D.), and the Production Pharmaceutique pour la Recherche Institutionnelle du Grand Ouest, Brest University Hospital, Brest (A.D., V.D.) - all in France
| | - Franck Perrotin
- From the Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux (L.S.), the Departments of Obstetrics and Gynecology (L.S.), Pharmacy (A.D., V.D.), and Clinical Research (J.-M.C.), Angers University Hospital, Angers, the Department of Obstetrics and Gynecology, University Medical Center of Nantes and the Centre d'Investigation Clinique Mère Enfant, University Hospital, the National Institute of Agricultural Research, Physiology of Nutritional Adaptations, University of Nantes, the Institute of Digestive Disease and Centre de Recherche en Nutrition Humaine Ouest, Nantes (N.W.), the Maternity Unit, Paris Saint Joseph Hospital (E.A.), INSERM Unité 1153, Obstetrical, Perinatal, and Pediatric Epidemiology Research Team, the Center for Epidemiology and Statistics, Sorbonne Paris Cité, University Hospital Department of Risks in Pregnancy (E.A., C.L.R., G.K., A.S., C.D.-T.), the Port Royal Maternity Unit, Cochin Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University Hospital Department of Risks in Pregnancy (C.L.R.), Paris Descartes University, the Department of Obstetrics and Gynecology, Bicêtre University Hospital, AP-HP (M.-V.S.), and the Department of Obstetrics and Gynecology, Trousseau Hospital, AP-HP (G.K.), Paris, the Department of Obstetrics and Gynecology, Caen University Hospital, Caen (D.V.), the Department of Obstetrics and Gynecology, Tours University Hospital, Tours (F.P.), the Department of Obstetrics and Gynecology, Saint Joseph Hospital, Marseille (R.D.), the Department of Obstetrics and Gynecology, Montpellier University Hospital, Montpellier (F.F.), the Center for Research in Epidemiology and Population Health, INSERM Unité 1018, Reproduction and Child Development, Villejuif (F.F.), the Department of Obstetrics and Gynecology, Centre Hospitalier Departemental, La Roche-sur-Yon (G.D.), the Hospices Civils de Lyon, Hôpital Femme Mère Enfant, Department of Obstetrics and Gynecology, University Lyon 1 (M.D.-D.), and the Department of Obstetrics and Gynecology, Croix Rousse University Hospital (C.H.), Lyon, the Department of Obstetrics and Gynecology, François Mitterrand Hospital, Pau (C.B.), the Department of Obstetrics and Gynecology, Jeanne de Flandre University Hospital, Lille (P.D.), and the Production Pharmaceutique pour la Recherche Institutionnelle du Grand Ouest, Brest University Hospital, Brest (A.D., V.D.) - all in France
| | - Raoul Desbrière
- From the Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux (L.S.), the Departments of Obstetrics and Gynecology (L.S.), Pharmacy (A.D., V.D.), and Clinical Research (J.-M.C.), Angers University Hospital, Angers, the Department of Obstetrics and Gynecology, University Medical Center of Nantes and the Centre d'Investigation Clinique Mère Enfant, University Hospital, the National Institute of Agricultural Research, Physiology of Nutritional Adaptations, University of Nantes, the Institute of Digestive Disease and Centre de Recherche en Nutrition Humaine Ouest, Nantes (N.W.), the Maternity Unit, Paris Saint Joseph Hospital (E.A.), INSERM Unité 1153, Obstetrical, Perinatal, and Pediatric Epidemiology Research Team, the Center for Epidemiology and Statistics, Sorbonne Paris Cité, University Hospital Department of Risks in Pregnancy (E.A., C.L.R., G.K., A.S., C.D.-T.), the Port Royal Maternity Unit, Cochin Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University Hospital Department of Risks in Pregnancy (C.L.R.), Paris Descartes University, the Department of Obstetrics and Gynecology, Bicêtre University Hospital, AP-HP (M.-V.S.), and the Department of Obstetrics and Gynecology, Trousseau Hospital, AP-HP (G.K.), Paris, the Department of Obstetrics and Gynecology, Caen University Hospital, Caen (D.V.), the Department of Obstetrics and Gynecology, Tours University Hospital, Tours (F.P.), the Department of Obstetrics and Gynecology, Saint Joseph Hospital, Marseille (R.D.), the Department of Obstetrics and Gynecology, Montpellier University Hospital, Montpellier (F.F.), the Center for Research in Epidemiology and Population Health, INSERM Unité 1018, Reproduction and Child Development, Villejuif (F.F.), the Department of Obstetrics and Gynecology, Centre Hospitalier Departemental, La Roche-sur-Yon (G.D.), the Hospices Civils de Lyon, Hôpital Femme Mère Enfant, Department of Obstetrics and Gynecology, University Lyon 1 (M.D.-D.), and the Department of Obstetrics and Gynecology, Croix Rousse University Hospital (C.H.), Lyon, the Department of Obstetrics and Gynecology, François Mitterrand Hospital, Pau (C.B.), the Department of Obstetrics and Gynecology, Jeanne de Flandre University Hospital, Lille (P.D.), and the Production Pharmaceutique pour la Recherche Institutionnelle du Grand Ouest, Brest University Hospital, Brest (A.D., V.D.) - all in France
| | - Florent Fuchs
- From the Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux (L.S.), the Departments of Obstetrics and Gynecology (L.S.), Pharmacy (A.D., V.D.), and Clinical Research (J.-M.C.), Angers University Hospital, Angers, the Department of Obstetrics and Gynecology, University Medical Center of Nantes and the Centre d'Investigation Clinique Mère Enfant, University Hospital, the National Institute of Agricultural Research, Physiology of Nutritional Adaptations, University of Nantes, the Institute of Digestive Disease and Centre de Recherche en Nutrition Humaine Ouest, Nantes (N.W.), the Maternity Unit, Paris Saint Joseph Hospital (E.A.), INSERM Unité 1153, Obstetrical, Perinatal, and Pediatric Epidemiology Research Team, the Center for Epidemiology and Statistics, Sorbonne Paris Cité, University Hospital Department of Risks in Pregnancy (E.A., C.L.R., G.K., A.S., C.D.-T.), the Port Royal Maternity Unit, Cochin Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University Hospital Department of Risks in Pregnancy (C.L.R.), Paris Descartes University, the Department of Obstetrics and Gynecology, Bicêtre University Hospital, AP-HP (M.-V.S.), and the Department of Obstetrics and Gynecology, Trousseau Hospital, AP-HP (G.K.), Paris, the Department of Obstetrics and Gynecology, Caen University Hospital, Caen (D.V.), the Department of Obstetrics and Gynecology, Tours University Hospital, Tours (F.P.), the Department of Obstetrics and Gynecology, Saint Joseph Hospital, Marseille (R.D.), the Department of Obstetrics and Gynecology, Montpellier University Hospital, Montpellier (F.F.), the Center for Research in Epidemiology and Population Health, INSERM Unité 1018, Reproduction and Child Development, Villejuif (F.F.), the Department of Obstetrics and Gynecology, Centre Hospitalier Departemental, La Roche-sur-Yon (G.D.), the Hospices Civils de Lyon, Hôpital Femme Mère Enfant, Department of Obstetrics and Gynecology, University Lyon 1 (M.D.-D.), and the Department of Obstetrics and Gynecology, Croix Rousse University Hospital (C.H.), Lyon, the Department of Obstetrics and Gynecology, François Mitterrand Hospital, Pau (C.B.), the Department of Obstetrics and Gynecology, Jeanne de Flandre University Hospital, Lille (P.D.), and the Production Pharmaceutique pour la Recherche Institutionnelle du Grand Ouest, Brest University Hospital, Brest (A.D., V.D.) - all in France
| | - Gilles Kayem
- From the Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux (L.S.), the Departments of Obstetrics and Gynecology (L.S.), Pharmacy (A.D., V.D.), and Clinical Research (J.-M.C.), Angers University Hospital, Angers, the Department of Obstetrics and Gynecology, University Medical Center of Nantes and the Centre d'Investigation Clinique Mère Enfant, University Hospital, the National Institute of Agricultural Research, Physiology of Nutritional Adaptations, University of Nantes, the Institute of Digestive Disease and Centre de Recherche en Nutrition Humaine Ouest, Nantes (N.W.), the Maternity Unit, Paris Saint Joseph Hospital (E.A.), INSERM Unité 1153, Obstetrical, Perinatal, and Pediatric Epidemiology Research Team, the Center for Epidemiology and Statistics, Sorbonne Paris Cité, University Hospital Department of Risks in Pregnancy (E.A., C.L.R., G.K., A.S., C.D.-T.), the Port Royal Maternity Unit, Cochin Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University Hospital Department of Risks in Pregnancy (C.L.R.), Paris Descartes University, the Department of Obstetrics and Gynecology, Bicêtre University Hospital, AP-HP (M.-V.S.), and the Department of Obstetrics and Gynecology, Trousseau Hospital, AP-HP (G.K.), Paris, the Department of Obstetrics and Gynecology, Caen University Hospital, Caen (D.V.), the Department of Obstetrics and Gynecology, Tours University Hospital, Tours (F.P.), the Department of Obstetrics and Gynecology, Saint Joseph Hospital, Marseille (R.D.), the Department of Obstetrics and Gynecology, Montpellier University Hospital, Montpellier (F.F.), the Center for Research in Epidemiology and Population Health, INSERM Unité 1018, Reproduction and Child Development, Villejuif (F.F.), the Department of Obstetrics and Gynecology, Centre Hospitalier Departemental, La Roche-sur-Yon (G.D.), the Hospices Civils de Lyon, Hôpital Femme Mère Enfant, Department of Obstetrics and Gynecology, University Lyon 1 (M.D.-D.), and the Department of Obstetrics and Gynecology, Croix Rousse University Hospital (C.H.), Lyon, the Department of Obstetrics and Gynecology, François Mitterrand Hospital, Pau (C.B.), the Department of Obstetrics and Gynecology, Jeanne de Flandre University Hospital, Lille (P.D.), and the Production Pharmaceutique pour la Recherche Institutionnelle du Grand Ouest, Brest University Hospital, Brest (A.D., V.D.) - all in France
| | - Guillaume Ducarme
- From the Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux (L.S.), the Departments of Obstetrics and Gynecology (L.S.), Pharmacy (A.D., V.D.), and Clinical Research (J.-M.C.), Angers University Hospital, Angers, the Department of Obstetrics and Gynecology, University Medical Center of Nantes and the Centre d'Investigation Clinique Mère Enfant, University Hospital, the National Institute of Agricultural Research, Physiology of Nutritional Adaptations, University of Nantes, the Institute of Digestive Disease and Centre de Recherche en Nutrition Humaine Ouest, Nantes (N.W.), the Maternity Unit, Paris Saint Joseph Hospital (E.A.), INSERM Unité 1153, Obstetrical, Perinatal, and Pediatric Epidemiology Research Team, the Center for Epidemiology and Statistics, Sorbonne Paris Cité, University Hospital Department of Risks in Pregnancy (E.A., C.L.R., G.K., A.S., C.D.-T.), the Port Royal Maternity Unit, Cochin Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University Hospital Department of Risks in Pregnancy (C.L.R.), Paris Descartes University, the Department of Obstetrics and Gynecology, Bicêtre University Hospital, AP-HP (M.-V.S.), and the Department of Obstetrics and Gynecology, Trousseau Hospital, AP-HP (G.K.), Paris, the Department of Obstetrics and Gynecology, Caen University Hospital, Caen (D.V.), the Department of Obstetrics and Gynecology, Tours University Hospital, Tours (F.P.), the Department of Obstetrics and Gynecology, Saint Joseph Hospital, Marseille (R.D.), the Department of Obstetrics and Gynecology, Montpellier University Hospital, Montpellier (F.F.), the Center for Research in Epidemiology and Population Health, INSERM Unité 1018, Reproduction and Child Development, Villejuif (F.F.), the Department of Obstetrics and Gynecology, Centre Hospitalier Departemental, La Roche-sur-Yon (G.D.), the Hospices Civils de Lyon, Hôpital Femme Mère Enfant, Department of Obstetrics and Gynecology, University Lyon 1 (M.D.-D.), and the Department of Obstetrics and Gynecology, Croix Rousse University Hospital (C.H.), Lyon, the Department of Obstetrics and Gynecology, François Mitterrand Hospital, Pau (C.B.), the Department of Obstetrics and Gynecology, Jeanne de Flandre University Hospital, Lille (P.D.), and the Production Pharmaceutique pour la Recherche Institutionnelle du Grand Ouest, Brest University Hospital, Brest (A.D., V.D.) - all in France
| | - Muriel Doret-Dion
- From the Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux (L.S.), the Departments of Obstetrics and Gynecology (L.S.), Pharmacy (A.D., V.D.), and Clinical Research (J.-M.C.), Angers University Hospital, Angers, the Department of Obstetrics and Gynecology, University Medical Center of Nantes and the Centre d'Investigation Clinique Mère Enfant, University Hospital, the National Institute of Agricultural Research, Physiology of Nutritional Adaptations, University of Nantes, the Institute of Digestive Disease and Centre de Recherche en Nutrition Humaine Ouest, Nantes (N.W.), the Maternity Unit, Paris Saint Joseph Hospital (E.A.), INSERM Unité 1153, Obstetrical, Perinatal, and Pediatric Epidemiology Research Team, the Center for Epidemiology and Statistics, Sorbonne Paris Cité, University Hospital Department of Risks in Pregnancy (E.A., C.L.R., G.K., A.S., C.D.-T.), the Port Royal Maternity Unit, Cochin Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University Hospital Department of Risks in Pregnancy (C.L.R.), Paris Descartes University, the Department of Obstetrics and Gynecology, Bicêtre University Hospital, AP-HP (M.-V.S.), and the Department of Obstetrics and Gynecology, Trousseau Hospital, AP-HP (G.K.), Paris, the Department of Obstetrics and Gynecology, Caen University Hospital, Caen (D.V.), the Department of Obstetrics and Gynecology, Tours University Hospital, Tours (F.P.), the Department of Obstetrics and Gynecology, Saint Joseph Hospital, Marseille (R.D.), the Department of Obstetrics and Gynecology, Montpellier University Hospital, Montpellier (F.F.), the Center for Research in Epidemiology and Population Health, INSERM Unité 1018, Reproduction and Child Development, Villejuif (F.F.), the Department of Obstetrics and Gynecology, Centre Hospitalier Departemental, La Roche-sur-Yon (G.D.), the Hospices Civils de Lyon, Hôpital Femme Mère Enfant, Department of Obstetrics and Gynecology, University Lyon 1 (M.D.-D.), and the Department of Obstetrics and Gynecology, Croix Rousse University Hospital (C.H.), Lyon, the Department of Obstetrics and Gynecology, François Mitterrand Hospital, Pau (C.B.), the Department of Obstetrics and Gynecology, Jeanne de Flandre University Hospital, Lille (P.D.), and the Production Pharmaceutique pour la Recherche Institutionnelle du Grand Ouest, Brest University Hospital, Brest (A.D., V.D.) - all in France
| | - Cyril Huissoud
- From the Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux (L.S.), the Departments of Obstetrics and Gynecology (L.S.), Pharmacy (A.D., V.D.), and Clinical Research (J.-M.C.), Angers University Hospital, Angers, the Department of Obstetrics and Gynecology, University Medical Center of Nantes and the Centre d'Investigation Clinique Mère Enfant, University Hospital, the National Institute of Agricultural Research, Physiology of Nutritional Adaptations, University of Nantes, the Institute of Digestive Disease and Centre de Recherche en Nutrition Humaine Ouest, Nantes (N.W.), the Maternity Unit, Paris Saint Joseph Hospital (E.A.), INSERM Unité 1153, Obstetrical, Perinatal, and Pediatric Epidemiology Research Team, the Center for Epidemiology and Statistics, Sorbonne Paris Cité, University Hospital Department of Risks in Pregnancy (E.A., C.L.R., G.K., A.S., C.D.-T.), the Port Royal Maternity Unit, Cochin Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University Hospital Department of Risks in Pregnancy (C.L.R.), Paris Descartes University, the Department of Obstetrics and Gynecology, Bicêtre University Hospital, AP-HP (M.-V.S.), and the Department of Obstetrics and Gynecology, Trousseau Hospital, AP-HP (G.K.), Paris, the Department of Obstetrics and Gynecology, Caen University Hospital, Caen (D.V.), the Department of Obstetrics and Gynecology, Tours University Hospital, Tours (F.P.), the Department of Obstetrics and Gynecology, Saint Joseph Hospital, Marseille (R.D.), the Department of Obstetrics and Gynecology, Montpellier University Hospital, Montpellier (F.F.), the Center for Research in Epidemiology and Population Health, INSERM Unité 1018, Reproduction and Child Development, Villejuif (F.F.), the Department of Obstetrics and Gynecology, Centre Hospitalier Departemental, La Roche-sur-Yon (G.D.), the Hospices Civils de Lyon, Hôpital Femme Mère Enfant, Department of Obstetrics and Gynecology, University Lyon 1 (M.D.-D.), and the Department of Obstetrics and Gynecology, Croix Rousse University Hospital (C.H.), Lyon, the Department of Obstetrics and Gynecology, François Mitterrand Hospital, Pau (C.B.), the Department of Obstetrics and Gynecology, Jeanne de Flandre University Hospital, Lille (P.D.), and the Production Pharmaceutique pour la Recherche Institutionnelle du Grand Ouest, Brest University Hospital, Brest (A.D., V.D.) - all in France
| | - Caroline Bohec
- From the Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux (L.S.), the Departments of Obstetrics and Gynecology (L.S.), Pharmacy (A.D., V.D.), and Clinical Research (J.-M.C.), Angers University Hospital, Angers, the Department of Obstetrics and Gynecology, University Medical Center of Nantes and the Centre d'Investigation Clinique Mère Enfant, University Hospital, the National Institute of Agricultural Research, Physiology of Nutritional Adaptations, University of Nantes, the Institute of Digestive Disease and Centre de Recherche en Nutrition Humaine Ouest, Nantes (N.W.), the Maternity Unit, Paris Saint Joseph Hospital (E.A.), INSERM Unité 1153, Obstetrical, Perinatal, and Pediatric Epidemiology Research Team, the Center for Epidemiology and Statistics, Sorbonne Paris Cité, University Hospital Department of Risks in Pregnancy (E.A., C.L.R., G.K., A.S., C.D.-T.), the Port Royal Maternity Unit, Cochin Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University Hospital Department of Risks in Pregnancy (C.L.R.), Paris Descartes University, the Department of Obstetrics and Gynecology, Bicêtre University Hospital, AP-HP (M.-V.S.), and the Department of Obstetrics and Gynecology, Trousseau Hospital, AP-HP (G.K.), Paris, the Department of Obstetrics and Gynecology, Caen University Hospital, Caen (D.V.), the Department of Obstetrics and Gynecology, Tours University Hospital, Tours (F.P.), the Department of Obstetrics and Gynecology, Saint Joseph Hospital, Marseille (R.D.), the Department of Obstetrics and Gynecology, Montpellier University Hospital, Montpellier (F.F.), the Center for Research in Epidemiology and Population Health, INSERM Unité 1018, Reproduction and Child Development, Villejuif (F.F.), the Department of Obstetrics and Gynecology, Centre Hospitalier Departemental, La Roche-sur-Yon (G.D.), the Hospices Civils de Lyon, Hôpital Femme Mère Enfant, Department of Obstetrics and Gynecology, University Lyon 1 (M.D.-D.), and the Department of Obstetrics and Gynecology, Croix Rousse University Hospital (C.H.), Lyon, the Department of Obstetrics and Gynecology, François Mitterrand Hospital, Pau (C.B.), the Department of Obstetrics and Gynecology, Jeanne de Flandre University Hospital, Lille (P.D.), and the Production Pharmaceutique pour la Recherche Institutionnelle du Grand Ouest, Brest University Hospital, Brest (A.D., V.D.) - all in France
| | - Philippe Deruelle
- From the Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux (L.S.), the Departments of Obstetrics and Gynecology (L.S.), Pharmacy (A.D., V.D.), and Clinical Research (J.-M.C.), Angers University Hospital, Angers, the Department of Obstetrics and Gynecology, University Medical Center of Nantes and the Centre d'Investigation Clinique Mère Enfant, University Hospital, the National Institute of Agricultural Research, Physiology of Nutritional Adaptations, University of Nantes, the Institute of Digestive Disease and Centre de Recherche en Nutrition Humaine Ouest, Nantes (N.W.), the Maternity Unit, Paris Saint Joseph Hospital (E.A.), INSERM Unité 1153, Obstetrical, Perinatal, and Pediatric Epidemiology Research Team, the Center for Epidemiology and Statistics, Sorbonne Paris Cité, University Hospital Department of Risks in Pregnancy (E.A., C.L.R., G.K., A.S., C.D.-T.), the Port Royal Maternity Unit, Cochin Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University Hospital Department of Risks in Pregnancy (C.L.R.), Paris Descartes University, the Department of Obstetrics and Gynecology, Bicêtre University Hospital, AP-HP (M.-V.S.), and the Department of Obstetrics and Gynecology, Trousseau Hospital, AP-HP (G.K.), Paris, the Department of Obstetrics and Gynecology, Caen University Hospital, Caen (D.V.), the Department of Obstetrics and Gynecology, Tours University Hospital, Tours (F.P.), the Department of Obstetrics and Gynecology, Saint Joseph Hospital, Marseille (R.D.), the Department of Obstetrics and Gynecology, Montpellier University Hospital, Montpellier (F.F.), the Center for Research in Epidemiology and Population Health, INSERM Unité 1018, Reproduction and Child Development, Villejuif (F.F.), the Department of Obstetrics and Gynecology, Centre Hospitalier Departemental, La Roche-sur-Yon (G.D.), the Hospices Civils de Lyon, Hôpital Femme Mère Enfant, Department of Obstetrics and Gynecology, University Lyon 1 (M.D.-D.), and the Department of Obstetrics and Gynecology, Croix Rousse University Hospital (C.H.), Lyon, the Department of Obstetrics and Gynecology, François Mitterrand Hospital, Pau (C.B.), the Department of Obstetrics and Gynecology, Jeanne de Flandre University Hospital, Lille (P.D.), and the Production Pharmaceutique pour la Recherche Institutionnelle du Grand Ouest, Brest University Hospital, Brest (A.D., V.D.) - all in France
| | - Astrid Darsonval
- From the Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux (L.S.), the Departments of Obstetrics and Gynecology (L.S.), Pharmacy (A.D., V.D.), and Clinical Research (J.-M.C.), Angers University Hospital, Angers, the Department of Obstetrics and Gynecology, University Medical Center of Nantes and the Centre d'Investigation Clinique Mère Enfant, University Hospital, the National Institute of Agricultural Research, Physiology of Nutritional Adaptations, University of Nantes, the Institute of Digestive Disease and Centre de Recherche en Nutrition Humaine Ouest, Nantes (N.W.), the Maternity Unit, Paris Saint Joseph Hospital (E.A.), INSERM Unité 1153, Obstetrical, Perinatal, and Pediatric Epidemiology Research Team, the Center for Epidemiology and Statistics, Sorbonne Paris Cité, University Hospital Department of Risks in Pregnancy (E.A., C.L.R., G.K., A.S., C.D.-T.), the Port Royal Maternity Unit, Cochin Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University Hospital Department of Risks in Pregnancy (C.L.R.), Paris Descartes University, the Department of Obstetrics and Gynecology, Bicêtre University Hospital, AP-HP (M.-V.S.), and the Department of Obstetrics and Gynecology, Trousseau Hospital, AP-HP (G.K.), Paris, the Department of Obstetrics and Gynecology, Caen University Hospital, Caen (D.V.), the Department of Obstetrics and Gynecology, Tours University Hospital, Tours (F.P.), the Department of Obstetrics and Gynecology, Saint Joseph Hospital, Marseille (R.D.), the Department of Obstetrics and Gynecology, Montpellier University Hospital, Montpellier (F.F.), the Center for Research in Epidemiology and Population Health, INSERM Unité 1018, Reproduction and Child Development, Villejuif (F.F.), the Department of Obstetrics and Gynecology, Centre Hospitalier Departemental, La Roche-sur-Yon (G.D.), the Hospices Civils de Lyon, Hôpital Femme Mère Enfant, Department of Obstetrics and Gynecology, University Lyon 1 (M.D.-D.), and the Department of Obstetrics and Gynecology, Croix Rousse University Hospital (C.H.), Lyon, the Department of Obstetrics and Gynecology, François Mitterrand Hospital, Pau (C.B.), the Department of Obstetrics and Gynecology, Jeanne de Flandre University Hospital, Lille (P.D.), and the Production Pharmaceutique pour la Recherche Institutionnelle du Grand Ouest, Brest University Hospital, Brest (A.D., V.D.) - all in France
| | - Jean-Marie Chrétien
- From the Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux (L.S.), the Departments of Obstetrics and Gynecology (L.S.), Pharmacy (A.D., V.D.), and Clinical Research (J.-M.C.), Angers University Hospital, Angers, the Department of Obstetrics and Gynecology, University Medical Center of Nantes and the Centre d'Investigation Clinique Mère Enfant, University Hospital, the National Institute of Agricultural Research, Physiology of Nutritional Adaptations, University of Nantes, the Institute of Digestive Disease and Centre de Recherche en Nutrition Humaine Ouest, Nantes (N.W.), the Maternity Unit, Paris Saint Joseph Hospital (E.A.), INSERM Unité 1153, Obstetrical, Perinatal, and Pediatric Epidemiology Research Team, the Center for Epidemiology and Statistics, Sorbonne Paris Cité, University Hospital Department of Risks in Pregnancy (E.A., C.L.R., G.K., A.S., C.D.-T.), the Port Royal Maternity Unit, Cochin Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University Hospital Department of Risks in Pregnancy (C.L.R.), Paris Descartes University, the Department of Obstetrics and Gynecology, Bicêtre University Hospital, AP-HP (M.-V.S.), and the Department of Obstetrics and Gynecology, Trousseau Hospital, AP-HP (G.K.), Paris, the Department of Obstetrics and Gynecology, Caen University Hospital, Caen (D.V.), the Department of Obstetrics and Gynecology, Tours University Hospital, Tours (F.P.), the Department of Obstetrics and Gynecology, Saint Joseph Hospital, Marseille (R.D.), the Department of Obstetrics and Gynecology, Montpellier University Hospital, Montpellier (F.F.), the Center for Research in Epidemiology and Population Health, INSERM Unité 1018, Reproduction and Child Development, Villejuif (F.F.), the Department of Obstetrics and Gynecology, Centre Hospitalier Departemental, La Roche-sur-Yon (G.D.), the Hospices Civils de Lyon, Hôpital Femme Mère Enfant, Department of Obstetrics and Gynecology, University Lyon 1 (M.D.-D.), and the Department of Obstetrics and Gynecology, Croix Rousse University Hospital (C.H.), Lyon, the Department of Obstetrics and Gynecology, François Mitterrand Hospital, Pau (C.B.), the Department of Obstetrics and Gynecology, Jeanne de Flandre University Hospital, Lille (P.D.), and the Production Pharmaceutique pour la Recherche Institutionnelle du Grand Ouest, Brest University Hospital, Brest (A.D., V.D.) - all in France
| | - Aurélien Seco
- From the Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux (L.S.), the Departments of Obstetrics and Gynecology (L.S.), Pharmacy (A.D., V.D.), and Clinical Research (J.-M.C.), Angers University Hospital, Angers, the Department of Obstetrics and Gynecology, University Medical Center of Nantes and the Centre d'Investigation Clinique Mère Enfant, University Hospital, the National Institute of Agricultural Research, Physiology of Nutritional Adaptations, University of Nantes, the Institute of Digestive Disease and Centre de Recherche en Nutrition Humaine Ouest, Nantes (N.W.), the Maternity Unit, Paris Saint Joseph Hospital (E.A.), INSERM Unité 1153, Obstetrical, Perinatal, and Pediatric Epidemiology Research Team, the Center for Epidemiology and Statistics, Sorbonne Paris Cité, University Hospital Department of Risks in Pregnancy (E.A., C.L.R., G.K., A.S., C.D.-T.), the Port Royal Maternity Unit, Cochin Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University Hospital Department of Risks in Pregnancy (C.L.R.), Paris Descartes University, the Department of Obstetrics and Gynecology, Bicêtre University Hospital, AP-HP (M.-V.S.), and the Department of Obstetrics and Gynecology, Trousseau Hospital, AP-HP (G.K.), Paris, the Department of Obstetrics and Gynecology, Caen University Hospital, Caen (D.V.), the Department of Obstetrics and Gynecology, Tours University Hospital, Tours (F.P.), the Department of Obstetrics and Gynecology, Saint Joseph Hospital, Marseille (R.D.), the Department of Obstetrics and Gynecology, Montpellier University Hospital, Montpellier (F.F.), the Center for Research in Epidemiology and Population Health, INSERM Unité 1018, Reproduction and Child Development, Villejuif (F.F.), the Department of Obstetrics and Gynecology, Centre Hospitalier Departemental, La Roche-sur-Yon (G.D.), the Hospices Civils de Lyon, Hôpital Femme Mère Enfant, Department of Obstetrics and Gynecology, University Lyon 1 (M.D.-D.), and the Department of Obstetrics and Gynecology, Croix Rousse University Hospital (C.H.), Lyon, the Department of Obstetrics and Gynecology, François Mitterrand Hospital, Pau (C.B.), the Department of Obstetrics and Gynecology, Jeanne de Flandre University Hospital, Lille (P.D.), and the Production Pharmaceutique pour la Recherche Institutionnelle du Grand Ouest, Brest University Hospital, Brest (A.D., V.D.) - all in France
| | - Valérie Daniel
- From the Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux (L.S.), the Departments of Obstetrics and Gynecology (L.S.), Pharmacy (A.D., V.D.), and Clinical Research (J.-M.C.), Angers University Hospital, Angers, the Department of Obstetrics and Gynecology, University Medical Center of Nantes and the Centre d'Investigation Clinique Mère Enfant, University Hospital, the National Institute of Agricultural Research, Physiology of Nutritional Adaptations, University of Nantes, the Institute of Digestive Disease and Centre de Recherche en Nutrition Humaine Ouest, Nantes (N.W.), the Maternity Unit, Paris Saint Joseph Hospital (E.A.), INSERM Unité 1153, Obstetrical, Perinatal, and Pediatric Epidemiology Research Team, the Center for Epidemiology and Statistics, Sorbonne Paris Cité, University Hospital Department of Risks in Pregnancy (E.A., C.L.R., G.K., A.S., C.D.-T.), the Port Royal Maternity Unit, Cochin Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University Hospital Department of Risks in Pregnancy (C.L.R.), Paris Descartes University, the Department of Obstetrics and Gynecology, Bicêtre University Hospital, AP-HP (M.-V.S.), and the Department of Obstetrics and Gynecology, Trousseau Hospital, AP-HP (G.K.), Paris, the Department of Obstetrics and Gynecology, Caen University Hospital, Caen (D.V.), the Department of Obstetrics and Gynecology, Tours University Hospital, Tours (F.P.), the Department of Obstetrics and Gynecology, Saint Joseph Hospital, Marseille (R.D.), the Department of Obstetrics and Gynecology, Montpellier University Hospital, Montpellier (F.F.), the Center for Research in Epidemiology and Population Health, INSERM Unité 1018, Reproduction and Child Development, Villejuif (F.F.), the Department of Obstetrics and Gynecology, Centre Hospitalier Departemental, La Roche-sur-Yon (G.D.), the Hospices Civils de Lyon, Hôpital Femme Mère Enfant, Department of Obstetrics and Gynecology, University Lyon 1 (M.D.-D.), and the Department of Obstetrics and Gynecology, Croix Rousse University Hospital (C.H.), Lyon, the Department of Obstetrics and Gynecology, François Mitterrand Hospital, Pau (C.B.), the Department of Obstetrics and Gynecology, Jeanne de Flandre University Hospital, Lille (P.D.), and the Production Pharmaceutique pour la Recherche Institutionnelle du Grand Ouest, Brest University Hospital, Brest (A.D., V.D.) - all in France
| | - Catherine Deneux-Tharaux
- From the Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux (L.S.), the Departments of Obstetrics and Gynecology (L.S.), Pharmacy (A.D., V.D.), and Clinical Research (J.-M.C.), Angers University Hospital, Angers, the Department of Obstetrics and Gynecology, University Medical Center of Nantes and the Centre d'Investigation Clinique Mère Enfant, University Hospital, the National Institute of Agricultural Research, Physiology of Nutritional Adaptations, University of Nantes, the Institute of Digestive Disease and Centre de Recherche en Nutrition Humaine Ouest, Nantes (N.W.), the Maternity Unit, Paris Saint Joseph Hospital (E.A.), INSERM Unité 1153, Obstetrical, Perinatal, and Pediatric Epidemiology Research Team, the Center for Epidemiology and Statistics, Sorbonne Paris Cité, University Hospital Department of Risks in Pregnancy (E.A., C.L.R., G.K., A.S., C.D.-T.), the Port Royal Maternity Unit, Cochin Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University Hospital Department of Risks in Pregnancy (C.L.R.), Paris Descartes University, the Department of Obstetrics and Gynecology, Bicêtre University Hospital, AP-HP (M.-V.S.), and the Department of Obstetrics and Gynecology, Trousseau Hospital, AP-HP (G.K.), Paris, the Department of Obstetrics and Gynecology, Caen University Hospital, Caen (D.V.), the Department of Obstetrics and Gynecology, Tours University Hospital, Tours (F.P.), the Department of Obstetrics and Gynecology, Saint Joseph Hospital, Marseille (R.D.), the Department of Obstetrics and Gynecology, Montpellier University Hospital, Montpellier (F.F.), the Center for Research in Epidemiology and Population Health, INSERM Unité 1018, Reproduction and Child Development, Villejuif (F.F.), the Department of Obstetrics and Gynecology, Centre Hospitalier Departemental, La Roche-sur-Yon (G.D.), the Hospices Civils de Lyon, Hôpital Femme Mère Enfant, Department of Obstetrics and Gynecology, University Lyon 1 (M.D.-D.), and the Department of Obstetrics and Gynecology, Croix Rousse University Hospital (C.H.), Lyon, the Department of Obstetrics and Gynecology, François Mitterrand Hospital, Pau (C.B.), the Department of Obstetrics and Gynecology, Jeanne de Flandre University Hospital, Lille (P.D.), and the Production Pharmaceutique pour la Recherche Institutionnelle du Grand Ouest, Brest University Hospital, Brest (A.D., V.D.) - all in France
| |
Collapse
|
23
|
Yildirim D, Ozyurek SE. Intramuscular oxytocin administration before vs. after placental delivery for the prevention of postpartum hemorrhage: A randomized controlled prospective trial. Eur J Obstet Gynecol Reprod Biol 2018. [DOI: 10.1016/j.ejogrb.2018.03.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
24
|
Girault A, Deneux-Tharaux C, Sentilhes L, Maillard F, Goffinet F. Undiagnosed abnormal postpartum blood loss: Incidence and risk factors. PLoS One 2018; 13:e0190845. [PMID: 29320553 PMCID: PMC5761868 DOI: 10.1371/journal.pone.0190845] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2016] [Accepted: 12/16/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND We aimed to evaluate the incidence of undiagnosed abnormal postpartum blood loss (UPPBL) after vaginal delivery, identify the risk factors and compare them to those of postpartum haemorrhage (PPH). METHOD The study population included women who participated in a randomized controlled trial of women with singleton low-risk pregnancy who delivered vaginally after 35 weeks' gestation (n = 3917). Clinical PPH was defined as postpartum blood loss ≥ 500 mL measured by using a collector bag and UPPBL was defined by a peripartum change in haemoglobin ≥ 2 g/dL in the absence of clinical PPH. Risk factors were assessed by multivariate multinomial logistic regression. RESULTS The incidence of UPPBL and PPH was 11.2% and 11.0% of vaginal deliveries, respectively. The median peripartum change in Hb level was comparable between UPPBL and PPH groups (2.5 g/dL interquartile range [2.2-3.0] and 2.4 g/dL IQR [1.5-3.3]). Risk factors specifically associated with UPPBL were Asian geographical origin (adjusted OR [aOR] 2.3, 95% confidence interval [CI] 1.2-4.2; p = 0.009), previous caesarean section (aOR 3.4, 2.1-5.5; p<0.001) and episiotomy (aOR 2.6, 1.8-3.6; p<0.001). Risk factors for both UPPBL and PPH were primiparity, long duration of labour, instrumental delivery and retained placenta. CONCLUSION Undiagnosed abnormal postpartum blood loss is frequent among women giving birth vaginally and has specific risk factors. The clinical importance of this entity needs further confirmation, and the benefit of systematic or targeted prevention strategies needs to be assessed.
Collapse
Affiliation(s)
- Aude Girault
- INSERM UMR 1153, Obstetrical, Perinatal and Paediatric Epidemiology Research Team (Epopé), Centre for Epidemiology and Statistics Sorbonne Paris Cité (CRESS), DHU Risks in pregnancy, Paris Descartes University, Paris, France
| | - Catherine Deneux-Tharaux
- INSERM UMR 1153, Obstetrical, Perinatal and Paediatric Epidemiology Research Team (Epopé), Centre for Epidemiology and Statistics Sorbonne Paris Cité (CRESS), DHU Risks in pregnancy, Paris Descartes University, Paris, France
| | - Loic Sentilhes
- Department of Obstetrics and Gynaecology, Angers University Hospital, France
| | - Françoise Maillard
- INSERM UMR 1153, Obstetrical, Perinatal and Paediatric Epidemiology Research Team (Epopé), Centre for Epidemiology and Statistics Sorbonne Paris Cité (CRESS), DHU Risks in pregnancy, Paris Descartes University, Paris, France
| | - François Goffinet
- INSERM UMR 1153, Obstetrical, Perinatal and Paediatric Epidemiology Research Team (Epopé), Centre for Epidemiology and Statistics Sorbonne Paris Cité (CRESS), DHU Risks in pregnancy, Paris Descartes University, Paris, France
- Port-Royal Maternity Unit, Department of Obstetrics Paris, Cochin Broca Hôtel-Dieu hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| |
Collapse
|
25
|
The Routine Use of Prophylactic Oxytocin in the Third Stage of Labor to Reduce Maternal Blood Loss. J Pregnancy 2017; 2017:3274901. [PMID: 29085678 PMCID: PMC5611883 DOI: 10.1155/2017/3274901] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 07/19/2017] [Accepted: 07/24/2017] [Indexed: 12/02/2022] Open
Abstract
Objective To demonstrate whether or not the routine use of prophylactic oxytocin (RUPO) reduces the blood loss and incidence of postpartum hemorrhaging (PPH). Methods We used a prospective cohort and a historical control in a tertiary perinatal care center in Japan. In the prospective cohort, we introduced RUPO in April 2012 by infusing 10 units of oxytocin per 500 mL of normal saline into a venous line after anterior shoulder delivery (RUPO group). In the historical control, oxytocin was administered via a case-selective approach (historical control group). We included completed singleton vaginal deliveries and compared the volume of blood loss and the incidence of PPH between the groups. Results We found a significantly lower volume of blood loss (520 ± 327 versus 641 ± 375 mL, p < 0.001) and a lower incidence of PPH (6.1% versus 14.0%, p < 0.001) in the RUPO group (n = 392) than in the control group (n = 407). Although the oxytocin dose was significantly higher in the RUPO group (12.8 ± 6.7 versus 10.1 ± 8.0 IU, p < 0.001), no adverse outcomes were observed to be associated with RUPO. Conclusions The introduction of RUPO significantly reduced blood loss and the incidence of PPH during completed singleton vaginal deliveries without an increase in adverse effects.
Collapse
|
26
|
Coad SL, Dahlgren LS, Hutcheon JA. Risks and consequences of puerperal uterine inversion in the United States, 2004 through 2013. Am J Obstet Gynecol 2017; 217:377.e1-377.e6. [PMID: 28522320 DOI: 10.1016/j.ajog.2017.05.018] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 05/01/2017] [Accepted: 05/07/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND Puerperal uterine inversion is a rare, potentially life-threatening obstetrical emergency. The current literature consists of small case series and a single nationwide study from Europe with only 15 cases. OBJECTIVE We aimed to define the incidence, temporal trends, and outcomes in women with uterine inversion using a nationally representative US cohort. STUDY DESIGN We used the Nationwide Inpatient Sample, a 20% sample of US hospital admissions, to identify all deliveries from 2004 through 2013. International Classification of Diseases, Ninth Revision diagnosis codes were used to identify cases of uterine inversion and associated adverse outcomes (maternal death, blood transfusion, maternal shock, need for surgical correction, and length of hospital stay). The incidence of uterine inversion overall and for each year of the study period was calculated with 95% confidence intervals. The case fatality and incidence of other adverse outcomes among women with a uterine inversion were also estimated. RESULTS Among 8,294,279 deliveries in 2004 through 2013, there were 2427 cases of puerperal uterine inversion, corresponding to an incidence of 2.9 per 10,000 deliveries (95% confidence interval, 2.8-3.0). There was 1 maternal death in our cohort (4.1 per 10,000 events). No change in the incidence of uterine inversion over the study period was detected. Among women with a uterine inversion, 37.7% (95% confidence interval, 35.8-39.6%) had an associated postpartum hemorrhage, 22.4% (95% confidence interval, 20.7-24.0%) received a blood transfusion, and 6.0% (95% confidence interval, 5.1-7.0%) required surgical management. Only 2.8% (95% confidence interval, 2.1-3.5%) underwent a hysterectomy. The median length of hospital stay was 3 days. CONCLUSION This study provides the largest population-based results on puerperal uterine inversion to date and highlights the high likelihood of adverse maternal outcomes associated with the condition. The results inform the optimization of clinical management, by preparing for possible postpartum hemorrhage, need for blood products, and surgical management in the rare event of uterine inversion.
Collapse
Affiliation(s)
- Sarah L Coad
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, British Columbia, Canada.
| | - Leanne S Dahlgren
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jennifer A Hutcheon
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, British Columbia, Canada
| |
Collapse
|
27
|
Sentilhes L, Maillard F, Brun S, Madar H, Merlot B, Goffinet F, Deneux-Tharaux C. Risk factors for chronic post-traumatic stress disorder development one year after vaginal delivery: a prospective, observational study. Sci Rep 2017; 7:8724. [PMID: 28821837 PMCID: PMC5562814 DOI: 10.1038/s41598-017-09314-x] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Accepted: 07/18/2017] [Indexed: 11/08/2022] Open
Abstract
Our study aimed to assess the prevalence of post-traumatic stress disorder (PTSD) after childbirth one year after vaginal delivery and to identify characteristics of women and deliveries associated with it. Questionnaires were mailed a year after delivery to 1103 women with prospectively collected delivery and postpartum data, including a question on day 2 assessing their experience of childbirth. PTSD was assessed a year later by the Impact of Event and Traumatic Event Scales; 22 women (4.2%, 95%CI 2.7-6.3%) met the PTSD diagnostic criteria and 30 (5.7%; 95%CI 3.9-8.0%) PTSD profile criteria. Factors associated with higher risk of PTSD profile were previous abortion (aOR 3.6, 95%CI 1.4-9.3), previous postpartum hemorrhage (Aor 5.3, 95%CI 1.3-21.4), and postpartum hemoglobin <9 g/dl (aOR 2.7, 95%CI 1.0-7.5). Among 56 women (10.3%) reporting bad childbirth memories at day 2 postpartum, 11 (21.1%) met PTSD diagnosis and 11 (21.1%) PTSD profile criteria a year later, compared with 11 (2.4%) (P < 0.001) and 18 (3.8%) (P < 0.001), respectively, of the 489 (87.7%) women with good memories. PTSD is not rare at one year after vaginal delivery in a low-risk population. A simple question at day 2 post partum may identify women most at risk of PTSD and help determine if early intervention is needed.
Collapse
Affiliation(s)
- Loïc Sentilhes
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux, France.
| | - Françoise Maillard
- Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé), Center for Epidemiology and Statistics Sorbonne Paris Cité (CRESS), DHU Risks in pregnancy, Paris Descartes University, Paris, France
| | - Stéphanie Brun
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux, France
| | - Hugo Madar
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux, France
| | - Benjamin Merlot
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux, France
| | - François Goffinet
- Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé), Center for Epidemiology and Statistics Sorbonne Paris Cité (CRESS), DHU Risks in pregnancy, Paris Descartes University, Paris, France
- Port-Royal Maternity Unit, Department of Obstetrics and Gynecology, Cochin University Hospital, APHP, Paris, France
| | - Catherine Deneux-Tharaux
- Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé), Center for Epidemiology and Statistics Sorbonne Paris Cité (CRESS), DHU Risks in pregnancy, Paris Descartes University, Paris, France
| |
Collapse
|
28
|
[Double-balloon catheter compared to vaginal dinoprostone for cervical ripening in obese women at term]. ACTA ACUST UNITED AC 2017; 45:521-527. [PMID: 28757105 DOI: 10.1016/j.gofs.2017.06.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Accepted: 06/20/2017] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To compare the efficacy of a double-balloon catheter versus vaginal prostaglandin E2 (dinoprostone) for cervical ripening in obese patients with unfavorable cervix at term. METHODS The study had an open-label, prospective combined with retrospective, observational design. From January 2013 until May 2016, a prospective cohort study of 46 women with pre-pregnancy BMI>30kg/m2, live singleton term fetuses (>37 weeks) in vertex presentation and unfavorable cervix (Bishop score<6), who underwent labor induction for conventional indications using a double-balloon catheter. In the same period, 46 obese women who had undergone cervical ripening using vaginal dinoprostone (3mg) were retrospectively included. Women in groups were paired according to Bishop score before the insertion, pre-pregnancy BMI and parity. The primary outcome was a favorable cervix (Bishop score ≥6) 24h after cervical ripening. RESULTS After 24h, there was a significantly higher rate of women with favorable cervix (Bishop score ≥6) in the double-balloon group than in dinoprostone group (80.4% vs 47.8%; P=0.001). After adjustment, a double-balloon catheter was significantly associated with an efficient cervical ripening compared to vaginal dinoprostone (aOR 7.81, 95% CI 2.58-23.60). No difference was observed in cesarean section rate (39.1% in each group; P=0.96) and in mean induction time to vaginal delivery (34.5h in the balloon group vs 36.5h in the dinoprostone group; P=0.53). Maternal and neonatal outcomes were similar. CONCLUSION For obese patients at term, cervical ripening using a double-balloon catheter is more efficient on Bishop score after 24h compared to vaginal dinoprostone.
Collapse
|
29
|
|
30
|
Brooks M, Legendre G, Brun S, Bouet PE, Mendes LP, Merlot B, Sentilhes L. Use of a Visual Aid in addition to a Collector Bag to Evaluate Postpartum Blood loss: A Prospective Simulation Study. Sci Rep 2017; 7:46333. [PMID: 28429722 PMCID: PMC5399603 DOI: 10.1038/srep46333] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Accepted: 03/15/2017] [Indexed: 11/18/2022] Open
Abstract
Postpartum hemorrhage (PPH) is one of the most common causes of mortality in obstetrics worldwide. The accuracy of estimated blood loss is a priority in determining appropriate treatment. Will the additional use of a visual aid improve physicians' accuracy in estimating blood loss compared to the use of a collector bag and baby scale alone? Simulation training sessions created three vaginal delivery scenarios for participants to estimate volumes of blood loss: firstly, using only a collector bag and a baby weight scale and secondly, adding a visual aid depicting known volumes of blood. The primary endpoint was to determine if participants could accurately evaluate blood loss within a 20% error margin. The addition of the visual estimator resulted in overestimation of blood loss. The rates of participants' estimations were significantly more accurate when using the collector bag with the baby weight scale without the addition of the visual aid; 85.5% versus 33.3% (p < 0.01) for 350 mL, 88.4% versus 50.7% (p < 0.01) for 1100 mL and 88.4% versus 78.3% (p < 0.01) for 2500 mL, respectively. Additional use of a visual aid with a collector bag does not seem to be useful in improving the accuracy in the estimation of blood loss.
Collapse
Affiliation(s)
- M. Brooks
- Department of Obstetrics and Gynecology, Angers University Hospital, Angers, France
| | - G. Legendre
- Department of Obstetrics and Gynecology, Angers University Hospital, Angers, France
| | - S. Brun
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux, France
| | - P. -E. Bouet
- Department of Obstetrics and Gynecology, Angers University Hospital, Angers, France
| | - L. Pereira Mendes
- Department of Obstetrics and Gynecology, Angers University Hospital, Angers, France
| | - B. Merlot
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux, France
| | - L. Sentilhes
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux, France
| |
Collapse
|
31
|
Kayem G, Deneux-Tharaux C. Authors' reply Quantifying haemorrhage is a central difficulty when dealing with primary postpartum haemorrhage. BJOG 2017; 124:526-527. [PMID: 28120541 DOI: 10.1111/1471-0528.14367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Gilles Kayem
- Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé), Inserm UMR 1153, Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Paris, France.,Department of Obstetrics and Gynecology, Trousseau Hospital, APHP, Université Pierre et Marie Curie, Paris, France
| | - Catherine Deneux-Tharaux
- Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé), Inserm UMR 1153, Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Paris, France
| |
Collapse
|
32
|
Sentilhes L, Merlot B, Madar H, Sztark F, Brun S, Deneux-Tharaux C. Postpartum haemorrhage: prevention and treatment. Expert Rev Hematol 2016; 9:1043-1061. [PMID: 27701915 DOI: 10.1080/17474086.2016.1245135] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Postpartum hemorrhage (PPH) is one of the leading causes of maternal death and severe maternal morbidity worldwide and strategies to prevent and treat PPH vary among international authorities. Areas covered: This review seeks to provide a global overview of PPH (incidence, causes, risk factors), prevention (active management of the third stage of labor and prohemostatic agents), treatment (first, second and third-line measures to control PPH), by also underlining recommendations elaborated by international authorities and using algorithms. Expert commentary: When available, oxytocin is considered the drug of first choice for both prevention and treatment of PPH, while peripartum hysterectomy remains the ultimate life-saving procedure if pharmacological and resuscitation measures fail. Nevertheless, the level of evidence for preventing and treating PPH is globally low. The emergency nature of PPH makes randomized controlled trials (RCT) logistically difficult. Population-based observational studies should be encouraged as they can usefully strengthen the evidence base, particularly for components of PPH treatment that are difficult or impossible to assess through RCT.
Collapse
Affiliation(s)
- Loïc Sentilhes
- a Department of Obstetrics and Gynecology , Bordeaux University Hospital, University of Bordeaux , Bordeaux , France
| | - Benjamin Merlot
- a Department of Obstetrics and Gynecology , Bordeaux University Hospital, University of Bordeaux , Bordeaux , France
| | - Hugo Madar
- a Department of Obstetrics and Gynecology , Bordeaux University Hospital, University of Bordeaux , Bordeaux , France
| | - François Sztark
- b Department of Anesthesiology , Bordeaux University Hospital, University of Bordeaux , Bordeaux , France
| | - Stéphanie Brun
- a Department of Obstetrics and Gynecology , Bordeaux University Hospital, University of Bordeaux , Bordeaux , France
| | - Catherine Deneux-Tharaux
- c INSERM U1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Center for Epidemiology and Statistics Sorbonne Paris Cité , Paris Descartes University , Paris , France
| |
Collapse
|
33
|
Sentilhes L, Goffinet F, Vayssière C, Deneux-Tharaux C. Comparison of postpartum haemorrhage guidelines: discrepancies underline our lack of knowledge. BJOG 2016; 124:718-722. [DOI: 10.1111/1471-0528.14305] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/29/2016] [Indexed: 11/30/2022]
Affiliation(s)
- L Sentilhes
- Department of Obstetrics and Gynaecology; Bordeaux University Hospital; Bordeaux France
| | - F Goffinet
- INSERM U1153; Obstetrical, Perinatal and Paediatric Epidemiology Research Team; Centre for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks and Pregnancy; Paris Descartes University; Paris France
- Port-Royal Maternity Unit; Cochin Broca Hôtel-Dieu University Hospital; APHP; Paris Descartes University; Paris France
| | - C Vayssière
- Department of Obstetrics and Gynaecology; Paule de Viguier University Hospital; Toulouse France
- UMR 1027 Inserm Toulouse III University ‘Epidémiologie Périnatale et handicap de l'enfant, Santé des adolescents’; Toulouse France
| | - C Deneux-Tharaux
- INSERM U1153; Obstetrical, Perinatal and Paediatric Epidemiology Research Team; Centre for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks and Pregnancy; Paris Descartes University; Paris France
| |
Collapse
|
34
|
|
35
|
Cummings K, Doherty DA, Magann EF, Wendel PJ, Morrison JC. Timing of manual placenta removal to prevent postpartum hemorrhage: is it time to act? J Matern Fetal Neonatal Med 2016; 29:3930-3. [PMID: 26953615 DOI: 10.3109/14767058.2016.1154941] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The length of the third stage of labor is an important risk factor for postpartum hemorrhage (PPH). Current practice recommends manual placenta removal, if not delivered spontaneously, within 30 min. The review reexamines the evidence to determine the optimal length of the third stage of labor. METHODS A MEDLINE search that associated the length of the third stage of labor with the risk of PPH was undertaken. RESULTS A retrospective cohort study revealed the risk of a PPH became significant at 10 min (odds ratio = 2.1, 95% confidence interval: 1.6-2.6), and had doubled by 20 min (odds ratio = 4.3, 95% confidence interval: 3.3-5.5). A receiver operator curve determined the optimal length of the third stage of labor to prevent PPH was 18 min. A follow up randomized controlled trial showed that hemodynamic compromise secondary to a PPH can be reduced with manual placenta removal at 10 compared to 15 min (6.4 versus 19.2%, p = 0.001). CONCLUSION The time interval of 15 min may be a more appropriate time interval to recommend placental removal to prevent PPH.
Collapse
Affiliation(s)
- Kelly Cummings
- a Department of Obstetrics and Gynecology , University of Arkansas for Medical Sciences , Little Rock , AR , USA
| | - Dorota A Doherty
- b School of Women's and Infants' Health, University of Western Australia , Perth , Australia , and
| | - Everett F Magann
- a Department of Obstetrics and Gynecology , University of Arkansas for Medical Sciences , Little Rock , AR , USA .,b School of Women's and Infants' Health, University of Western Australia , Perth , Australia , and
| | - Paul J Wendel
- a Department of Obstetrics and Gynecology , University of Arkansas for Medical Sciences , Little Rock , AR , USA
| | - John C Morrison
- c Department of Obstetrics and Gynecology , University of Mississippi Medical Center , Jackson , MS , USA
| |
Collapse
|
36
|
Systematic prophylactic oxytocin injection and the incidence of postpartum hemorrhage: A before-and-after study. ACTA ACUST UNITED AC 2016; 45:147-54. [PMID: 26747233 DOI: 10.1016/j.jgyn.2015.11.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2015] [Revised: 11/01/2015] [Accepted: 11/04/2015] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Assess the impact of routine injection of 5 units of oxytocin as soon as the anterior shoulder is delivered on the incidence of postpartum haemorrhage (PPH) in a context of daily practice. MATERIALS AND METHODS Single-centre before-and-after study evaluating the effect of a change in the protocol for PPH prevention as applied in our obstetrical unit. During the first period, oxytocin (5 units) was to be injected only in case of PPH risk factors. During the second period, the injection was systematic. RESULTS In the "before" study period, there were 1953 patients vaginal deliveries and 843 (43%) oxytocin injections, with a protocol compliance of 85%. In the "after" study period, 2018 women had vaginal deliveries and 1911 (95%) had an oxytocin injection (protocol compliance: 95%). The whole study period was associated with a reduced risk of moderate haemorrhage (13.4% vs. 9.2%, P<0.001), but no significant reduced risk of severe haemorrhage was observed (2.1% vs. 2.0%, P=0.79). After logistic regression, the study period remained associated with a significant reduction in the risk of moderate PPH (OR=0.72 [0.58-0.89]). CONCLUSION Routine injection of 5 units of oxytocin makes it possible to reduce the risk of moderate PPH, but it does not affect the risk of severe PPH.
Collapse
|
37
|
Maternal and Neonatal Morbidity After Attempted Operative Vaginal Delivery According to Fetal Head Station. Obstet Gynecol 2015; 126:521-529. [PMID: 26244539 DOI: 10.1097/aog.0000000000001000] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare severe short-term maternal and neonatal morbidity associated with midpelvic and low pelvic attempted operative vaginal delivery. METHODS Prospective study of 2,138 women with live singleton term fetuses in vertex presentation who underwent an attempted operative vaginal delivery in a tertiary care university hospital. We used multivariate logistic regression and propensity score methods to compare outcomes associated with midpelvic and low pelvic delivery. Severe maternal morbidity was defined as third- or fourth-degree perineal laceration, perineal hematoma, cervical laceration, extended uterine incision for cesarean delivery, postpartum hemorrhage greater than 1,500 mL, surgical hemostatic procedures, uterine artery embolization, blood transfusion, infection, thromboembolic events, admission to the intensive care unit, and maternal death; severe neonatal morbidity was defined as 5-minute Apgar score less than 7, umbilical artery pH less than 7.00, need for resuscitation or intubation, neonatal trauma, intraventricular hemorrhage greater than grade 2, neonatal intensive care unit admission for more than 24 hours, convulsions, sepsis, and neonatal death. RESULTS From December 2008 through October 2013 there were 2,138 attempted operative vaginal deliveries; 18.3% (n=391) were midpelvic, 72.5% (n=1,550) low, and 9.2% (n=197) outlet. Severe maternal morbidity occurred in 10.2% (n=40) of midpelvic, 7.8% (n=121) of low, and 6.6% (n=13) of outlet attempts (P=.21); and severe neonatal morbidity in 15.1% (n=59), 10.2% (n=158), and 10.7% (n=21) (P=.02), respectively. Multivariable logistic regression analysis found no significant difference between midpelvic and low attempted operative vaginal delivery for either composite severe maternal (adjusted odds ratio [OR] 1.01, 95% confidence interval [CI] 0.66-1.55) or neonatal morbidity (adjusted OR 1.25, 95% CI 0.84-1.86). Similarly, propensity score matching found no significant difference between midpelvic and low operative vaginal delivery for either severe maternal (adjusted OR 0.69, 95% CI 0.39-1.22) or neonatal morbidity (adjusted OR 0.88, 95% CI 0.53-1.45). CONCLUSION In singleton term pregnancies, midpelvic attempted operative vaginal delivery compared with low pelvic attempted operative vaginal delivery was not associated with an increase in severe short-term maternal or neonatal morbidity. LEVEL OF EVIDENCE II.
Collapse
|
38
|
Dahlke JD, Mendez-Figueroa H, Maggio L, Hauspurg AK, Sperling JD, Chauhan SP, Rouse DJ. Prevention and management of postpartum hemorrhage: a comparison of 4 national guidelines. Am J Obstet Gynecol 2015; 213:76.e1-76.e10. [PMID: 25731692 DOI: 10.1016/j.ajog.2015.02.023] [Citation(s) in RCA: 172] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Revised: 12/31/2014] [Accepted: 02/19/2015] [Indexed: 02/09/2023]
Abstract
OBJECTIVE The purpose of this study was to compare 4 national guidelines for the prevention and management of postpartum hemorrhage (PPH). STUDY DESIGN We performed a descriptive analysis of guidelines from the American College of Obstetrician and Gynecologists practice bulletin, the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, the Royal College of Obstetrician and Gynaecologists (RCOG), and the Society of Obstetricians and Gynaecologists of Canada on PPH to determine differences, if any, with regard to definitions, risk factors, prevention, treatment, and resuscitation. RESULTS PPH was defined differently in all 4 guidelines. Risk factors that were emphasized in the guidelines conferred a high risk of catastrophic bleeding (eg, previous cesarean delivery and placenta previa). All organizations, except the American College of Obstetrician and Gynecologists, recommended active management of the third stage of labor for primary prevention of PPH in all vaginal deliveries. Oxytocin was recommended universally as the medication of choice for PPH prevention in vaginal deliveries. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists and RCOG recommended development of a massive transfusion protocol to manage PPH resuscitation. Recommendations for nonsurgical treatment strategies such as uterine packing and balloon tamponade varied across all guidelines. All organizations recommended transfer to a tertiary care facility for suspicion of abnormal placentation. Specific indications for hysterectomy were not available in any guideline, with RCOG recommending hysterectomy "sooner rather than later" with the assistance of a second consultant. CONCLUSION Substantial variation exists in PPH prevention and management guidelines among 4 national organizations that highlights the need for better evidence and more consistent synthesis of the available evidence with regard to a leading cause of maternal death.
Collapse
|
39
|
Bouet PE, Ruiz V, Legendre G, Gillard P, Descamps P, Sentilhes L. Policy of high-dose tranexamic acid for treating postpartum hemorrhage after vaginal delivery. J Matern Fetal Neonatal Med 2015; 29:1617-22. [PMID: 26118386 DOI: 10.3109/14767058.2015.1056731] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
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.
Collapse
Affiliation(s)
- Pierre-Emmanuel Bouet
- a Department of Obstetrics and Gynecology , Angers University Hospital , Angers , France
| | - Vanessa Ruiz
- a Department of Obstetrics and Gynecology , Angers University Hospital , Angers , France
| | - Guillaume Legendre
- a Department of Obstetrics and Gynecology , Angers University Hospital , Angers , France
| | - Philippe Gillard
- a Department of Obstetrics and Gynecology , Angers University Hospital , Angers , France
| | - Philippe Descamps
- a Department of Obstetrics and Gynecology , Angers University Hospital , Angers , France
| | - Loïc Sentilhes
- a Department of Obstetrics and Gynecology , Angers University Hospital , Angers , France
| |
Collapse
|
40
|
Abstract
BACKGROUND Postpartum haemorrhage (PPH) is a common and potentially life-threatening complication of labour. Several options for preventing PPH are available, but further advances in this field are important, especially the identification of safe, easy to use and cost-effective regimens. Tranexamic acid (TA), which is an antifibrinolytic agent that is used widely to prevent and treat haemorrhage, merits evaluation to assess whether it meets these criteria. OBJECTIVES To determine, from the best available evidence, whether TA is effective and safe for preventing PPH in comparison to placebo or no treatment (with or without uterotonic co-treatment), or to uterotonic agents. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (28 January 2015) and reference lists of retrieved studies. SELECTION CRITERIA All published, unpublished and ongoing randomised controlled trials (RCTs) evaluating the use of TA alone or in addition to uterotonics in the third stage of labour or during caesarean section (CS) to prevent PPH. DATA COLLECTION AND ANALYSIS Two review authors independently assessed for inclusion all the potential studies identified as a result of the search strategy. We entered the data into Review Manager software and checked for accuracy. MAIN RESULTS Twelve trials involving 3285 healthy women at low risk of excessive bleeding undergoing elective CS (nine trials, 2453 participants) or spontaneous birth (three trials, 832 participants) satisfied inclusion criteria and contributed data to the analysis. All participants received routine prophylactic uterotonics in accordance with the local guideline in addition to TA or placebo or no intervention. Overall, included studies had moderate risk of bias for random sequence generation, allocation concealment, blinding, selective reporting and low risk of bias for incomplete data. The quality of evidence was also as assessed using GRADE.Blood loss greater than 400 mL or 500 mL, and more than 1000 mL was less common in women who received TA versus placebo or no intervention (risk ratio (RR) 0.52, 95% confidence interval (CI) 0.42 to 0.63, six trials, 1398 women; moderate quality evidence) and (RR 0.40, 95% CI 0.23 to 0.71, six trials, 2093 women; moderate quality evidence), respectively. TA was effective in decreasing the incidence of blood loss greater than 1000 mL in women who had undergone CS (RR 0.43, 95% CI 0.23, 0.78, four trials, 1534 women), but not vaginal birth (RR 0.28, 95% CI 0.06, 1.36, two trials 559 women). The effect of TA on blood loss greater than 500 mL or 400 mL was more pronounced in the group of women having vaginal birth than in women who had CS. Mean blood loss (from delivery until two hours postpartum) was lower in women who received TA versus placebo or no intervention (mean difference MD - 77.79 mL, 95% CI -97.95, -57.64, five trials, 1186 women) and this effect was similar following vaginal birth and CS.Additional medical interventions (moderate quality evidence) and blood transfusions were less frequent in women receiving TA versus placebo or no interventions. Mild side effects such as nausea, vomiting, dizziness were more common with the use of TA (moderate quality evidence). The effect of TA on maternal mortality, severe morbidity and thromboembolic events is uncertain (low quality evidence). AUTHORS' CONCLUSIONS TA (in addition to uterotonic medications) decreases postpartum blood loss and prevents PPH and blood transfusions following vaginal birth and CS in women at low risk of PPH based on studies of mixed quality. There is insufficient evidence to draw conclusions about serious side effects, but there is an increase in the incidence of minor side effects with the use of TA. Effects of TA on thromboembolic events and mortality as well as its use in high-risk women should be investigated further.
Collapse
Affiliation(s)
- Natalia Novikova
- Department of Obstetrics and Gynaecology, East London Hospital Complex, Walter Sisulu University, Private Bag X9047, East London, South Africa, 5200
| | | | | |
Collapse
|
41
|
Sentilhes L, Daniel V, Darsonval A, Deruelle P, Vardon D, Perrotin F, Le Ray C, Senat MV, Winer N, Maillard F, Deneux-Tharaux C. Study protocol. TRAAP - TRAnexamic Acid for Preventing postpartum hemorrhage after vaginal delivery: a multicenter randomized, double-blind, placebo-controlled trial. BMC Pregnancy Childbirth 2015; 15:135. [PMID: 26071040 PMCID: PMC4465316 DOI: 10.1186/s12884-015-0573-5] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 05/28/2015] [Indexed: 01/31/2023] Open
Abstract
Background Postpartum hemorrhage (PPH) is a major cause of maternal mortality, accounting for one quarter of all maternal deaths worldwide. Estimates of its incidence in the literature vary widely, from 3 % to 15 % of deliveries. Uterotonics after birth are the only intervention that has been shown to be effective in preventing PPH. Tranexamic acid (TXA), an antifibrinolytic agent, has been investigated as a potentially useful complement to uterotonics for prevention because it has been proved to reduce blood loss in elective surgery, bleeding in trauma patients, and menstrual blood loss. Randomized controlled trials for PPH prevention after cesarean (n = 10) and vaginal (n = 2) deliveries show that women who received TXA had significantly less postpartum blood loss without any increase in their rate of severe adverse effects. However, the quality of these trials was poor and they were not designed to test the effect of TXA on the reduction of PPH incidence. Large, adequately powered, multicenter randomized controlled trials are required before the widespread use of TXA to prevent PPH can be recommended. Methods and design A multicenter, double-blind, randomized controlled trial will be performed. It will involve 4000 women in labor for a planned vaginal singleton delivery, at a term ≥ 35 weeks. Treatment (either TXA 1 g or placebo) will be administered intravenously just after birth. Prophylactic oxytocin will be administered to all women. The primary outcome will be the incidence of PPH, defined by blood loss ≥500 mL, measured with a graduated collector bag. This study will have 80 % power to show a 30 % reduction in the incidence of PPH, from 10.0 % to 7.0 %. Discussion In addition to prophylactic uterotonic administration, a complementary component of the management of third stage of labor acting on the coagulation process may be useful in preventing PPH. TXA is a promising candidate drug, inexpensive, easy to administer, and simple to add to the routine management of deliveries in hospitals. This large, adequately powered, multicenter, randomized placebo-controlled trial seeks to determine if the risk-benefit ratio favors the routine use of TXA after delivery to prevent PPH. Trial registration ClinicalTrials.gov NCT02302456 (November 17, 2014)
Collapse
Affiliation(s)
- Loïc Sentilhes
- Department of Obstetrics and Gynecology, Angers University Hospital, 4, rue Larrey, 49933, Angers, France.
| | - Valérie Daniel
- Department of Pharmacy, Angers University Hospital, Angers, France. .,PPRIGO (Production Pharmaceutique pour la Recherche Institutionnelle du Grand Ouest) Brest University Hospital, Brest, France.
| | - Astrid Darsonval
- Department of Pharmacy, Angers University Hospital, Angers, France. .,PPRIGO (Production Pharmaceutique pour la Recherche Institutionnelle du Grand Ouest) Brest University Hospital, Brest, France.
| | - Philippe Deruelle
- Department of Obstetrics and Gynecology, Jeanne de Flandre University Hospital, Lille, France.
| | - Delphine Vardon
- Department of Obstetrics and Gynecology, Caen University Hospital, Caen, France.
| | - Franck Perrotin
- Department of Obstetrics and Gynecology, Tours University Hospital, Tours, France.
| | - Camille Le Ray
- Port-Royal Maternity Unit, Department of Obstetrics and Gynecology, Cochin University Hospital, APHP, Paris, France. .,INSERM, Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Center for Epidemiology and Biostatistics (U1153), Risks in pregnancy DHU, Paris-Descartes University, Paris, France.
| | - Marie-Victoire Senat
- Department of Obstetrics and Gynecology, Kremlin-Bicetre University Hospital, APHP, Paris, France.
| | - Norbert Winer
- Department of Obstetrics and Gynecology, Nantes University Hospital, Nantes, France.
| | - Françoise Maillard
- INSERM, Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Center for Epidemiology and Biostatistics (U1153), Risks in pregnancy DHU, Paris-Descartes University, Paris, France.
| | - Catherine Deneux-Tharaux
- INSERM, Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Center for Epidemiology and Biostatistics (U1153), Risks in pregnancy DHU, Paris-Descartes University, Paris, France.
| |
Collapse
|
42
|
Sentilhes L, Lasocki S, Ducloy-Bouthors A, Deruelle P, Dreyfus M, Perrotin F, Goffinet F, Deneux-Tharaux C. Tranexamic acid for the prevention and treatment of postpartum haemorrhage. Br J Anaesth 2015; 114:576-87. [DOI: 10.1093/bja/aeu448] [Citation(s) in RCA: 87] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
|
43
|
López-Garrido B, García-Gonzalo J, Patrón-Rodriguez C, Marlasca-Gutiérrez MJ, Gil-Pita R, Toro-Flores R. Influence of acupuncture on the third stage of labor: a randomized controlled trial. J Midwifery Womens Health 2015; 60:199-205. [PMID: 25782852 DOI: 10.1111/jmwh.12262] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
INTRODUCTION A prolonged third stage of labor is considered to be a risk factor for postpartum hemorrhage. The objective of this study was to determine the ability of acupuncture to reduce the length of the third stage of labor. METHODS Seventy-six puerperal women who had a normal spontaneous birth at the Hospital Universitario Principe de Asturias, Alcalá de Henares, Spain, were included in a single-blind randomized trial and evaluated by a third party. Women were randomly assigned to receive true acupuncture or placebo acupuncture (also known as sham acupuncture). In the first group, a sterilized steel needle was inserted at the Ren Mai 6 point, which is located on the anterior midline between the umbilicus and the upper part of the pubic symphysis. In the second group, the insertion site was located at the same horizontal level as the Ren Mai 6 point but shifted slightly to the left of the anterior midline. The management of the third stage of labor was the same in both groups. RESULTS Statistically significant differences were found, with an average time to placental expulsion of 15.2 minutes in the placebo group and 5.2 minutes in the acupuncture group. No major complications occurred in either group. DISCUSSION These results confirm that acupuncture at the Ren Mai 6 point can decrease the time to placental expulsion. This treatment represents a simple, safe, and inexpensive way of decreasing the duration of the third stage of labor.
Collapse
|
44
|
Hoogenboom G, Thwin MM, Velink K, Baaijens M, Charrunwatthana P, Nosten F, McGready R. Quality of intrapartum care by skilled birth attendants in a refugee clinic on the Thai-Myanmar border: a survey using WHO Safe Motherhood Needs Assessment. BMC Pregnancy Childbirth 2015; 15:17. [PMID: 25652646 PMCID: PMC4332741 DOI: 10.1186/s12884-015-0444-0] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Accepted: 01/19/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Increasing the number of women birthing with skilled birth attendants (SBAs) as one of the strategies to reduce maternal mortality and morbidity must be partnered with a minimum standard of care. This manuscript describes the quality of intrapartum care provided by SBAs in Mae La camp, a low resource, protracted refugee context on the Thai-Myanmar border. METHODS In the obstetric department of Shoklo Malaria Research Unit (SMRU) the standardized WHO Safe Motherhood Needs Assessment tool was adapted to the setting and used: to assess the facility; interview SBAs; collect data from maternal records during a one year period (August 2007 - 2008); and observe practice during labour and childbirth. RESULTS The facility assessment recorded no 'out of stock' or 'out of date' drugs and supplies, equipment was in operating order and necessary infrastructure e.g. a stand-by emergency car, was present. Syphilis testing was not available. SBA interviews established that danger signs and symptoms were recognized except for sepsis and endometritis. All SBAs acknowledged receiving theoretical and 'hands-on' training and regularly attended deliveries. Scores for the essential elements of antenatal care from maternal records were high (>90%) e.g. providing supplements, recording risk factors as well as regular and correct partogram use. Observed good clinical practice included: presence of a support person; active management of third stage; post-partum monitoring; and immediate and correct neonatal care. Observed incorrect practice included: improper controlled cord traction; inadequate hand washing; an episiotomy rate in nulliparous women 49% (34/70) and low rates 30% (6/20) of newborn monitoring in the first hours following birth. Overall observed complications during labour and birth were low with post-partum haemorrhage being the most common in which case the SBAs followed the protocol but were slow to recognize severity and take action. CONCLUSIONS In the clinic of SMRU in Mae La refugee camp, SBAs were able to comply with evidence-based guidelines but support to improve quality of care in specific areas is required. The structure of the WHO Safe Motherhood Needs Assessment allowed significant insights into the quality of intrapartum care particularly through direct observation, identifying a clear pathway for quality improvement.
Collapse
Affiliation(s)
- Gabie Hoogenboom
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand.
| | - May Myo Thwin
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand.
| | - Kris Velink
- AVAG Midwifery Academy Amsterdam Groningen, Amsterdam, The Netherlands.
| | - Marijke Baaijens
- AVAG Midwifery Academy Amsterdam Groningen, Amsterdam, The Netherlands.
| | - Prakaykaew Charrunwatthana
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.
| | - François Nosten
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand. .,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - Rose McGready
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand. .,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| |
Collapse
|
45
|
Bouet PE, Ruiz V, Legendre G, Gillard P, Descamps P, Sentilhes L. High-dose tranexamic acid for treating postpartum haemorrhage after vaginal delivery. Br J Anaesth 2015; 114:339-41. [DOI: 10.1093/bja/aeu468] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
|
46
|
Abstract
BACKGROUND Active management of the third stage of labour (AMTSL) consists of a group of interventions, including administration of a prophylactic uterotonic (at at or after delivery of the baby), baby, cord clamping and cutting, controlled cord traction (CCT) to deliver the placenta, and uterine massage. Recent recommendations are to delay cord clamping until the caregiver is ready to initiate CCT. The package of AMTSL reduces the risk of postpartum haemorrhage, (PPH), as does one component, routine use of uterotonics. The contribution, if any, of CCT needs to be quantified, as it is uncomfortable, and women may prefer a 'hands-off' approach. In addition its implementation has resource implications in terms of training of healthcare providers. OBJECTIVES To evaluate the effects of controlled cord traction during the third stage of labour, either with or without conventional active management. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (29 January 2014), PubMed (1966 to 29 January 2014), and reference lists of retrieved studies. SELECTION CRITERIA Randomised controlled trials comparing planned CCT versus no planned CCT in women giving birth vaginally. DATA COLLECTION AND ANALYSIS Two authors assessed trial quality and extracted data using a standard data extraction form. MAIN RESULTS We included three methodologically sound trials with data on 199, 4058 and 23,616 women respectively. Blinding was not possible, but bias could be limited by the fact that blood loss was measured objectively.There was no difference in the risk of blood loss ≥ 1000 mL (three trials, 27,454 women; risk ratio (RR) 0.91, 95% confidence interval (CI) 0.77 to 1.08). Manual removal of the placenta was reduced with CCT (two trials, 27,665 women; RR 0.69, 95% CI 0.57 to 0.83). In the World Health Organization (WHO) trial the reduction in manual removal occurred mainly in sites where ergometrine was used routinely in the third stage of labour. The non-prespecified analysis excluding sites routinely using ergometrine for management of the third stage of labour found no difference in the risk of manual removal of the placenta in the WHO trial (one trial, 23,010 women; RR 1.03, 95% CI 0.73 to 1.46). The policy of restricting the third stage of labour to 30 minutes (4057 women; RR 0.69, 95% CI 0.53 to 0.90) may have had an effect in the French study.Among the secondary outcomes, there were reductions in blood loss ≥ 500 mL (three trials, 27,454 women; RR 0.93, 95% CI 0.88 to 0.99), mean blood loss (two trials, 27,255 women; mean difference (MD) -10.85 mL, 95% CI -16.73 to -4.98), and duration of the third stage of labour (two trials, 27,360 women; standardised MD -0.57, -0.59 to -0.54). There were no clear differences in use of additional uterotonics (three trials, 27,829 women; average RR 0.95, 95% CI 0.88 to 1.02), blood transfusion, maternal death/severe morbidity, operative procedures nor maternal satisfaction. Maternal pain (non-prespecified) was reduced in one trial (3760 women; RR 0.78, 95% CI 0.61 to 0.99).The following secondary outcomes were not reported upon in any of the trials: retained placenta for more than 60 minutes or as defined by trial author; maternal haemoglobin less than 9 g/dL at 24 to 48 hours post-delivery or blood transfusion; organ failure; intensive care unit admission; caregiver satisfaction; cost-effectiveness; evacuation of retained products; or infection. AUTHORS' CONCLUSIONS CCT has the advantage of reducing the risk of manual removal of the placenta in some circumstances, and evidence suggests that CCT can be routinely offered during the third stage of labour, provided the birth attendant has the necessary skills. CCT should remain a core competence of skilled birth attendants. However, the limited benefits of CCT in terms of severe PPH would not justify the major investment which would be needed to provide training in CCT skills for birth attendants who do not have formal training. Women who prefer a less interventional approach to management of the third stage of labour can be reassured that when a uterotonic agent is used, routine use of CCT can be omitted from the 'active management' package without increased risk of severe PPH, but that the risk of manual removal of the placenta may be increased.Research gaps include the use of CCT in the absence of a uterotonic, and the place of uterine massage in the management of the third stage of labour.
Collapse
Affiliation(s)
- G Justus Hofmeyr
- Walter Sisulu University, University of Fort Hare, University of the Witwatersrand, Eastern Cape Department of HealthEast LondonSouth Africa
| | - Nolundi T Mshweshwe
- Effective Care Research UnitDepartment of Obstetrics and GynaecologyFrere Maternity HospitalAmalinda DriveEast LondonEastern CapeSouth Africa5200
| | - Ahmet Metin Gülmezoglu
- World Health OrganizationUNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research20 Avenue AppiaGenevaSwitzerland1211
| | | |
Collapse
|
47
|
Kataoka Y, Nakayama K, Yaju Y, Eto H, Horiuchi S. Comparison of Policies for the Management of Care for Women and Newborns During the Third Stage of Labor Among Japanese Hospitals, Clinics, and Midwifery Birth Centers. INTERNATIONAL JOURNAL OF CHILDBIRTH 2015. [DOI: 10.1891/2156-5287.5.4.200] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE: To determine the care policies for both mothers and newborns implemented during and after the third stage of labor and to compare the rate of adoption of these care policies among hospitals, clinics, and midwifery birth centers in Japan.METHOD: A cross-sectional survey of the care policies affecting mothers and newborns during and after the third stage of labor was conducted from October 2010 to July 2011. A postal questionnaire with follow-up was sent to all 684 maternity institutions in Tokyo metropolitan areas.RESULTS: The overall response rate was 255 (37%). Most hospitals and clinics had a policy of early cord clamping; however, nearly 70% of the midwifery birth centers adopted the policy of waiting until the cord stopped pulsating. The policy of administering prophylactic uterotonics was adopted by 50% of the hospitals and 63% of the clinics, although midwifery birth centers did not adopt this policy. All midwifery birth centers, 50% of the hospitals, and 50% of the clinics routinely adopted the policy of early skin-to-skin contact.CONCLUSION: Adoption of various care policies differed considerably among the hospitals, clinics, and midwifery birth centers. In addition, there were several gaps between evidence-based care and care policies.
Collapse
|
48
|
|
49
|
Dupont C, Ducloy-Bouthors AS, Huissoud C. [Clinical and pharmacological procedures for the prevention of postpartum haemorrhage in the third stage of labor]. ACTA ACUST UNITED AC 2014; 43:966-97. [PMID: 25447388 DOI: 10.1016/j.jgyn.2014.09.025] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To describe the clinical and pharmacological procedures for the prevention of Postpartum Haemorrhage (PPH). MATERIALS AND METHODS We searched the Medline and the Cochrane Library (1st December 2004 to 1st March 2014) and we checked the international guidelines. RESULTS Vaginal birth: only the use of uterotonics reduces the incidence of PPH. Oxytocin is the treatment of choice if it is readily available (grade A). Oxytocin can be used either after the shoulders expulsion or rapidly after the placental delivery (grade B). A dose of 5 or 10IU must be administrated IV over at least 1minute or directly by an intramuscular injection (professional agreement) except in women with documented cardiovascular disease in which the duration of the IV perfusion should be over at least 5minutes (professional agreement). Mechanical procedures have no significant impact on PPH. The decision to use a collector bag is left to the medical team (professional agreement). A systematic complementary oxytocin perfusion is not recommended (professional agreement). Caesarean delivery: There is no evidence to recommend a particular type of caesarean technique to prevent PPH (professional agreement) but a lower uterine section is recommended (grade B). All types of incision expansion may be used (professional agreement). A controlled cord traction is associated with lower blood losses than manual removal of the placenta (grade B). A dose of 5 or 10IU can be injected (IV) over 1minute, and over 5minutes in women with cardiovascular disease (professional agreement). Carbetocin reduces the incidence of PPH but there is presently no inferiority study comparing oxytocin and carbetocin so that oxytocin remains the gold standard therapy to prevent PPH in C-section (professional agreement).
Collapse
Affiliation(s)
- C Dupont
- Réseau périnatal Aurore, université Lyon-1, hôpital de la Croix-Rousse, 103, Grande-Rue-de-la-Croix-Rousse, 69004 Lyon, France; EA 4129, laboratoire « santé, individu, société », faculté de médecine Laennec, 7, rue Guillaume-Paradin, 69372 Lyon cedex 08, France.
| | - A-S Ducloy-Bouthors
- Pôle d'anesthésie-réanimation, maternité Jeanne de Flandre, CHRU de Lille, 59037 Lille cedex, France
| | - C Huissoud
- Réseau périnatal Aurore, université Lyon-1, hôpital de la Croix-Rousse, 103, Grande-Rue-de-la-Croix-Rousse, 69004 Lyon, France; Inserm U846, Stem Cell and Brain Research Institute, 18, avenue Doyen-Lépine, 69675 Bron cedex, France
| |
Collapse
|
50
|
Du Y, Ye M, Zheng F. Active management of the third stage of labor with and without controlled cord traction: a systematic review and meta-analysis of randomized controlled trials. Acta Obstet Gynecol Scand 2014; 93:626-33. [PMID: 24828584 DOI: 10.1111/aogs.12424] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Accepted: 04/20/2014] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine the specific effect of controlled cord traction in the third stage of labor in the prevention of postpartum hemorrhage. DATA SOURCES We searched PubMed, Scopus and Web of Science (inception to 30 October 2013). STUDY SELECTION Randomized controlled trials comparing controlled cord traction with hands-off management in the third stage of labor were included. RESULTS Five randomized controlled trials involving a total of 30 532 participants were eligible. No significant difference was found between controlled cord traction and hands-off management groups with respect to the incidence of severe postpartum hemorrhage (relative risk 0.91, 95% confidence interval 0.77-1.08), need for blood transfusion (relative risk 0.96, 95% confidence interval 0.69-1.33) or therapeutic uterotonics (relative risk 0.94, 95% confidence interval 0.88-1.01). However, controlled cord traction reduced the incidence of postpartum hemorrhage in general (relative risk 0.93, 95% confidence interval 0.87-0.99; number-needed-to-treat 111, 95% confidence interval 61-666), as well manual removal of the placenta (relative risk 0.70, 95% confidence interval 0.58-0.84) and duration of the third stage of labor (mean difference -3.20, 95% confidence interval -3.21 to -3.19). CONCLUSIONS Controlled cord traction appears to reduce the risk of any postpartum hemorrhage in a general sense, as well as manual removal of the placenta and the duration of the third stage of labor. However, the reduction in the occurrence of severe postpartum hemorrhage, need for additional uterotonics and blood transfusion is not statistically significant.
Collapse
Affiliation(s)
- Yongming Du
- Department of Obstetrics & Gynecology, First Affiliated Hospital, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | | | | |
Collapse
|