Intervention of the obstetrician during childbirth in a supposedly low-risk population and influence of parity

OBJECTIVE

Compare obstetrician intervention and calling rates during labour and delivery between low-risk and high-risk women and study the influence of parity on these rates.

MATERIAL AND METHODS

Descriptive retrospective study conducted on 227 patients in a university maternity unit (level 3 university hospital maternity unit) between 1st and 30th January 2014. The low- and high-risk populations were characterised according to the French National Authority for Health (HAS) and NICE guidelines. The obstetrician intervention criteria were: Caesarean section, instrumental vaginal delivery, artificial delivery/uterus examination and postpartum haemorrhage. The obstetrical team also had to call the obstetrician in case of foetal heart rate abnormalities, scalp blood pH measurement, third and/or fourth degree perineal tears, labour dystocia, or any other severe event occurring during labour or delivery.

RESULTS

In univariate analysis, the obstetrician intervention rates were respectively 44.5% and 34.4% in the high- and low-risk groups (P=0.13). The obstetrician calling rates were similar between the two groups. Using logistic regression model including parity, the obstetrician intervention rate became significantly higher in the "high-risk" group (OR 2.044, 95% CI 1.129-3.703, P=0.018). In the low-risk population, the intervention rate was significantly increased for nulliparous women compared with multiparas (47.5% versus 9.7%, P<0.001, OR=8.2, CI 95% 2.2 to 46.9).

CONCLUSION

One third of the women defined as low-risk patients appear to need an obstetrician intervention during labour and delivery, with a major influence of parity.

[Profile of bacterial resistance in pediatric urinary tract infections in 2014]

In pediatric units, bacteria-producing extended-spectrum-betalactamase (ESBL) have an increasing prevalence among bacteria causing febrile urinary tract infections (UTIs). The purpose of this study was to evaluate the epidemiology of bacteria resistance patterns observed in UTIs, in order to assess the current antibiotic treatment protocols. This study is based upon a single-center retrospective chart review of the cytobacteriological urine cultures performed in UTIs between 1 January and 31 December 2014, in the medical pediatric unit of the Caen University Hospital. Out of the total of 219 cases of UTI, 26.9% were recurrences of UTI, 18.3% were infections in infants less than 3 months old, 21% of the patients suffered from underlying uropathy, and 16.4% of the patients had recently been exposed to antibiotics. In 80.3% of the cases, Escherichia coli was found, while Enterococcus faecalis was found in 5.6%. The antibiograms proved that 33.5% of the bacteria were sensitive. Half of E. coli were resistant to ampicillin, 4.9% to cefixime, 4.9% to ceftriaxone, 1.1% to gentamicin, and 27.8% to trimethoprim-sulfamethoxazole. Nine E. coli and one Enterobacter cloacae produced ESBL, accounting for 4.6% of the UTIs. We did not find any bacteria-producing high-level cephalosporinase. Cefixime resistance was statistically linked to ongoing antibiotic treatment (OR=5.98; 95% CI [1.44; 24.91], P=0.014) and underlying uropathy (OR=6.24; 95% CI [1.47; 26.42], P=0.013). Ceftriaxone resistance was statistically related to ongoing antibiotic treatment (OR=6.93; 95% CI [1.45; 33.13], P=0.015). These results argue in favor of maintaining intravenous ceftriaxone for probabilistic ambulatory treatment. However, in case of hospitalization, cefotaxime can replace ceftriaxone, due to its lower ecological impact. Moreover, it is necessary to continue monitoring bacterial resistance and regularly review our treatment protocols.

[Analysis of the anatomical sites of 172 lower-limb venous thromboses occurring in a hormonal context in 996 young women; impact of the duplex-Doppler exploration]

AIM

To analyze localizations of duplex ultrasonography-diagnosed lower-limb venous thrombosis in young women in hormonal periods in order to optimize the ultrasound exploration.

PATIENTS AND METHODS

From 42,018 standardized ultrasonography report forms, incremented in a database (January 2001 - July 2013), those performed for a first diagnosis of venous thrombosis in women ≤ 45 years were selected (n = 996). Among those, diagnosed venous thrombosis (n = 172) were classified into three groups: oral contraception (n = 74), pregnancy (n = 39) and post-partum period (n = 59). Clinical symptoms and thrombosis distribution were analyzed.

RESULTS

In the contraception group, pulmonary symptoms at presentation were much more frequent than in the obstetrical group: 69% vs 20% (P < 0.001). The thrombosis was limited to the iliac veins in 31% (23/74) and to the left internal iliac vein in six patients. During pregnancy, the thrombosis was limited to the iliac veins in 28% (11/39), and to the left internal iliac vein in two patients. In the post-partum period, superficial venous thromboses were found more frequently (37/59). Among the 22 deep venous thromboses, nine were limited to the proximal segment, including four in the vena cava coming from a right ovarian vein thrombosis.

CONCLUSION

Duplex ultrasonography in young women taking oral contraception, as during pregnancy, must target iliac venous segments, especially on the left side, otherwise one thrombosis out of three may be missed; in the post-partum period, the inferior vena cava and superficial veins are to be explored too.

French sclerotherapy and compression: Practice patterns

Based on the recommendations of experts, and supported by a low level of proof, compression after sclerotherapy is applied all over the world.

OBJECTIVE

Investigating the practice of French vascular physicians for sclerotherapy and the use of post-sclerotherapy compression.

METHODS

A questionnaire concerning their practices was sent to French vascular physicians through their regional vascular medicine professional development associations.

RESULTS

A total of 366 vascular physicians replied to the questionnaire, of whom 63% (229/366) were in private practice, 6% (21/366) in hospitals and 31% (115/366) had a mixed private-hospital practice. Sclerotherapy was practised by 88% (323/366) of them. Two-thirds of the vascular physicians used sclerosing foam and practised sclerotherapy using ultrasound guidance. Less than one-third of the vascular physicians regularly applied compression after sclerotherapy. When compression was applied, it was usually after treatment of saphenous or accessory saphenous veins and, in most cases, medical compression stockings of 15-20 mm Hg were used. With respect to the period recommended for wearing compression, this ranged from 48 h to 1 week for 65% (193/299) of the vascular physicians questioned.

CONCLUSION

The great majority of vascular physicians who answered the questionnaire employ ultrasound guidance to perform sclerotherapy and use sclerosing foam. Compression after sclerotherapy is diversely applied in France and does not comply with the recommendations of the French Health Authorities who recommend wearing a stocking of 15-20 or 20-36 mm Hg for a period of 4-6 weeks. Thus, less than one-third of the vascular physicians regularly used elastic compression and when they did, it was usually a medical compression stocking of 15-20 mm Hg, for 1 week or less.

Longitudinal left ventricular strain impairment in type 1 diabetes children and adolescents: a 2D speckle strain imaging study

AIM

Type 1 diabetes (T1D) involves complex metabolic disturbances in cardiomyocytes leading to morphological and functional abnormalities of the myocardium. The relationship between T1D and cardiac structure and function in children is not well established. Our study investigated whether T1D is associated with early subclinical myocardial disturbances in children and adolescents, and whether the state of metabolic control and diabetes duration are influential factors.

METHODS

Standard echocardiography, tissue Doppler imaging (TDI) and two-dimensional (2D) strain imaging were prospectively performed in 100 T1D children (age: 11.3 ± 3.6 years, 52 boys) and compared with 79 controls.

RESULTS

The diabetic and control children were comparable with respect to age, gender, heart rate and blood pressure. There were no significant differences between the two groups in left ventricular (LV) ejection fraction, LV remodelling and TDI parameters. Conventional mitral Doppler demonstrated significantly fewer diastolic filling abnormalities with an early filling wave in the diabetes group. Global longitudinal strain (GLS) was also significantly lower in the T1D children, while circumferential strain and radial strain did not differ. GLS correlated with HbA1c (r=0.52; P<0.01), but there was no correlation with diabetes duration.

CONCLUSION

Our results suggest that LV longitudinal myocardial deformation is decreased in young patients with T1D, and glycaemic control may be the main risk factor for these changes. Further follow-up is now necessary to precisely determine the clinical significance of these myocardial changes detected by 2D strain imaging in T1D children.

Geographical variation in incidence of knee arthroscopy for patients with osteoarthritis: a population-based analysis of Victorian hospital separations data

BACKGROUND/AIM

To evaluate the frequency and geographical variation in knee arthroscopy for adults (>25 years) with a concomitant diagnosis of osteoarthritis.

METHODS

This was a retrospective cohort study of hospital separations involving an elective knee arthroscopy in public and private hospitals in Victoria, Australia. Participants included patients receiving knee arthroscopies with a diagnosis code indicating osteoarthritis (OA) from 1 July 2008 to 30 June 2009. Records were excluded if the patient was under 25 years or their arthroscopy involved a ligament reconstruction. Crude rates per 100 000 population and negative binomial regression offset by total knee arthroscopy volume were used to analyse differences by region.

RESULTS

There were 9620 arthroscopic procedures meeting the inclusion criteria. There were 5500 (57.2%) admissions where the principal diagnosis was knee OA (gonarthrosis) and 3510 (36.5%) where the principal diagnosis indicated a mechanical derangement and there was a primary or associated diagnosis of OA. When we examined the incidence rate ratios (IRR) by region, after adjustment for relevant factors and accounting for the total knee arthroscopy volume within each region, we identified significant variation in knee arthroscopy rates for patients with OA. The region with the highest adjusted IRR was Barwon South Western (IRR: 1.26, 95% confidence interval (CI): 1.16-1.36) and the region with lowest adjusted incidence rate ratio was the Gippsland region (IRR: 0.89, 95% CI: 0.80-0.98).

CONCLUSIONS

We identified considerable geographical variation in arthroscopies for people with OA across Victoria. Further investigation is needed to understand whether this variation is a reflection of differences in OA prevalence, clinical decision-making or access.

High prevalence of diabetes mellitus and hospital-related hyperglycaemia in French general wards

AIM

The study evaluated the in-hospital prevalence of diabetes and hospital-related hyperglycaemia in a variety of French general wards.

METHODS

The multicentre cross-sectional study involving nine French hospitals measured venous fasting plasma glucose (FPG) on a single day in patients hospitalized in adult medical and surgical short-term wards. Diabetes status and length of stay were recorded.

RESULTS

Of the 2141 inpatients included in the study, 355 (16.5%) had known diabetes, 156 (7.3%) had screened diabetes (FPG ≥7 mmol/L with no diabetes history), 515 (24.1%) had impaired fasting glucose (IFG; FPG 5.5-6.9 mmol/L) and 1115 (52.1%) had normal glucose values (FPG < 5.5 mmol/L). Diabetes prevalence varied from 11% in hospitals in the west of France to 21% in hospitals in northern and eastern regions. The highest known diabetes prevalence was observed in units for cardiovascular surgery (33%), infectious diseases (27%) and kidney disorders (26%). In cancer units, one-fifth of patients had screened diabetes and one-sixth had known diabetes. Among the known diabetes patients, 127 (36%) were already being treated with insulin, while an additional 41 (12%) started insulin therapy during their hospital stay. Patients with known and screened diabetes were older (70.8 ± 12.2 and 71.1 ± 15.6 years, respectively) than the normal-glucose patients (65.6 ± 18.9 years; P<0.001). Average length of stay was no different between known diabetes and normal-glucose patients after adjusting for age (11.3 ± 7.7 vs 10.0 ± 7.4 days; NS).

CONCLUSION

Overall, metabolic glucose disorders (known or screened diabetes and IFG) were found in 48% of inpatients in various French hospital general wards.

[Failure of vacuum extractions: risk factors, maternal and fetal issues]

OBJECTIVES

Determine cases which are at risk of vacuum extraction failure as well as maternal and foetal issues depending on the delivery outcome.

MATERIAL AND METHODS

It was a retrospective study comparing 147 vacuum failures, from January 2002 to December 2010, with a control group randomly composed of 526 successful vacuum extractions. The outcomes were high risk situations of vacuum failure, maternal and neonatal morbidity depending on the delivery method (caesarean section or other instrumental extraction).

RESULTS

The global vacuum failure rate was 3.3 %. During labour, we identified several situations at risk of vacuum extraction failure: cephalhematomas prior to extraction (P<0.001), deflexion attitude (P<0.001), posterior variety (P<0.001), entering above the inlet strait (P<0.001), occiput posterior delivery (P<0.001), fœtal weight greater than 3500g (P=0.023). Neonatals consequency were more Apgar score below 7 at five minutes life (P=0.007), fœtal acidosis (pH<7,20) (P=0.032), neonatal resuscitation (P<0.001), and craniofacial damages (P<0.001).

CONCLUSION

Many dystocic situations occurring during labour require intense care when practicing vacuum extraction since they more frequently result in failure. In case of vacuum extraction failure, immediate adaptation to extra-uterine life seems to be more difficult for new-born babies.

Beware of suboptimal medical management of patients with atherosclerosis requiring revascularization

AIM

The aim of this paper was to assess a daily-life evaluation of vascular risk factor control, pharmacological treatment and prognosis in patients with atherosclerosis referred for revascularization.

METHODS

Prospective observational study conducted in a French University Hospital with collection of atherosclerosis referral site information, reported patient history, documented atherosclerosis sites seen on examination, biological data, and clinical outcomes.

RESULTS

956 patients (82.6% men, 64.5±10.1 years) were enrolled for supra-aortic vessel disease (SVD, 24.6%), coronary heart disease (CHD, 40.4%), peripheral artery occlusive disease (PAOD, 34.2%), and visceral artery disease (1.7%). Involvement of >2 vascular territories was documented in 85%. Vascular risk factor frequency results were: previous (65.7%) or current (10.6%) tobacco use, hypertension (64.3%), hyperlipidaemia (75.4%), diabetes (25.8%), overweight (43.8%), and obesity (25.2%). LDL-cholesterol was >100 mg/dL for 38.1%, most frequently seen in patients with PAOD referral (P<0.001) or history (P=0.002), and for 29.2% of the patients taking a statin. HbA1c levels were >6.5% for 53.8% of patients with diabetes. The triple combination of an antiplatelet agent, a statin, and a renin-angiotensin-system inhibitor was not prescribed often enough, especially for PAOD referrals (PAOD referrals, 45.1%; SVD referrals, 48.1%; CHD referrals, 65.9%). Independent risk factors for all-cause mortality were: a previous CHD or PAOD clinical event, body mass index <25 kg/m2, HbA1c >6.5%, and no aspirin treatment.

CONCLUSION

Even at the time of revascularization, medical management of atherosclerosis was not optimal. The need for continuing education of physicians and patients remains essential.

[From the impact of French guidelines to reduce episiotomy's rate]

OBJECTIVES

Following the publication of the French Guidelines on episiotomy in 2005 by the French National College of Gynaecologists and Obstetricians (CNGOF), our unit decided to adopt a restrictive politics to replace the former liberal one. The goal of this study was to evaluate the impact of this modification of trend in the Unit of Gynaecology and Obstetrics of the teaching hospital from Caen. This was the start point of an internal audit with the objective of an enhancement of the care during delivery.

PATIENTS AND METHODS

It was a retrospective study concerning the period going from January, 2004 till December, 2009, measuring the impact of the guidelines on the episiotomy rates and perineal tears. The totality of the population of the women naturally delivered at a term superior or equal to 37 weeks of gestation and a cephalic presentation was included. To modify the practices, after diffusion of the guidelines by some obstetrical leaders, we imposed to notify the indication of the episiotomy in the computerized obstetrical files. Moreover, we published monthly screenboards with all the detailed results to all the practioners acting in the delivery room (obstetricians, midwives).

RESULTS

Between 2004 and 2009, we observed a dramatic decline of the episiotomy rates from 55.7 to 13.3%. This trend was the same for primiparae and multiparae, as wall as for spontaneous or assisted delivery (mostly vacuum extraction in our unit). We noticed a slight increased in minor perineal tears without functional consequences. There was no statistically significant difference between severe perineal tear (1.3% vs. 1.1%). By contrary, the rate of intact perineum significantly raised (17.6% vs. 21.7%, p<0.001), especially in vacuum extractions.

DISCUSSION

Our results are in accordance with those of the national guidelines. However, our rate does not decrease in 2007 and 2008 (20%), contrary to some results obtained in the literature. Some reports mentioned the weak impact of the publication of national guidelines to modify the usual practice. However, we believe that retro-information to practitioners has a real impact on their daily current practice. Hence we insisted again on the importance of these national guidelines at the end of 2008 and we could demonstrate a real decline of the rate of episiotomy. Our efforts have to be continued, especially for instrumental delivery.

Severe osteogenesis imperfecta caused by a small in-frame deletion in CRTAP

Mutations of proteins involved in posttranslational modification of collagen type I can cause osteogenesis imperfecta (OI) inherited in a recessive pattern. The cartilage-associated protein (CRTAP) is part of a heterotrimeric complex (together with prolyl-3-hydroxylase-1 [P3H1] and cyclophilin B) that 3-hydroxylates the alpha 1 chain of collagen type I at proline residue 986 and plays a collagen chaperon role. CRTAP mutations usually cause severe OI. We report on a patient with OI and a homozygous in-frame deletion in CRTAP and a severe form of OI. The girl was born with markedly deformed long bones. Despite intravenous bisphosphonate treatment, she developed multiple vertebral compression fractures and severe scoliosis and at 4 years of age was able to sit only with support. Although CRTAP transcript levels were normal in the patient's fibroblasts, protein levels of both CRTAP and P3H1 were severely reduced. The degree of 3-hydroxylation at proline residue 986 was also decreased. This report characterizes a patient with a CRTAP small in-frame deletion. We are unaware of prior reports of this finding. We suggest that this deletion affects crucial amino acids that are important for the interaction and/or stabilization of CRTAP and P3H1.