Michel Berland

Bedside assessment of fibrinogen level in postpartum haemorrhage by thrombelastometry

Objectives  To establish whether reagent‐supported thrombelastometry with the rotation thrombelastometry system (ROTEM®) point‐of‐care device correlated with fibrinogen level in postpartum haemorrhages.

Coagulation assessment by rotation thrombelastometry in normal pregnancy

We analysed changes in coagulation during normal pregnancy with a novel point-of-care device based on thrombelastometry (ROTEM). We compared the results obtained with those of standard coagulation tests in 104 patients: 20 non-pregnant women (controls) and 84 women in the first (T1, n = 17), second (T2, n = 9) and third (T3, n = 58) trimesters of pregnancy. We measured the clotting time (CT), the maximum clot firmness (MCF), the early clot amplitude at 5 and 15 minutes (CA(5), CA(15)) and the clot lysis index (CLI(30)) with four tests containing specific reagents. (a) The INTEM test involving ellagic acid activated the intrinsic pathway and (b) the EXTEM test using tissue factor triggered the extrinsic pathway; (c) The FIBTEM test based on a platelet inhibitor (cytochalasin D) evaluated the contribution of fibrinogen to clot formation and (d) the APTEM test was similar to the EXTEM but was based on inhibition in vitro of fibrinolysis by aprotinin. CT and CLI(30) were not significantly modified during pregnancy whereas MCF, CA(5) and CA(15) (INTEM, EXTEM, FIBTEM) increased significantly between the second and third trimesters (e.g. median [interquartile range]: MCF-FIBTEM, 13 [11-16] mm vs. 19 [17-23] mm, respectively, in controls and T3, p < 0.001). EXTEM values were not significantly different from those measured with APTEM. There were significant correlations between the results obtained with ROTEM and those from standard coagulation tests. ROTEM analysis showed a marked increase in coagulability during normal pregnancy. ROTEM values may serve as the basis for future studies in pregnant women.

A risk score for the management of pregnant women with increased risk of venous thromboembolism: a multicentre prospective study.

Patients with thrombophilia and/or a history of venous thromboembolism (VTE) exhibit a high risk of thrombosis during pregnancy. The present multicentre study prospectively assessed a prophylaxis strategy, based on a risk score, in pregnancies with increased risk of VTE. Among 286 patients included in the study, 183 had a personal history of VTE (63·98%) and 191 patients (66·8%) had a thrombophilia marker. Eighty nine (46·6%) thrombophilic women had a personal history of VTE. Patients were assigned to one of three prophylaxis strategies according to the risk scoring system. In postpartum, all patients received low molecular weight heparin (LMWH) prophylaxis for at least 6 weeks. In antepartum, LMWH prophylaxis was prescribed to 61·8% of patients with high risk of VTE. Among them, 37·7% were treated in the third trimester only and 24·1% were treated throughout pregnancy. In this cohort, one antepartum‐related VTE (0·35%) and two postpartum‐related VTE (0·7%) occurred. No case of pulmonary embolism was observed during the study period. The rate of serious bleeding was 0·35%. There was no evidence of heparin‐induced thrombocytopenia or osteoporosis. The use of a risk score may provide a rational decision process to implement safe and effective antepartum thromboprophylaxis in pregnant women at high risk of VTE.

Red, orange and green Caesarean sections: A new communication tool for on-call obstetricians

OBJECTIVE To evaluate the effect of a novel communication tool, related to the degree of urgency for Caesarean sections (CSs), on the decision-to-delivery interval for emergency CS. STUDY DESIGN Red CS are very urgent cases corresponding to life-threatening maternal or foetal situations, orange CS are urgent cases and green CS are non-urgent intrapartum CS. We carried out this cohort study in a French maternity hospital. The study included all emergency Caesarean sections during two 6-month periods, before and after introduction of the code. We compared the decision-to-delivery interval of the two study periods. RESULTS Our study included 174 emergency CS. The mean decision-to-delivery interval after introduction of the code was 31.7 min, significantly shorter (p=0.02) than the 39.6 min interval before introduction of the colour code. Except for the preparation time, each time interval decreased. This included transporting the patient into the operating theatre, and the incision-to-delivery time interval. CONCLUSION This study suggests that the use of the three-colour code could significantly shorten the decision-to-delivery interval in emergency CS. Further prospective studies are needed to confirm this result.

Cost-effectiveness analysis of gestational diabetes mellitus screening in France

OBJECTIVE To compare three strategies for gestational diabetes screening (i) screening of high-risk pregnant women with the 50 g oral glucose tolerance test (OGTT); (ii) screening of all pregnant women with the 50 g OGTT; (iii) screening of all pregnant women according to the 75 g OGTT. STUDY DESIGN Cost-effectiveness analysis. The outcome measures, i.e. macrosomia, prematurity, perinatal mortality, hypertensive disorders rates were estimated from published studies and the costs from a prospective study involving 120 pregnant women. RESULTS Compared to the first strategy, the cost to obtain one unit of additional effectiveness with the second screening strategy, was up to 1.1 times more expensive, and with the third strategy was up to 3.7 times more expensive. CONCLUSION The costs per case prevented reflect a favourable cost-effectiveness ratio (CER) for screening of high-risk pregnant women by 50 g oral glucose test.

Does forceps training on a birth simulator allow obstetricians to improve forceps blade placement

OBJECTIVE The aim of this study was to evaluate whether forceps training on a birth simulator allows obstetricians to improve forceps blade placement. STUDY DESIGN Analysis was based on 600 forceps blade placements performed by ten trainees on a simulator. The trajectories used by the trainees were assessed using reference spheres that reflected an optimal bimalar placement. Three definitions of success were used: small-sphere success, medium-sphere success and large-sphere success were respectively defined by the forceps blade tip being within 5, 10 or 15mm of the center of the sphere (the small-sphere being nested within the medium-sphere and the small and medium being nested within the large-sphere). Wilcoxon paired analysis was performed to compare the first (50 trajectories) and final (50 trajectories) sets of five forceps placements. Graphical representation and linear regression were used to visualize the learning process. RESULTS 596 trajectories were available for analysis. During the last set of five forceps the success rate was respectively 28%, 72% and 86% for small-sphere, medium-sphere and large-sphere success with the right blade and 8%, 32% and 70% for the left blade. Wilcoxon analysis showed a highly significant improvement for all kinds of success in the right blade and for large-sphere success in the left blade. Linear regression slopes were significant. Using a projection, the theoretical numbers of placements needed to achieve a 100% success rate for small-sphere, medium-sphere and large-sphere were respectively 80, 45 and 35. CONCLUSION These results strongly suggest that performing forceps blade placement on birth simulator allows obstetricians to improve their skills.

Specific information about the WHO guidelines for gestational diabetes screening improves clinical practices.

RATIONALE, AIMS AND OBJECTIVE To evaluate the impact of specific information on World Health Organization (WHO) guidelines for gestational diabetes mellitus (GDM) screening on clinical practices and to estimate its acceptance by women. METHODS A non-randomized interventional study, comparing two periods, that is, before (period I) and after (period II) the implementation of the WHO guidelines during year 2000 in three obstetrical units, using reminders, meetings and pre-printed prescription sheets. Women were interviewed on GDM screening acceptance. RESULTS A total of 333 pregnant women were included in period I and 345 in period II. The proportion of women who were screened significantly increased between period I and period II (0.9% in period I, 59.1% in period II, P < 10(-3)). The screening test was realized in accordance with guidelines for 80% of women in period II. The acceptability of the test by women was estimated at 98%. Furthermore, 90% of them would accept to be screened again during another pregnancy. DISCUSSION Specific information about WHO screening guidelines improves doctor practices. Moreover, the high rate of acceptance by women is an argument to promote more widespread WHO screening for GDM during pregnancy.

Paralysie sciatique transitoire après embolisation de l’artère utérine

Early postpartum bleeding remains in France the leading cause of maternal mortality in perinatal period. In association with obstetrical and medical measures to control bleeding, uterine arteries embolization constitutes an efficient non-surgical measure whose potential side effects must be kept in mind. We report the case of a patient that presented a popliteal sciatic paralysis in the hours following the procedure. Through this case, we will review the different types of embolization complications.

Cas cliniqueParalysie sciatique transitoire après embolisation de l’artère utérineSciatic paralysis following uterine artery embolization

Early postpartum bleeding remains in France the leading cause of maternal mortality in perinatal period. In association with obstetrical and medical measures to control bleeding, uterine arteries embolization constitutes an efficient non-surgical measure whose potential side effects must be kept in mind. We report the case of a patient that presented a popliteal sciatic paralysis in the hours following the procedure. Through this case, we will review the different types of embolization complications.

Maternal infection rates after cesarean delivery by Pfannenstiel or Joel-Cohen incision: a multicenter surveillance study.

OBJECTIVE Our purpose was to evaluate maternal nosocomial infection rates according to the incision technique used for caesarean delivery, in a routine surveillance study. STUDY DESIGN This was a prospective study of 5123 cesarean deliveries (43.2% Joel-Cohen, 56.8% Pfannenstiel incisions) in 35 maternity units (Mater Sud Est network). Data on routine surveillance variables, operative duration, and three additional variables (manual removal of the placenta, uterine exteriorization, and/or cleaning of the parieto-colic gutter) were collected. Multiple logistic regression analysis was used to identify independent risk factors for infection. RESULTS The overall nosocomial infection and endometritis rates were higher for the Joel-Cohen than Pfannenstiel incision (4.5% vs. 3.3%, 0.8% vs. 0.3%, respectively). The higher rate of nosocomial infections with the Joel-Cohen incision was due to a greater proportion of patients presenting risk factors (i.e., emergency delivery, primary cesarean, blood loss > or =800 mL, no manual removal of the placenta and no uterine exteriorization). However, the Joel-Cohen technique was an independent risk factor for endometritis. CONCLUSION The Joel-Cohen technique is faster than the Pfannenstiel technique but is associated with a higher incidence of endometritis.