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Bonnet MP, de Vries PLM, Levet S, Saucedo M, Morau E, Dreyfus M, Goffinet F, Deneux-Tharaux C. Trends in Maternal Mortality From Obstetric Hemorrhage in France: 15 Years of Confidential Enquiry Into Maternal Deaths. Anesth Analg 2024:00000539-990000000-00822. [PMID: 38781094 DOI: 10.1213/ane.0000000000006864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
BACKGROUND The aim of this study was to assess temporal trends in incidence and underlying causes of maternal deaths from obstetric hemorrhage in France and to describe clinical care before and after implementation of the first national guidelines published in 2004 and updated in 2014. METHODS Data from all hemorrhage-related maternal deaths between 2001 and 2015 were extracted from the French Confidential Enquiry into Maternal Deaths. We compared the maternal mortality ratio (MMR), cause of obstetric hemorrhage, and death preventability by triennium. Critical care, transfusion, and obstetric management among women who died were described for 2001 to 2003 and 2013 to 2015. RESULTS The MMR from obstetric hemorrhage significantly decreased over time from 2.3 of 100,000 livebirths (54 of 2,391,551) in 2001 to 2003 to 0.8 of 100,000 livebirths (19 of 2,412,720) in 2013 to 2015. In 2001 to 2003, uterine atony accounted for 50% (27 of 54) of maternal deaths vs 21% (4 of 19) in 2013 to 2015. As compared to 2001 to 2003, an increased proportion of women had hemodynamic continuous monitoring in 2013 to 2015 (30%, 9 of 30, vs 47%, 8 of 18) and received vasopressor infusion therapy (57%, 17 of 30, vs 72%, 13 of 18), and a smaller proportion was extubated during active hemorrhage (17%, 5 of 30, vs 0 of 18). Transfusion therapy was initiated more frequently and earlier in 2013 to 2015 (71 vs 58 minutes). In 2013 to 2015, 88% of maternal deaths due to hemorrhage remained preventable. The main identified improvable care factors were related to delays in diagnosis and surgical management, particularly after cesarean delivery. CONCLUSIONS Maternal mortality by obstetric hemorrhage decreased dramatically in France between 2001 and 2015, particularly mortality due to uterine atony. Among women who died, we detected fewer instances of substandard transfusion management or critical care. Nevertheless, opportunities for improvement were observed in most of the recent cases.
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Affiliation(s)
- Marie-Pierre Bonnet
- From the Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Université Paris Cité, INSERM, INRAE, Paris, France
- Department of Anesthesia and Critical Care, Armand-Trousseau Hospital, Sorbonne Université, Paris, France
| | - Pauline L M de Vries
- Department of Obstetrics, Leiden University Medical Centre, Leiden, the Netherlands
- Department of Obstetrics, Port-Royal Maternity Unit, Cochin Hospital, Paris, France
| | - Solène Levet
- Department of Obstetrics, Port-Royal Maternity Unit, Cochin Hospital, Paris, France
| | - Monica Saucedo
- From the Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Université Paris Cité, INSERM, INRAE, Paris, France
| | - Estelle Morau
- Department of Anesthesia and Critical Care, Nîmes University Hospital, Nîmes, France
| | - Michel Dreyfus
- Department of Gynecology and Obstetrics, Caen University Hospital, Caen, France
| | - François Goffinet
- From the Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Université Paris Cité, INSERM, INRAE, Paris, France
- Department of Obstetrics, Port-Royal Maternity Unit, Cochin Hospital, Paris, France
| | - Catherine Deneux-Tharaux
- From the Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Université Paris Cité, INSERM, INRAE, Paris, France
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Bouchghoul H, Madar H, Resch B, Pineles BL, Mattuizzi A, Froeliger A, Sentilhes L. Uterine-sparing surgical procedures to control postpartum hemorrhage. Am J Obstet Gynecol 2024; 230:S1066-S1075.e4. [PMID: 37729440 DOI: 10.1016/j.ajog.2022.06.018] [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: 03/19/2022] [Revised: 06/05/2022] [Accepted: 06/12/2022] [Indexed: 09/22/2023]
Abstract
Postpartum hemorrhage remains one of the principal causes of maternal mortality in the United States and throughout the world. Its management, which must be multidisciplinary (obstetrics, midwifery, anesthesiology, interventional radiology, and nursing), depends on the speed of both diagnosis and implementation of medical and surgical treatment to control the hemorrhage. The aim of this work is to describe the various techniques of vessel ligation and of uterine compression for controlling and treating severe hemorrhage, and to present the advantages and disadvantages of each. It is not difficult to perform vessel ligation of the uterine arteries: O'Leary's bilateral ligation of the uterine artery, Tsirulnikov's triple ligation, and AbdRabbo's stepwise uterine devascularization (that is, stepwise triple ligation). These procedures are associated with a high success rate (approximately 90%) and a low complication rate. Bilateral ligation of the internal iliac (hypogastric) arteries is more difficult to perform and potentially less effective (approximately 70% effectiveness) than the previously mentioned procedures. Its complication rate is low, but the complications are most often serious. There is no evidence that future fertility or subsequent obstetrical outcomes are impaired by ligation of either the uterine or internal iliac arteries. There are many techniques used for uterine compression sutures, and none has shown clear superiority to another. Uterine compression suture has an effectiveness rate of approximately 75% after failure of medical treatment and approximately 80% as a second-line procedure after unsuccessful vessel ligation. The risk of synechiae after uterine compression suture has not yet been adequately evaluated, but is probably around 5%. The risk of synechiae after uterine compression suture has not yet been adequately evaluated, but probably ranges between 5% and 10%. The methodologic quality of the studies assessing uterine-sparing surgical procedures remains limited, with no comparative studies. Accordingly, no evidence suggests that any one of these methods is better than any other. Accordingly, the choice of surgical technique to control hemorrhage must be guided firstly by the operator's experience. If the hemorrhage continues after a first-line uterine-sparing surgical procedure and the patient remains hemodynamically stable, a second-line procedure can be chosen. Nonetheless, the application of these procedures must not delay the performance of a peripartum hysterectomy in cases of hemodynamic instability.
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Affiliation(s)
- Hanane Bouchghoul
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux, France
| | - Hugo Madar
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux, France
| | - Benoit Resch
- Department of Obstetrics and Gynecology, Rouen University Hospital, Rouen, France; Department of Gynecologic Surgery, Clinique Mathilde, Rouen, France
| | - Beth L Pineles
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center, Houston, TX
| | - Aurélien Mattuizzi
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux, France
| | - Alizée Froeliger
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux, France
| | - Loïc Sentilhes
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux, France.
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Lumbreras-Marquez MI, Campos-Zamora M, Ramirez-De Avila AL, Soto-Galindo JC, Olivas-Chavez JC, Tecayehuatl-Delgado G, Hernandez-Rayon YI, Ramirez-Calvo JA, Farber MK. Training for the surgical management of postpartum hemorrhage: a multicenter survey of resident physicians. J Matern Fetal Neonatal Med 2019; 34:3503-3509. [PMID: 31744352 DOI: 10.1080/14767058.2019.1685974] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Background: To actively address maternal morbidity and mortality in Mexico, proficiency among obstetrics and gynecology (OBGYN) residents in the surgical management of postpartum hemorrhage (PPH) is a priority. However, the capacity of programs to provide this training is unknown.Objective: The self-reported knowledge, education, and proficiency of common surgical techniques for the management of PPH among OBGYN residents in Mexico was evaluated. Educational resources, perceived barriers to acquiring skills, and clinical decision-making were explored.Materials and methods: In July of 2018, an anonymous electronic survey was sent to 86 residents at four hospitals throughout Mexico. Surgical techniques queried included uterine tamponade (UT), uterine compression sutures (UCS), uterine devascularization (UD), hypogastric artery ligation (HAL), and gravid hysterectomy (HT). Participants also answered case-based questions about a patient with PPH.Results: The survey response rate was 59.3% (51/86). Seventy-nine percent of residents reported understanding the rationale and techniques for the surgical intervention of PPH. However, 43.9% reported limited ability to perform these procedures with autonomy. Eighty-six percent of residents reported exposure to these techniques while performing a rescue procedure during PPH and 49% reported learning these procedures while performing prophylactic techniques in patients without PPH. Only 25.5% had been exposed to simulation training. Lack of a training module for these skills in their curriculum was noted by 74.5%. The majority of the participants chose UCS, UD, HAL, and HT as the first, second, third, and fourth rescue procedures to perform for PPH, respectively.Conclusion: Most residents reported theoretical knowledge of surgical interventions for PPH, but their self-rated ability to independently perform such skills and a curriculum focused on PPH management was suboptimal.
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Affiliation(s)
- Mario Isaac Lumbreras-Marquez
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Melissa Campos-Zamora
- Master of Medical Science in Medical Education, Harvard Medical School, Boston, MA, USA
| | - Ana Laura Ramirez-De Avila
- Department of Obstetrics and Gynecology, Hospital Central "Dr. Ignacio Morones Prieto", San Luis Potosí, Mexico
| | | | | | | | - Yessica Ivonne Hernandez-Rayon
- Department of Obstetrics and Gynecology, Hospital Materno Infantil de Durango, Durango, Mexico.,Deparment of Maternal and Fetal Medicine, Instituto Nacional de Perinatologia, Mexico City, Mexico
| | | | - Michaela Kristina Farber
- Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Bouet PE, Madar H, Froeliger A, El Hachem H, Schinkel E, Mattuizi A, Sentilhes L. Surgical treatment of postpartum haemorrhage: national survey of French residents of obstetrics and gynecology. BMC Pregnancy Childbirth 2019; 19:91. [PMID: 30866846 PMCID: PMC6415489 DOI: 10.1186/s12884-019-2237-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 02/26/2019] [Accepted: 03/05/2019] [Indexed: 11/25/2022] Open
Abstract
Background Postpartum haemorrhage (PPH) is a major cause of maternal morbidity and one of the leading causes of maternal mortality worldwide. Many medical treatments and interventions are available nowadays, but surgical treatment is sometimes required when less invasive methods are unsuccessful. This study aimed to assess the theoretical and practical knowledge of French residents of Obstetrics and Gynecology concerning the surgical treatment of postpartum haemorrhage. Study design We performed a questionnaire study for senior residents of Obstetrics and Gynecology in France (fourth and fifth year of training). An anonymous survey was sent by email. Between December 2013 and April 2014, a total of 370 residents responded. Result The response rate was 47.6% (176/370). Only 156 questionnaires were fully completed and included for analysis. In all, 74% (115/156) of residents reported not mastering sufficiently or at all the technique for bilateral ligation of uterine arteries, 79% (123/156) for uterine compression sutures, 95% (148/156) for ligation of the internal iliac arteries, and 78% (122/156) for emergency peripartum hysterectomy. More than half of respondents (55%, 86/156) stated that they had not mastered any of these techniques. Conclusion An alarmingly high number of French senior residents in Obstetrics and Gynecology report that they have not acquired the sufficient surgical skills during their training to be able to perform the surgeries required for the management of PPH. Electronic supplementary material The online version of this article (10.1186/s12884-019-2237-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Pierre-Emmanuel Bouet
- Department of Obstetrics and Gynecology, Montreal University Hospital, Montreal, Canada.
| | - Hugo Madar
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux, France
| | - Alizée Froeliger
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux, France
| | - Hady El Hachem
- Department of Obstetrics and Gynecology, Clemenceau Medical Center, Beirut, Lebanon
| | - Elsa Schinkel
- Clinical Research Center, Angers University Hospital, Angers, France
| | - Aurélien Mattuizi
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux, France
| | - Loïc Sentilhes
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux, France
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Collis R, Guasch E. Managing major obstetric haemorrhage: Pharmacotherapy and transfusion. Best Pract Res Clin Anaesthesiol 2017. [DOI: 10.1016/j.bpa.2017.02.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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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.
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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
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