[Reprint of: Severe pre-eclampsia: guidelines for clinical practice from the French Society of anesthesiology and intensive care (SFAR) and the French College of gynaecologists and obstetricians (CNGOF)]

OBJECTIVE

To provide national guidelines for the management of women with severe preeclampsia.

DESIGN

A consensus committee of 26 experts was formed. A formal conflict of interest (COI) policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized.

METHODS

The last SFAR and CNGOF guidelines on the management of women with severe preeclampsia was published in 2009. The literature is now sufficient for an update. The aim of this expert panel guidelines is to evaluate the impact of different aspects of the management of women with severe preeclampsia on maternal and neonatal morbidities separately. The experts studied questions within 7 domains. Each question was formulated according to the PICO (Patients Intervention Comparison Outcome) model and the evidence profiles were produced. An extensive literature review and recommendations were carried out and analyzed according to the GRADE® methodology.

RESULTS

The SFAR/CNGOF experts panel provided 25 recommendations: 8 have a high level of evidence (GRADE 1±), 9 have a moderate level of evidence (GRADE 2±), and for 7 recommendations, the GRADE method could not be applied, resulting in expert opinions. No recommendation was provided for 3 questions. After one scoring round, strong agreement was reached between the experts for all the recommendations.

CONCLUSIONS

There was strong agreement among experts who made 25 recommendations to improve practices for the management of women with severe preeclampsia.

Racial implicit bias among obstetricians and midwives, and information on Down syndrome screening

Background and objectives

Previous studies showed disparities in prenatal screening for Down syndrome according to the maternal place of birth. Among the factors that might be involved in these differences, social cognition offers the concept of implicit bias (IB) used to describe the fact of having attitudes towards people or associating stereotypes with them without necessarily conscious knowledge. In line with theoretical and empirical contributions in social psychology that postulate and demonstrate the role of automatic processes in determining behavior, IBs often predict how individuals behave more accurately than conscious values. The existence of IB among health professionals has been demonstrated in emergency care or pain management. To our knowledge, no study of IB has been conducted in Europe, nor in the field of perinatal care. Thus, our objectives were to test for IBs towards African women in terms of evaluation (negative bias) and strength (positive bias) among perinatal health professionals and test whether these IBs predicted treatment recommendations toward African vs. French patients.

Methods

Through online data collection, 887 perinatal care practicians (obstetrician-gynecologists, midwives) answered a series of case vignettes depicting African vs. French patients, with one specific to a Down syndrome screening situation. Then, participants completed two Implicit Association Tests to assess valence and strength IBs toward African vs. French women.

Results

81.3% of the sample showed an implicit evaluative preference for French over African women, and 60.2% had an implicit perception of African women as stronger than French. However, decision toward Down syndrome screening were not influenced by the patient's origin nor by the healthcare professional implicit bias.

Conclusions

Perinatal practicians seem to have implicit biases toward African women, but the way they provide information regarding Down Syndrome screening is not affected.

When and how should I transfuse during obstetric hemorrhage?

The incidence of maternal hemorrhage and blood transfusion has increased over time. Causes of massive hemorrhage, defined as a transfusion > 10 units of erythrocytes, include abnormal placental insertion, preeclampsia, and placental abruption. Although ratio-based transfusion has been described for managing massive hemorrhage, a goal-directed approach using laboratory or point-of-care data may lead to better outcomes. Autotransfusion, which involves the collection, washing, and filtration of maternal shed blood, avoids many of the complications associated with allogeneic blood transfusion. In this review, we provide an overview of transfusion practices related to the management of obstetric hemorrhage.

Clinical profiles of placenta accreta spectrum: the PACCRETA population-based study

OBJECTIVE

To describe and compare the characteristics of women with placenta accreta spectrum (PAS) and their pregnancy outcomes according to the presence of placenta praevia and a prior caesarean section.

DESIGN

Prospective population-based study.

SETTING

All 176 maternity hospitals of eight French regions.

POPULATION

Two hundred and forty-nine women with PAS, from a source population of 520 114 deliveries.

METHODS

Women with PAS were classified into two risk-profile groups, with or without the high-risk combination of placenta praevia (or an anterior low-lying placenta) and at least one prior caesarean. These two groups were described and compared.

MAIN OUTCOME MEASURES

Population-based incidence of PAS, characteristics of women, pregnancies, deliveries and pregnancy outcomes.

RESULTS

The PAS population-based incidence was 4.8/10 000 (95% CI 4.2-5.4/10 000). After exclusion of women lost to follow up from the analysis, the group with placenta praevia and a prior caesarean included 115 (48%) women and the group without this combination included 127 (52%). In the group with both factors, PAS was more often suspected antenatally (77% versus 17%; P < 0.001) and more often percreta (38% versus 5%; P < 0.001). This group also had more hysterectomies (53% versus 21%, P < 0.001) and higher rates of blood product transfusions, maternal complications, preterm births and neonatal intensive care unit admissions. Sensitivity analysis showed similar results after exclusion of women who delivered vaginally.

CONCLUSION

More than half the cases of PAS occurred in women without the combination of placenta praevia and a prior caesarean delivery, and these women had better maternal and neonatal outcomes. We cannot completely rule out that some of the women who delivered vaginally had placental retention rather than PAS; however, we found similar results among women who delivered by caesarean.

TWEETABLE ABSTRACT

Half the women with PAS do not have both placenta praevia and a prior caesarean delivery, and they have better maternal outcomes.

Gestational anaemia and severe acute maternal morbidity: a population-based study

Anaemia is frequently diagnosed during pregnancy. However, there are few data regarding its incidence, and the association with severe maternal morbidity remains uncertain and potentially biased in high-resource countries. The purpose of this study was to explore the association between gestational anaemia and severe acute maternal morbidity during and after delivery. We performed a cohort-nested case-control analysis from the epidemiology of severe maternal mortality (EPIMOMS) prospective study conducted in six French regions (2012-2013, n = 182,309 deliveries). There were 1669 women with severe acute maternal morbidity during or after delivery, according to a standardised definition obtained by expert consensus. The control group were randomly selected among women without severe morbidity who delivered in the same health centres (n = 3234). We studied the association between gestational anaemia and severe acute maternal morbidity during or after delivery overall, by cause, and by mode of delivery, using multivariable logistic regression and multiple imputation. Gestational anaemia was significantly more frequent in women with severe acute maternal morbidity (25.3%) than in controls (16.3%), p < 0.001, and mostly mild in both groups. After adjustment for confounders, women with gestational anaemia were at increased risk of overall severe acute maternal morbidity during and after delivery (adjusted OR (95%CI) 1.8 (1.5-2.1)). This association was also found for severe postpartum haemorrhage (adjusted OR (95%CI) 1.7 (1.5-2.0)), even after omitting the transfusion criterion (adjusted OR (95%CI) 1.9 (1.6-2.3)), and for severe acute maternal morbidity secondary to causes other than haemorrhage or pregnancy-related hypertensive disorders (adjusted OR (95%CI) 2.7 (1.9-4.0)). These results highlight the importance of optimising the diagnosis and management of anaemia during pregnancy.

Anaphylaxis in pregnancy: a population-based multinational European study

Anaphylaxis in pregnancy is a rare but severe complication for both mother and infant. Population-based data on anaphylaxis in pregnancy are lacking from mainland European countries. This multinational study presents the incidence, causative agents, management and maternal and infant outcomes of anaphylaxis in pregnancy. This descriptive multinational study used a combination of retrospective (Finnish medical registries) and prospective population-based studies (UK, France, Belgium and the Netherlands) to identify cases of anaphylaxis. Sixty-five cases were identified among 4,446,120 maternities (1.5 per 100,000 maternities; 95%CI 1.1-1.9). The incidence did not vary between countries. Approximately three-quarters of reactions occurred at the time of delivery. The most common causes were antibiotics in 27 women (43%), and anaesthetic agents in 11 women (17%; including neuromuscular blocking drugs, 7), which varied between countries. Anaphylaxis had very poor outcomes for one in seven mothers and one in seven babies; the maternal case fatality rate was 3.2% (95%CI 0.4-11.0) and the neonatal encephalopathy rate was 14.3% (95%CI 4.8-30.3). Across Europe, anaphylaxis related to pregnancy is rare despite having a multitude of causative agents and different antibiotic prophylaxis protocols.

Factors associated with the use of non-pharmacological analgesia for labor pain management

Background

For a decade, pain labor management has evolved: if neuraxial analgesia remains the gold standard, non-pharmacological methods are developing. We aimed to identify individual and organizational factors associated with the use of non-pharmacological analgesia, combined or not with neuraxial analgesia.

Methods

Women who attempted vaginal delivery with labor analgesia were selected from the 13,147 participants of the 2016 National Perinatal Survey. Labor analgesia was studied as follows: neuraxial analgesia only (NA), non-pharmacological analgesia only (NPA) or neuraxial and non-pharmacological methods combined (NA+NPA). Associations between individual and organizational characteristics were studied using a multilevel multinomial logistic regression.

Results

Among the 9 231 women included, 62.4% had NA only, 6.5% had NPA only and 31.1% had NA+NPA. Both NPA and NA+NPA were associated with multiparity with antenatal classes, educational level ≥ 5 years post graduate, antenatal preference to deliver without NA, and delivery in public maternity units. The use of NPA only was positively associated with non-permanent availability of the anesthesiologist and with a high number of midwives per shift in maternity units. Contrastingly, NPA only was negatively associated with foreign nationality and oxytocin use for induction or augmentation of obstetrical labor. NA+NPA was positively associated with primiparity with antenatal classes, but negatively with inadequate prenatal care.

Conclusions

Less than 40% of parturients used non-pharmacological analgesia during labor and for the most of them as complementary methods to neuraxial analgesia. NPA and NA+NPA were associated with individual characteristics as well as characteristics of management of labor and organization of maternity units. Non-pharmacological analgesia appears to be dedicated to high educated and well-integrated women in perinatal health care system.

Key messages

Less than 40% of parturients used non-pharmacological analgesia during labor and for the most of them as complementary methods to neuraxial analgesia. Non-pharmacological analgesia appears to be dedicated to high educated and well-integrated women in perinatal health care system.

Seasonal effect on trace metal elements behaviour in a reservoir of northern Thailand

Trace metal elements (TME) can be real threats for living organisms. However, few studies dealt with TME in reservoirs in rural areas where farming practises could induce negative effects. Mae Thang reservoir (northern Thailand) has been studied for 3 years to understand the seasonal behaviour of dissolved TME: Fe, Mn, Cd, Al, Pb, V, Cr, Co, Ni, Cu, Zn, Mo, U and As and associated physicochemical parameters. In situ measurements of these parameters were done during the dry and the wet seasons as well as water samples along the water column for further analyses and TME determination by inductively coupled plasma-mass spectrometry (ICP-MS). In the dry season, the water column was characterized by a strong stratification and anoxic conditions in the hypolimnion. High rain and water input from the watershed during the wet season induced mixing of the water. All TME, except Ni, Co and Cr were less concentrated in the wet season indicating a dilution effect by water input. There was thus no important dissolved pollution coming from the watershed. The anoxic conditions in the dry season enhanced the reduction of Fe and Mn and the desorption processes. Depth, and thus oxic-anoxic conditions were the main drivers of TME in the dry season, while in the wet season, dissolution processes from parent rocks of watershed were favoured. The average concentrations of TME in the reservoir were in the limit of the international and Thai standards. Only localized values in the bottom of the reservoir for Fe and Mn were higher than the limits.

[Transfusion for post-partum haemorrhage: what's new in 2011?]

Post-partum haemorrhage is the first cause of maternal death in France. In addition to the treatment of the cause, its treatment consists in the association of procoagulant drugs and blood transfusion. At risk situations requiring blood transfusion are well identified. However, they are not found in one third of the actually transfused patients. Therefore, for all deliveries, the medical team should be prepared to face a post-partum haemorrhage and to transfuse. As post-partum haemorrhage onset is most frequently acute, it is rare to be able to base the transfusion decision on biological parameters such as haemoglobin concentration and / or coagulation tests. The recently defined policy of early use of fresh frozen plasma in order to better control the coagulopathy frequently associated with a large haemorrhage has not been established in obstetrical situations. However, it is recommended to apply it in large volume post-partum haemorrhage, with a fresh frozen plasma/red blood cells concentrate ratio between 1/1 and 1/2. The post-partum haemorrhage treatment may benefit from the use of drugs, the most frequently used being antifibrinolytics, such as tranexemic acid, which help to reduce the magnitude of post-partum haemorrhage. Conversely, activated factor VII use should be restricted to situations where all other conventional treatments failed, as a last attempt to avoid hysterectomy.

Effect of prophylactic 5-HT3 receptor antagonists on pruritus induced by neuraxial opioids: a quantitative systematic review

Pruritus is a frequent adverse event observed after neuraxial administration of opioids. Central 5-hydroxytryptamine subtype 3 (5-HT3) receptors may be activated in this process. This systematic review aimed to evaluate the efficacy of prophylactic 5-HT3 receptor antagonists on neuraxial opioid-induced pruritus. We searched Medline, Embase, and Cochrane Collaboration Library databases. Studies were evaluated with the Oxford Validity Scale. Studies with a score of 3 or more and reporting prophylactic administration of 5-HT3 receptor antagonists vs placebo were included. Fifteen randomized double-blind controlled trials (n=1337) were selected. 5-HT3 antagonists (n=775) significantly reduced pruritus [odds ratio (OR) 0.44 (95% confidence interval, 95% CI, 0.29-0.68), P=0.0002, number-needed-to-treat (NNT) 6 (95% CI, 4-14)], the treatment request for pruritus [OR 0.58 (95% CI, 0.43-0.78), P=0.0003, NNT 10 (95% CI, 7-20)], the intensity of pruritus [weighted mean difference (WMD) -0.35 (95% CI, -0.59 to -0.10), P=0.007], the incidence and the intensity of postoperative nausea and vomiting (PONV), and the need of rescue treatment [respectively, Peto odds ratio (Peto OR) 0.43 (95% CI, 0.31-0.58), P<0.00001, NNT 7 (95% CI, 6-10); WMD -0.12 (95% CI, -0.24 to 0.00), P=0.05 and OR 0.42 (95% CI, 0.20-0.86), P=0.02, NNT 8 (95% CI, 5-35)]. However, the funnel plot was asymmetric, suggesting a risk of publication bias. 5-HT3 receptor antagonists may be an effective strategy in preventing neuraxial opioid-induced pruritus and PONV. Further large randomized controlled trials are required to confirm these findings.

L'anesthésie comme cause de souffrance fœtale?

OBJECTIVE

To describe the effects of anaesthetic techniques and agents on the risk of fetal distress during labour pain relief and anaesthesia for caesarean section.

STUDY DESIGN

Data on obstetric anaesthesia- and analgesia-induced fetal distress were searched in Medline database using MESH terms: fetal distress, anaesthesia, analgesia, labour, caesarean section, and umbilical artery pH. Trials published in English or French language were selected.

RESULTS

Because of their haemodynamic effects, regional anaesthesia and analgesia, especially spinal anaesthesia for Caesarean section, could induce a decrease in umbilical artery pH (UApH). Moreover, intravenous ephedrine, especially when used in large doses can worsen the acidosis. Labour epidural analgesia is associated with a better acid-base balance than systemic analgesia. Experimental studies have demonstrated harmful effects of systemic opioids and hypnotic drugs on UApH and the foetal brain respectively. Clinical implications of these potentially detrimental effects remain to be determined.

CONCLUSION

All obstetric anaesthesia and analgesia techniques are associated with a theoretical risk of fetal distress, but given the fact that regional anaesthesia techniques are also associated with well-demonstrated benefits for the mother and the newborn, the latter remain the preferred choice in obstetric practice.

The relationship of intracranial pressure Lundberg waves to electroencephalograph fluctuations in patients with severe head trauma

Lundberg (or B) waves, defined as repetitive changes in intracranial pressure (ICP) occurring at frequencies of 0.5 to 2 waves/min, have been attributed to cerebral blood flow fluctuations induced by central nervous system pace-makers or cerebral pressure autoregulation. We prospectively recorded and digitalized at a frequency rate of 10 Hz (AcqKnowledge software) the following parameters in 6 brain injured patients: mean arterial pressure, heart rate, ICP, mean flow velocity of the middle cerebral artery (MFVMCA) (transcranial Doppler WAKI) and left and right spectral edge frequency (SEFl, SEFr) of continuous electroencephalogram (EEG) recordings (Philips technologies). All patients were sedated using a combination of sufentanil and midazolam and mechanically ventilated. Cerebral electrical activity (oscillations of SEF at a mean frequency of 26+/-9 mHz) and MFVMCA fluctuations were found strongly correlated with the intracranial Lundberg B waves (mean frequency 23+/-7 mHz). These result support the existence of a neuropacemaker at the origin of the Lundberg B waves. The change in cerebral electrical activity, resulting from cerebral pacemakers, could increase cerebral metabolic rate of oxygen (CMRO2) and thus lead to an increase in cerebral blood flow and secondarily of ICP through a change in cerebral blood volume.