[Prolonged and post-term pregnancies: a regional survey of French clinical practices]

OBJECTIVE

To assess professional practices of prolonged and post-term pregnancies in accordance to French guidelines. The secondary outcome was to evaluate neonatal and maternal morbidity during prolonged pregnancy.

METHODS

Descriptive retrospective study was conducted in the 23 maternity hospitals of perinatal network between September and December 2018. The inclusion criterion was a birth term of≥41⁺⁰ weeks of gestation. Primary outcome was conformity to the national guidelines based on 10 items (conformity score≥80%). The secondary outcome was a composite criteria of neonatal morbidity (ventilation, resuscitation and/or Apgar score<7 at 5minutes) and maternal morbidity (obstetrical anal sphincter injury and/or postpartum hemorrhage).

RESULTS

A total of 596 patients were included and the conformity was obtained in 65.3% of cases. Inconsistent criteria were amniotic fluid evaluation by the deepest vertical pocket (46.8%, n=279), and information of patients on prolonged pregnancy management (14.8%, n=88). Adverse perinatal outcome occurred for 40 newborns (6.0%) with shoulder dystocia (OR=5.2; CI 95%: 1.4-19.7) as a principal risk factor. Maternal morbidity outcome occurred in 70 cases (10.6%) primarily with increase in labour duration (OR=1.1 by hour of labour; CI 95%: 1.02-1.24) and prior caesarian section (OR=4.4; CI 95%: 1.8-11.0).

CONCLUSIONS

Management of prolonged and post-term pregnancies matching with the French national guidelines. Points of improvement are amniotic fluid evaluation at term by a single deepest vertical pocket, and the information about induction of labour at term.

[Survey of 319 women satisfaction using abortion in centers of Pays de la Loire in France]

CONTEXT

Perinatal network the "Security birth" Pays de la Loire (RSN), in collaboration with the regional network "Sexual health" (RRSS) organized a satisfaction survey in 2014 among women who had an induced abortion in the centers in Pays de la Loire. The objective of the study is to evaluate the satisfaction of women who resort to abortion centers, study the factors and propose actions for improvement.

METHODS

A questionnaire, developed with professionals, was offered to women after the end of the abortion act. The scales of satisfaction were based on Likert scales to 4 degrees. They were collected for the period of contact centers, for the abortion itself, and overall. Data were collected on the civil status, the care pathway to get to the abortion center, features centers and professionals met, acts anesthesia and end of abortion, wait times and overall satisfaction of women. The women with rather poor satisfaction were compared with other women by univariate analysis with odds ratios (OR) and multivariate with adjusted odds ratios (ORa).

RESULTS

Of the 18 centers, 13 participated and 319 responses were analyzed. The abortions were performed on average 8±SA 2. Among the methods, 40.1 % were drug, and 59.9 % with anesthesia (14.0 % with general anesthesia [AG] and 45.9 % under local anesthesia [AL]). The first contacts on average to 5.7 SA were mostly general practitioners (38 %), then the abortion centers directly (22 %), and planning centers (16 %). The information was considered clear (94 %), the appropriate orientation (97 %), with respect to the application (98 %). The first meeting at the center was done 7 days after the call (6.7 SA), and met women overall. The abortion was performed 16 days after the first call center (8.0 SA) with satisfaction by field 78 % (waiting time) to 98 % (confidentiality, privacy…). The overall satisfaction rate was 89.0 % and 8.2 % were not satisfied. Factors related to the non-satisfaction in multivariate analysis were the least easy access to the center (ORa=0.31 [.11 to 0.86; p=0.02]), pain perceived≥4 (ORa=3 50 [1.32 to 9.28], p=0.02), the lack of explanation (ORa=0.23 [0.05 to 0.97]; p=0.04), and the accompanying inability (ORa=0.27 [0.10 to 0.70], p=0.007). Finally, 12.6 % of women reported for improvement with clear remarks.

DISCUSSION

This is the first regional survey on the satisfaction of women resorting to abortion. Delays from the first contact are satisfactory and show no organizational problem. The various dimensions of satisfaction showed a high satisfaction rate in the 13 participating centers. The least satisfactory factors are related to organizational problems (waiting circuits especially trips to the operating room and maternity) and problems related to the care itself (not enough explanations, reduced ability to reassure and support Savory absence, lack of choice of the method of anesthesia, pain experienced). Five areas for improvement have been proposed to the care-givers of the centers.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

DISCUSSION

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

CONCLUSION

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

[Evolution of waiting time and length of stay between 2005 and 2012 in an obstetric and gynaecologic emergency unit in a French teaching hospital]

OBJECTIVES

To compare and analyze waiting time and length of stay between 2005 and 2012 in the obstetric and gynaecologic emergency unit of Nantes teaching hospital, new unit opened in 2004.

METHODS

Descriptive study from the registers over 2months' periods in 2005 and 2012.

RESULTS

Despite an increase of the daily average number of visits from 28 to 39 (P<0.0001), the waiting time increased in obstetrics from 15minutes to 18 in 2012, P<0.03. In gynaecology, waiting time decreased in 2012 on daytime weekdays (37minutes versus 44) and increased on weekend (41minutes versus 28) and at night (37minutes versus 23) P<0.01. The length of stay was similar in obstetrics (108minutes versus 104) but reduced on daytime weekdays (124minutes in 2005, 109 in 2012, P<0.05). In gynaecology duration was similar (108minutes versus 105), but decreased on daytime weekdays (110minutes in 2005, 101 in 2012) and increased on overnight weekend (94minutes in 2005, 121 in 2012) (P<0.05).

CONCLUSION

Our organization enabled to improve some lengths of time despite an increased activity. Those lengths of time should be monitored as they reflect our organizations and are indicators of efficiency.

[Pure 46XY gonadal dysgenesis]

46 XY pure gonad dysgenesia, also known as Swyer syndrome, is a disorder of sexual differentiation. The patients are phenotypic females with a 46 XY karyotype and hypoplastic gonads without germ cells. They present most often with primary amenorrhea. The study of this abnormality in testicular differentiation contributed to the identification of the gene SRY, testis determining factor. To date, 20% of 46 XY pure gonad dysgenesia are explained by a mutation or a deletion in SRY. In 80%, SRY is apparently normal. The risk of gonadal neoplasia is high, dictating early prophylactic removal of these dysgenetic gonads. Gonadoblastoma and dysgerminoma are the most frequently reported malignancies. Because of the possible inheritance of XY gonad dysgenesia all family members should undergo a thorough screening.