Gynecologie, obstetrique, fertilite & senologie
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Gynecol Obstet Fertil Senol · May 2018
Review[To the question of elective induction of labor at 39 weeks of gestation, the answer lies in the question].
The goal of induction of labor is to achieve vaginal delivery when the benefits of expeditious delivery outweigh the risks of continuing the pregnancy. In order to correctly understand the problematic of the elective induction of labor at 39 weeks of gestation (WG), two questions must be raised. (i) What is the perinatal mortality evolution according the gestational age at delivery? All the most recent and methodologically well-conducted studies are convergent: they show that the fetal mortality risk exceeds the perinatal/infant (during the first year of life) mortality risk from 39 WG. The benefit/risk balance related to the expectant management is therefore reversed from 39 WG in favor of the elective induction of labor when the considered issue is the perinatal mortality. (ii) What are the associated risks with elective induction of labor? While some observational studies suggested that the elective induction of labor after 37 WG was associated with an increased risk of cesarean sections, these studies presented a major methodological bias: an error in the control group selection. ⋯ Three systematic reviews with meta-analysis of randomized controlled trials comparing induction of labor with expectant management were published: two showed that the cesarean section risk was lowered with the induction of labor compared to an expectant management and the third that the cesarean section rates were similar. Finally, the most recent randomized controlled trial, published in 2016, showed no significant difference between the 2 arms in the cesarean section rate. In all, the most recent literature data, free from comparative bias, show that elective induction of labor at term is associated with a significant reduction in the cesarean section risk and perinatal morbidity and mortality compared to an expectant management.
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Gynecol Obstet Fertil Senol · Dec 2017
Case Reports[Maternal deaths due to haemorrhage: Results from the French confidential enquiry into maternal deaths, 2010-2012].
Haemorrhage is the first cause of maternal mortality and morbidity in France and a quality of care marker. Haemorrhage rate in France is around 5 to 10% of deliveries. PPH is defined as a post-partum blood loss≥500mL whatever the delivery route and sometime blood can be concealed inside the pelvis. ⋯ Haemorrhage cases decreased from last triennium (2007-2009) especially for uterine atony cases (12/29) but remains the first leading cause of direct maternal death. Patients with previous cesarean birth were more represented than in general obstetrical population (11/23). Substandard care were mainly due to delays in diagnosis of hemoperitoneum, delays in adequate resuscitation because of reassuring vital signs (normal blood pressure or normal hematocrite at the initial stage of bleeding) or organisational mistakes.
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Gynecol Obstet Fertil Senol · Dec 2017
Case Reports[Maternal deaths due to hypertensive disorders. Results from the French confidential enquiry into maternal deaths, 2010-2012].
Between 2010 and 2012, the rate of maternal death caused by hypertensive disorders (0,5/100,000 living birth) was reduced by 50% compared to the 2007-2009 period. Hypertensive disorders were responsible from 5% of maternal deaths and from 10% of direct maternal mortality. ⋯ The main causes of suboptimal management were: unappropriated or insufficient obstetrical and anesthetic treatments, undiagnosed HELLP syndrome and subcapsular liver hematoma, delayed treatment. The analysis of these maternal deaths gave the opportunity to stress some major lessons to optimize medical management in case of hypertensive diseases during pregnancy: abdominal symptoms during third trimester of pregnancy lead to search hypertensive disorders; HELLP syndrome with severe anemia indicate to carry out abdominal ultrasound.
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To describe, for the period 2010-2012, the frequency, the causes, the risk factors, the adequacy of care and the avoidability of maternal deaths in France. ⋯ Direct maternal mortality and in particular maternal mortality from hemorrhage has decreased significantly over the past 10 years, indicating improved obstetric care. However, territorial and social inequalities persist, and the majority of deaths remain preventable, which shows that the identification of opportunities for improvement must continue. To go even further in understanding the mechanisms involved, and to identify precise avenues of prevention, it is necessary to analyze in detail the stories of each maternal death in order to identify the repetitive elements in the series of deaths. This is what the following articles in this issue propose, with an analysis by cause of death, according to the idea that the same cause produces the same effects.
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Gynecol Obstet Fertil Senol · Dec 2017
Case Reports[Maternal deaths due to anesthesia complications. Results from the French confidential enquiry into maternal deaths, 2010-2012].
Over the period 2010-2012, maternal mortality linked to anesthesia accounted for 2% of maternal deaths, with no significant change since 2007-2009. Of the 7 maternal deaths analyzed by the expert committee, anesthetic complications were in 5 cases the main cause of death: 4 attributed to direct causes related to anesthetic procedures during childbirth and 1 to indirect cause in connection with an ENT complication during pregnancy. ⋯ In two other cases, anesthetic complications were identified as associated causes of death, the primary cause being intracerebral hemorrhage stroke and pulmonary hypertension. In most of the cases analyzed over the period 2010-2012, anesthesia and resuscitation have been involved in the occurrence of maternal deaths, mainly through strategic errors in the management of patients with severe pathology before delivery, as well as through insufficient cardiac resuscitation duration after cardiac arrest.