Which strategy after a failure of cervical ripening by dinoprostone vaginal insert?

La meilleure stratégie de déclenchement en cas de persistance d’un col défavorable après un échec de 24 heures de Propess® n’est pas connue. L’objectif de cette étude était d’analyser et de comparer les issues obstétricales en cas de persistance d’un col immature (score de Bishop < 6) après une première maturation cervicale par Propess®. La population source était celle de l’étude MEDIP, cohorte prospective observationnelle en population, au sein de 94 maternités françaises, durant 1 mois en 2015, avec inclusion de 3042 femmes de façon consécutive dont le travail était déclenché. Étaient incluses les grossesses monofoetales, sur utérus sain, avec un score de Bishop < 6 à J2 après Propess® et pour lesquelles la deuxième ligne de déclenchement était soit des prostaglandines E2 (PGE2, second Propess® ou Prostine® gel) soit de l’Ocytocine (±amniotomie). Le critère de jugement principal de l’étude était l’accouchement par césarienne. Les critères secondaires étaient : césarienne < 6 cm, hémorragie de la délivrance et morbidité néonatale (pH < 7,10 et/ou APGAR < 7 à 5 minutes et/ou hospitalisation néonatale). Le groupe PGE2 était comparé au groupe Ocytocine. Plusieurs analyses statistiques ont été conduites pour prendre en compte les facteurs de confusion notamment la parité et le score de Bishop : régression logistique multivariée avant et après appariement sur la parité et le score de Bishop, appariement selon la technique du « coarsened exact matching » (CEM) et selon un score de propension (SP). Résultats. Parmi les patientes avec une maturation cervicale par Propess®, 16,2% (n=197/1216) avaient un score de Bishop < 6 à J2. La seconde méthode de déclenchement était des PGE2 pour 59,9% (n=118/197) et de l’Ocytocine (±amniotomie) pour 38,1% (n=75/197). Le score médian de Bishop était plus élevé dans le groupe Ocytocine : 4 [espaceIQ=3-5] vs 3 [2-4] (p<0,001). Après ajustement sur les facteurs de confusion, le risque de césarienne était similaire entre les 2 groupes quelle que soit l’analyse statistique effectuée, régression logistique (OR ajusté=0,76, IC95%[0,33-1,76]), appariement sur la parité et le score de Bishop (ORa=0,98 [0,40-2,40]), CEM (ORa=0,95 [0,42-2,15]), ou SP (OR=1,12 [0,52-2,37]). Les césariennes < 6 cm, hémorragie du post-partum et la morbidité néonatale étaient comparables entre les 2 groupes. Après échec d’une première maturation cervicale par Propess®, les issues obstétricales semblent identiques entre la poursuite du déclenchement par PGE2 ou l’utilisation d’emblée d’Ocytocine, quelle que soit l’analyse statistique effectuée.The best strategy to induce labor in case of persistence of an unfavorable cervix after first line of ripening is not well documented. Our objective was to analyze and compare obstetric and neonatal outcomes between different strategies after a failure of cervical ripening by dinoprostone 10 mg vaginal insert (DVI). Data source was the MEDIP prospective population-based cohort study, conducted in 94 French maternity units, during 1 month in 2015 including 3042 consecutive women undergoing induction of labor. We included women with singleton pregnancies, unscarred uterus, Bishop score < 6 at day 2 following ripening by DVI and for which the 2nd line of labor induction was either prostaglandin E2 (PGE2, 2nd DVI or dinoprostone gel) or oxytocin (±amniotomy). The primary outcome was cesarean delivery. Secondary outcomes were cesarean delivery < 6 cm, post-partum hemorrhage and composite neonatal morbidity (pH < 7.10 and/or 5-minute Apgar score < 7 and/or neonatal hospitalization). We compared outcomes among women having a 2nd line PGE2 and those having oxytocin. We performed several analyses to take into account confounders, especially parity and Bishop score : multivariate multilevel logistic regression before and after matching for parity and Bishop score, coarsened exact m! atching (CEM) and propensity score (PS) matching. Results. Among women with cervical ripening by DVI, 16.2% (n=197/1216) had a Bishop score < 6 at day 2. The 2nd line of labor induction was PGE2 for 59.9% (n=118/197) and oxytocin (±amniotomy) for 38.1% (n=75/197). Cesarean rate was 38.7% (n=29/75) in oxytocin group and 36.4% (n=43/118) in PGE2 group (p=0.76). The median Bishop score was higher in oxytocin group : 4 [IQ range=3-5] vs 3 [2-4] (p<0.001). After controlling for confounders, the risk of cesarean was similar between the 2 groups, using a logistic regression (adjusted OR=0.76, 95%CI[0.33-1.76]) as after matching for parity and Bishop score (aOR=0.98 [0.40-2.40]), or using CEM (aOR=0.95 [0.42-2.15]) or PS matching (OR=1.12 [0.52-2.37]). Cesarean delivery before 6 cm, post-partum hemorrhage and neonatal morbidity were comparable between the 2 groups. After a failure of ripening using DVI, it seems that maternal and neonatal outcomes are similar between continue ripening using a second line PGE2 or start oxytocin, whatever the statistical methods used

Etat de stress post-traumatique 2 mois après un accouchement par césarienne : une étude prospective multicentrique

International audienceBackground: The prevalence and risk factors of posttraumatic stress disorder (PTSD) after cesarean delivery, outside high-risk contexts, remain unclear.Objective: To assess posttraumatic stress disorder prevalence and risk factors at 2 months postpartum among a general population of women with cesarean delivery.Study design: Prospective ancillary cohort study of the Tranexamic Acid for Preventing Postpartum Hemorrhage after Cesarean Delivery (TRAAP2) trial, conducted in 27 French hospitals in 2018-2020 and enrolling women expected to undergo cesarean delivery before or during labor at 34 or more weeks of gestation. After randomization, characteristics of the cesarean delivery and postpartum blood loss were prospectively collected. Two months after childbirth, posttraumatic stress disorder profile (presence of PTSD symptoms) and provisional diagnosis (positive screening for diagnosis consistent with a PTSD) were assessed by 2 self-administered questionnaires (Impact of Event Scale Revised (IESR) and Traumatic of Event Scale (TES)). The corrected posttraumatic stress disorder prevalence was estimated with inverse probability weighting to take nonresponse into account. Associations between potential risk factors and posttraumatic stress disorder were analyzed by multivariate logistic or linear regression modeling according to the type of dependent variable. Results: In all, 2785 of 4431 women returned the IES-R questionnaire and 2792 the TES (response rates of 62.9% and 63.0%). The prevalence of posttraumatic stress disorder profile was 9.0% (95% confidence interval (CI) 7.8-10.3%) and of provisional diagnosis 1.7% (95%CI 1.2-2.4%). Characteristics associated with a higher risk of posttraumatic stress disorder profile were prepregnancy vulnerability factors - young age, high BMI and Africa-born migrant – and cesarean-related obstetric factors - cesarean delivery after induced labor (adjusted odds ratio [aOR] 1.81, 95%CI 1.14-2.87), postpartum hemorrhage (aOR 1.61, 95%CI 1.04-2.46) and high intensity pain during the postpartum stay (aOR 1.90, 95%CI 1.17-3.11). Women who had immediate skin-to-skin contact with their newborn were at lower risk of posttraumatic stress disorder (aOR 0.66, 95%CI 0.46-0.98), and women with bad memories of delivery on day 2 postpartum at higher risk (aOR 3.20, 95%CI 1.97-5.12). The IES-R and the TES scales yielded consistent results. Conclusions: Around one in 11 women with cesarean deliveries had posttraumatic stress disorder symptoms at 2 months postpartum. Some obstetric interventions and components of cesarean management may influence this risk

Pelvic Floor Disorders 6 Months after Attempted Operative Vaginal Delivery According to the Fetal Head Station: A Prospective Cohort Study.

To evaluate the effect of the fetal head station at attempted operative vaginal delivery (aOVD), and specifically midpelvic or low aOVD, on urinary incontinence (UI), anal incontinence (AI), and perineal pain at 6 months.Prospective cohort study.1941 women with singleton term fetuses in vertex presentation with midpelvic or low aOVD between 2008 and 2013 in a tertiary care university hospital.Symptoms of urinary incontinence (UI) using the Bristol Female Lower Urinary Tract Symptoms questionnaire, and symptoms of anal incontinence (AI) severity using Fecal Incontinence Severity Index (FISI) were assessed 6 months after aOVD. We measured the association between midpelvic or low aOVD and symptoms of UI, AI, and perineal pain at 6 months using multiple regression and adjusting for demographics, and risk factors of UI and AI, with adjusted odds ratios (aORs) and 95% confidence intervals (95% CI).The study included 907 women (46.7%) who responded to the questionnaire; 18.4% (167/907) had midpelvic aOVD, and 81.6% (740/907) low; and none of women with symptoms of UI (26.6%, and 22.4%, respectively; p = 0.31), AI (15.9%, and 21.8%; p = 0.09), the FISI score, and perineal pain (17.2%, and 12.7%; p = 0.14) differed significantly between groups. The same was true for stress, urge, and mixed-type UI, severe UI and difficulty voiding. Compared with low pelvic aOVD, the aORs for symptoms of UI in midpelvic aOVD were 0.70 (0.46-1.05) and AI 1.42 (0.85-2.39). Third- and fourth-degree tears were a major risk factor of symptoms of UI (aOR 3.08, 95% CI 1.35-7.00) and AI (aOR 3.47, 95% CI 1.43-8.39).Neither symptoms of urinary nor anal incontinence differed at 6 months among women who had midpelvic and low pelvic aOVD. These findings are reassuring and need further studies at long-term to confirm these short-term data

Br J Anaesth

BACKGROUND: Prophylactic administration of tranexamic acid is associated with a reduction of blood loss after Caesarean delivery, but cost-effectiveness for this indication has not been assessed. METHODS: We used data from the TRAAP2 trial, a multicentre, double-blinded, RCT aimed at estimating the efficacy of tranexamic acid for preventing postpartum haemorrhage among women undergoing Caesarean delivery. Women recruited at 27 French maternity hospitals from 2018 to 2020 were enrolled before the procedure if they had a Caesarean delivery before or during labour at 34 or more weeks of gestation. The main outcomes were the cost of hospital stay for delivery and the incremental cost per delivery without complication within 90 days after delivery with tranexamic acid compared with placebo. Differences in costs and the incremental net monetary benefit (INMB) were estimated using linear regression models, and the cost-effectiveness probability of tranexamic acid compared with placebo was estimated through the parametric distribution of the INMB. RESULTS: The proportion of women without complications at day 90 was 70.7% in the tranexamic acid group and 66.0% in the placebo group. Mean total costs until occurrence of a complication of interest were €3321 in the tranexamic acid group and €3260 in the placebo group, resulting in a difference between the two groups of 7.2% and €55 after multiple imputation. The adjusted incremental cost-effectiveness ratio was €762 per additional Caesarean delivery without a complication at 90 days after delivery. At a cost-effectiveness threshold of €10,000, the cost-effectiveness probability of tranexamic acid compared with placebo was 99.9%, varying from 5.8% to 100.0% for thresholds from €0 to €10,000 per additional delivery without a complication at day 90. CONCLUSION: Tranexamic acid for the prevention of blood loss is cost-effective in reducing complications after Caesarean delivery at day 90 postpartum. However, the effect size (in cost and effectiveness) is very low. CLINICAL TRIAL REGISTRATION: NCT03431805

Jama Surg

IMPORTANCE The stereotype that men perform surgery better than women is ancient. Surgeons have long been mainly men, but in recent decades an inversion has begun; the number of women surgeons is increasing, especially in obstetrics and gynecology. Studies outside obstetrics suggest that postoperative morbidity and mortality may be lower after surgery by women.OBJECTIVE To evaluate the association between surgeons' gender and the risks of maternal morbidity and postpartum hemorrhage (PPH) after cesarean deliveries. DESIGN, SETTING, AND PARTICIPANTS This prospective cohort study was based on data from the Tranexamic Acid for Preventing Postpartum Hemorrhage after Cesarean Delivery (TRAAP2) trial, a multicenter, randomized, placebo-controlled trial that took place from March 2018 through January 2020 (23 months). It aimed to investigate whether the administration of tranexamic acid plus a prophylactic uterotonic agent decreased PPH incidence after cesarean delivery compared with a uterotonic agent alone. Women having a cesarean delivery before or during labor at or after 34 weeks' gestation were recruited from 27 French maternity hospitals.EXPOSURES Self-reported gender (man or woman), assessed by a questionnaire immediately after delivery.MAIN OUTCOMES AND MEASURES The primary end point was the incidence of a composite maternal morbidity variable, and the secondary end point was the incidence of PPH (the primary outcome of the TRAAP2 trial), defined by a calculated estimated blood loss exceeding 1000 mL or transfusion by day 2.RESULTS Among 4244 women included, men surgeons performed 943 cesarean deliveries (22.2%) and women surgeons performed 3301(77.8%). The rate of attending obstetricians was higher among men (441 of 929 [47.5%]) than women (687 of 3239 [21.2%]). The risk of maternal morbidity did not differ for men and women surgeons: 119 of 837 (14.2%) vs 476 of 2928 (16.3%) (adjusted risk ratio, 0.92 [95% CI, 0.77-1.13]). Interaction between surgeon gender and level of experience on the risk of maternal morbidity was not statistically significant. Similarly, the groups did not differ for PPH risk (adjusted risk ratio, 0.98 [95% CI, 0.85-1.13]).CONCLUSIONS AND RELEVANCE Risks of postoperative maternal morbidity and of PPH exceeding 1000 mL or requiring transfusion by day 2 did not differ by the surgeon's gender

Surgical treatment of postpartum haemorrhage: national survey of French residents of obstetrics and gynecology

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

Sexual function and postpartum depression 6 months after attempted operative vaginal delivery according to fetal head station: A prospective population-based cohort study

<div><p>Objective</p><p>To evaluate the effect of the fetal head station at attempted operative vaginal delivery (aOVD), and specifically midpelvic or low aOVD, on female and male sexual function and symptoms of postpartum depression (PPD) at 6 months.</p><p>Design</p><p>Prospective population-based cohort study.</p><p>Setting</p><p>1,941 women with singleton term fetuses in vertex presentation with midpelvic or low aOVD between 2008 and 2013 in a tertiary care university hospital.</p><p>Methods</p><p>Symptoms of female sexual dysfunction using the Pelvic Organ Prolapse/Urinary Incontinence/Sexual Function Short Form Questionnaire (PISQ-12), symptoms of PPD using the Edinburgh Postnatal Depression Scale (EPDS) score, symptoms of male sexual dysfunction using the International Index of Erectile Function (IIEF-15) and perineal pain were assessed 6 months after aOVD. We measured the association between midpelvic or low aOVD and symptoms of female and male sexual function and symptoms of PPD at 6 months using multiple regression and adjusting for demographics, and risk factors of sexual dysfunction, symptoms of PPD and perineal pain with adjusted odds ratios (aORs) and 95% confidence intervals (95% CI).</p><p>Results</p><p>The study included 907 women (46.7%) who responded to the questionnaire; 18.4% (167/907) had midpelvic aOVD, and 81.6% (740/907) low. Most women (873/907 [96.3%]) of those with partners reported sexual activity at 6 months. No significant difference was observed for PISQ-12, EPDS, IIEF-15 scores and perineal pain between mid and low pelvic groups. Compared with low pelvic aOVD, midpelvic aOVD was not significantly associated with either female or male sexual dysfunction (p = 0.89 and p = 0.76, respectively), or maternal symptoms of PPD (p = 0.83). Perineal pain significantly increased the risk of male and female sexual dysfunction and maternal symptoms of PPD at 6 months (p = 0.02, p = 0.006, and p = 0.02, respectively).</p><p>Conclusion</p><p>Midpelvic compared with low pelvic aOVD was not associated with an increase in sexual dysfunction, nor with symptoms of PPD at 6 months.</p></div

Characteristics of mothers and their labor and maternal and neonatal outcomes in respondents, according to the ACOG classification.

<p>Characteristics of mothers and their labor and maternal and neonatal outcomes in respondents, according to the ACOG classification.</p

Cohort flowchart.

<p>Cohort flowchart.</p

Univariate and multiple linear regression analysis of female sexual function 6 months after midpelvic and low attempted operative vaginal delivery.

<p>Univariate and multiple linear regression analysis of female sexual function 6 months after midpelvic and low attempted operative vaginal delivery.</p