Réseau Sentinelle Audipog 2004–2005. Partie 2 : évaluation des pratiques professionnelles

Pre-gestational diabetes and the risk of congenital heart defects in the offspring: A French nationwide study

AIM

To compare the frequencies and types of congenital heart defects for infants of women without and with pre-gestational diabetes, type 1 and type 2 diabetes (T1DM, T2DM) and to identify risk factors.

METHODS

All live births between 2012 and 2020 were screened for maternal diabetes and infant congenital heart defects using the French Medical Information System Program in Medicine, Surgery and Obstetrics database (PMSI-MCO). Incidences of these defects were estimated, and a logistic model evaluated maternal and fetal prognostic risk factors.

RESULTS

Overall, 6,038,703 mothers did not have pre-gestational diabetes (no-diabetes), 23,147 had T1DM, and 14,401 had T2DM. The incidence of infant congenital disease was 6.2% for the no-diabetes group, 8.0%, for women with T1DM, and 8.4% for women with T2DM (P < 0.001); for congenital heart defects, incidences were respectively 0.8%, 3.0% and 2.7% (P < 0.001). In comparison with the no-diabetes group, the odds ratios (95%CI) of coronary heart defects were 2.07 (1.91;2.24) (P < 0.001) for women with T1DM and 2.20 (1.99;2.44) (P < 0.001) for women with T2DM, with no difference between T1DM and T2DM (P = 0.336). cesarian section, small and large for gestational age, and prematurity were also associated with an increased risk of congenital heart defects.

CONCLUSION

In this study we observed higher incidences of congenital heart defects in infants of women with pre-gestational diabetes compared to women without pre-gestational diabetes, with no difference between women with T1DM or T2DM. These data call for intensifying preconception care and justify systematic cardiac echography in selected fetuses.

[Retrospective evaluation of relevance of care in the management of presumed benign ovarian tumors]

INTRODUCTION

The relevance of care is defined by the right act, for the right patient, at the right time. We were interested in the relevance of the management of presumed benign ovarian tumors before and after the release of the CNGOF guidelines 2013 (French guidelines).

METHODS

This is a retrospective observational study conducted at the University Hospital in Strasburg France from 01/01/2013 to 31/12/2017 including all patients treated for a presumed benign ovarian cyst. We were interested in the diagnostic approach: relevance of the prescribed imaging and the use of CA 125 dosage, in the therapeutic approach: the relevance of the technique used as well as the relevance of the surgical indication. We compared our practices between 2013 and 2017 for these same items.

RESULTS

We included 682 cysts for 621 patients, the imaging performed was relevant in 55% of cases, not relevant but justified in 25% and irrelevant in 20%. The CA 125 assay or its absence of assay was relevant in 84% of cases. The surgical technique was relevant in 67% of cases and not relevant but justified in 29%. With a significant improvement 7.1% in 2013 of irrelevant against 0.9% for the year 2017. The surgical indication was relevant in 72% of cases, not relevant but justified in 20% and irrelevant in 2.7%.

CONCLUSIONS

The analysis of the relevance of care allows an evaluation of our practices. Professional recommendations can have an impact on the quality of care.

Birthweight of IVF children is still a current issue and still related to maternal factors

RESEARCH QUESTION

Does fresh embryo transfer after IVF with or without intracytoplasmic sperm injection (ICSI) increase the small for gestational age (SGA) rate, and frozen embryo transfer (FET) after IVF with or without ICSI increase the large for gestational age (LGA) rate versus natural conception?

DESIGN

Retrospective comparison of an exposed historical group/cohort involving singletons conceived after fresh embryo transfer and after FET with an unexposed group/cohort involving singletons conceived after a natural conception.

RESULTS

A total of 1961 fresh embryo transfer babies and 366 FET babies were compared with 6981 natural conception babies. The SGA rate in fresh embryo transfer babies was not significantly different to natural conception babies (6.9% versus 6.8%, P = 0.856). This outcome was not influenced by the fresh embryo transfer (adjusted odds ratio [aOR] 1.0; 95% confidence interval [CI] 0.8-1.3), but rather by a low rate of multiparity (aOR 0.5; 95% CI 0.3-0.7), advanced maternal age (aOR 1.1; 95% CI 1.0-1.2), maternal underweight (aOR 1.5; 95% CI 1.1-2.1), maternal smoking or cessation during pregnancy (aOR 1.8; 95% CI 1.4-2.3), pre-existing hypertension (aOR 2.3; 95% CI 1.3-4.1) and pregnancy-induced hypertension (aOR 2.5; 95% CI 1.7-3.7). The LGA rate in FET babies was significantly different from natural conception babies (6.6% versus 3.2%, P = 0.012). This outcome was influenced by the transfer of frozen embryos (aOR 2.2; 95% CI 1.3-3.8) and by a high maternal weight (aOR 1.9; 95% CI 1.1-3.6).

CONCLUSIONS

Maternal background and obstetric parameters are more likely to influence the SGA rate than fresh embryo transfer conception. FET conception could be associated with an increase in LGA rate.

[Fetal expulsion: Which interventions for perineal prevention? CNGOF Perineal Prevention and Protection in Obstetrics Guidelines]

OBJECTIVE

The objective for all obstetricians and midwifes who intervene during the release of the fetal presentation is to prevent at best the perineal lesions. This work consisted in analyzing the literature, researching and evaluating interventions that reduce this perineal risk during the release.

METHODS

A keyword search for each medical intervention during the expulsion phase was conducted by selecting studies assessing perineal risk. Interventions during pregnancy and during delivery before the expulsion phase were specifically addressed in other sections of the recommendations.

RESULTS

Firstly, the degree of perineal stretching during the second stage of labour does not appear to be a risk factor for OASIS, postpartum incontinence, or sexual disorders (LE3) and that a substantial stretching of the perineum is not an indication of episiotomy (Professional consensus). Then, manual control of the expulsion of the fetus at the end of the second stage of labour and support of the posterior perineum during this time appear to reduce the rate of OASIS (LE3). The crowning of the baby's head should be manually controlled and the posterior perineum manually supported manually to reduce the risk of OASIS (GradeC). There is no recognised benefit to episiotomy in normal deliveries (LE1); the liberal practice of episiotomy results in fewer intact perineums than its restrictive practice, and the latter does not result in increasing the number of cases of OASIS. No evidence indicates that an episiotomy for women with a breech presentation, twin pregnancy, or posterior position prevents OASIS (LE3). Indication for episiotomy during delivery depends on individual risk factors and obstetric conditions (Professional consensus). It is recommended that the indication for episiotomy be explained and the woman's consent received before its performance. The performance of an episiotomy during normal deliveries is not recommended to reduce the risk of OASIS (Grade A). The liberal practice of episiotomy to prevent OASIS is not recommended for women with a breech presentation, twin pregnancy, or posterior position (GradeC). Episiotomy during an instrumental delivery appears to be associated with a reduction of the risk of OASIS (LE3). The vacuum extractor appears to induce fewer cases of OASIS than other instruments (LE3). Episiotomy may be indicated in instrumental deliveries to avoid OASIS (GradeC). Training in perineal protection in obstetrics is recommended (Grade B). In operative vaginal deliveries when several instruments can be used, a vacuum extractor is preferentially recommended to reduce the risk of OASIS (GradeC). When forceps or spatulas are used, it is preferable that they be withdrawn just before cephalic deflexion so that the fetal head is not "capped" with these instruments at birth (Professional consensus). Couder's maneuver, which consists of lowering the forearm during the release of the fetal shoulders, appears to decrease the rate of second-degree perineal tears and increase the rate of intact perineum (LE3).

CONCLUSION

Manual control of the expulsion and perineal support reduce the risk of perineal injury. There is no benefit to episiotomy in normal delivery, nor in special cases such the breech presentation for example. On the other hand, in case of instrumental delivery, an episiotomy may be indicated to avoid OASIS (GradeC), and it is recommended if it is possible to use the ventouse preferentially. The Couder's maneuver seems to reduce the rate of 2^nd degree perineal lesions (LE3). Finally, training in perineal obstetric protection is recommended (Grade B).

[The practice of episiotomy in France 10 years after the recommendations of CNGOF: What inventory?]

Since its creation, the practice of episiotomy has evolved, being influenced by several factors. Various stances on its use were stated, until the eventual reduction of this practice, as suggested by numerous practical guides. In 2005, the National College of Obstetricians and Gynecologists in France published its French Guidelines for Clinical practice in this area. Today, it seems appropriate to focus on the evolution of the use of episiotomy, ten years after the publication of these recommendations. The authors propose a literature review, browsing through all the available epidemiological data in France related to episiotomy, recording all national statistics and some local trends, as there are regional specificities. This review allows to follow the overall evolution of the practice of episiotomy in France between 1981 and 2014, and to identify territorial disparities. Finally, in the specific context of the practice of episiotomy in French gynecological and obstetrics field, the authors conclude it by considering the possible evolution of this surgical practice, as well as, the Clinical Practice Recommendations related to it.

[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.

[Post-partum haemorrhage in delivery room: anaesthetists' practioner in Auvergne]

OBJECTIVE

To assess the management of post-partum haemorrhage (PPH) in delivery rooms by the anaesthetists of the Auvergne region.

STUDY DESIGN

Cross sectional study.

METHODS

An anonymous postal survey was sent to all the anaesthetists working in a public or private hospital with a maternity unit.

RESULTS

The response rate was about 70 %. Eight percent of the respondents never practiced in obstetrics; others all declared to have managed PPH at least once. Only 66 % declared to know the right definition of PPH, 98 % declared to have guidelines in the delivery room, 87 % to use graduate blood receipt pockets, 85 % to work under midwives-directed delivery at expulsion, 88 % to have a HemoCue™ system. More than 80 % declared to use first oxytocin and to switch for prostaglandins in case of failure, to put two venous catheters and a urinary catheter, to administer broad-spectrum prophylactic antibiotic and to draw a blood sample for early biology. Packed red cells, platelets and fresh frozen plasma were accessible in less than 30 minutes for 98 %. Transfusion guidelines were applied. Only 27 % could have arterial radiologic embolisation on site. The knowledge about PPH and its consensual care tended to be poorer in practitioners from the university hospital, and younger under 40 also.

CONCLUSION

This survey, with a good response rate, showed a practice generally fitting to the guidelines, although with some failures depending on the practioner's age and type of hospital.

Early postpartum discharge and breastfeeding: an observational study from France

BACKGROUND

Early postpartum discharge is a recent practice in France, but the influence of a shortened hospital stay on subsequent breastfeeding is unknown. The objective of the present study was to compare the breastfeeding mode after early discharge (ED) and conventional discharge (CD) from a hospital maternity unit.

METHODS

An observational study was conducted in a French university hospital among 135 breastfeeding mothers, who delivered between 1 January and 31 July 2006. Forty-five ED mothers were matched with 90 CD mothers on 13 criteria. A structured questionnaire was used to collect data regarding feeding practices at 10 weeks postpartum, the period corresponding to paid maternity leave.

RESULTS

Exclusive breast-, mixed, and bottle feedings were reported by, respectively, 35 (77.8%), three (6.7%) and seven (15.5%) ED mothers and 64 (71.1%), 12 (13.3%) and 14 (15.6%) CD mothers (no significant differences). Satisfaction with support for breastfeeding and reasons for switching to mixed or bottle feeding were comparable in the two groups. Multivariate analysis indicated that only the planned duration of breastfeeding and the mother's dissatisfaction with help significantly influenced breastfeeding prevalence.

CONCLUSIONS

Early postpartum hospital discharge organized by skilled professionals is compatible with a satisfactory rate of exclusive breastfeeding up to the return to work. Formalized programs of instruction for perinatal professionals would help to reduce early abandonment.