Immediate postpartum haemorrhage : Visual estimates of blood loss by midwives and student midwives and Prevalences of psychological disorders after immediate postpartum haemorrhage : PSYCHE study

Objectifs : Les objectifs de notre travail étaient d’une part d'évaluer la précision des estimations visuelles des pertes sanguines (EVPS) par les sages-femmes et les étudiants sage-femme (Volet 1) et d’autre part d’évaluer les conséquences psychologiques maternelles après une hémorragie du post-partum immédiat (HPP) (Volet 2). Volet 1 : Nous avons réalisé une étude transversale multicentrique (n=16 656). Les étudiants en maïeutique et les sages-femmes françaises devaient estimer via un questionnaire en ligne 8 photographies de volume de pertes sanguines différentes. Chaque photographie était dupliquée et distribuée aléatoirement dans le questionnaire avec une mesure étalon de 50 mL. Nous avons observé que le pourcentage global d’estimation exacte du volume des pertes proposé était faible dans les deux groupes de répondants (34,1%). Le seuil de l’HPP a toujours été diagnostiqué avec succès mais identifié dans moins de la moitié des cas pour l’HPP sévère. L’accord intra-observateur était plus fort (kappa pondéré ≥ 0,8) pour les valeurs les plus élevées (1 000 ml et 1 500 ml). Les sages-femmes avaient tendance à sous-estimer la quantité de perte de sang mais dans une moindre mesure que les étudiants. Indépendamment de la catégorie de répondant ou du diagnostic (HPP ou HPP sévère), la spécificité de l’EVPS en tant que test diagnostic était supérieure à sa sensibilité. Volet 2 : Notre second volet était une étude monocentrique transversale répétée descriptive et à visée étiologique sur une cohorte de femmes ayant accouché au CHU de Clermont-Ferrand [n= 1 298 ; 528 femmes avec une HPP = exposées (GE) et 770 femmes sans HPP = non exposées (GNE)]. La prévalence de la dépression chez les femmes après une HPP immédiat (< 24 heures) est évaluée à M2, M6 et M12 du post-partum via le questionnaire l’EPDS. L’anxiété est évaluée aux mêmes périodes avec les questionnaires STAI-YA et le GAD-7 et le trouble de stress post-traumatique (TSPT) via l’IES-R. Tous les questionnaires étaient auto-renseignés. La participation globale des femmes à M2 était de 63,7% (GE: 63% et GNE : 64,1%). Nous avons retrouvé des prévalences chez les exposées de 24,1% pour la DPP (vs. GNE : 18,3%), 20,4 % d’anxiété (vs. GNE : 13,4%) et 12,9% de TSPT (vs. GNE : 7,8%). Après ajustement, seul le risque d’avoir un TSPT à M2 restait significativement augmenté chez les femmes ayant eu une HPP (ORa=2,11 ; IC95% : 1,11-4,00). Les analyses à M6 et M12 seront réalisées lorsque le suivi de toutes les femmes sera terminé. Conclusion : Volet 1 : Les étudiants en maïeutique avaient tendance à sous-estimer la quantité de perte de sang plus souvent que les sages-femmes malgré l’aide d’une mesure étalon. L’HPP (≥ 500 ml) a toujours été identifiée mais la sévérité (≥ 1 000 ml) dans moins de la moitié des cas. La difficulté de l’EVPS doit être soulignée lors de la formation initiale des étudiants et lors de la formation continue des professionnels.Volet 2 : La DPP, l’anxiété et le TSPT sont fréquents dans le post-partum y compris parmi les femmes n’ayant pas eu d’HPP. La survenue d’un TSPT est à surveiller à M2 chez les femmes ayant une HPP. Il est important de repérer ces troubles chez toutes les femmes en post-partum afin de mettre en place un suivi adapté et individualisé et ainsi favoriser le lien mère-enfant.Objectives: The objectives were to assess the accuracy of visual estimates of blood loss (EVPS) by midwives and midwifery students (Part 1) and secondly to assess the psychological consequences after postpartum haemorrhage (PPH) (Part 2). Part 1: We performed a multicenter cross-sectional study (n = 16,656). French practicing midwives and midwifery students were asked to estimate eight photographs of the volume of blood loss via online survey. Each photograph was duplicated and randomly ordered in the questionnaire with a reference 50 mL. We observed that the overall percentage of exact estimates of the volume of losses proposed was low in both groups of respondents (34.1%). PPH threshold was always successfully diagnosed but identified in less than half of the cases for severe PPH. Intra-observer agreement was better for the extreme values (100 mL and 1500 mL) with higher agreement (weighted kappa ≥ 0.8) for the highest values (1000 mL and 1500 mL). Midwives tended to underestimate the amount of blood loss but to a lesser extent than students. Regardless of respondent category or diagnosis (HPP or severe PPH), the specificity of the EVPS as a diagnostic test was greater than its sensitivity. Part 2: Our second component was a monocentric cross-sectional descriptive and etiologically oriented study on a cohort of women who gave birth at Clermont-Ferrand University Hospital [n = 1298; 528 women with HPP = exposed (GE) and 770 women without HPP = unexposed (GNE)]. The prevalence of depression in women after immediate PPH (<24 hours) was assessed at postpartum M2, M6 and M12 using the EPDS questionnaire. Anxiety was assessed at the same time with the STAI-YA and GAD-7 questionnaires and post-traumatic stress disorder (PTSD) via the IES-R. All questionnaires were self-reported. The overall participation of women at M2 was 63,7% (GE: 63% and GNE: 64,1%). We found prevalences in exposed patients of 24,1% for DPP (vs. GNE: 18,3%), 20,4% anxiety (vs. GNE: 13,4%) and 12,9% TSPT (vs. GNE: 7,8%). After adjustment, only the risk of having PTSD at M2 remained significantly increased in women who had PPH (ORa = 2,11, 95% CI: 1,14-4,00). Analyzes at M6 and M12 will be carried out when the follow-up is completed. Conclusion: Part 1: Students midwives tended to underestimate the amount of blood loss more often than midwives despite using a standard measure. HPP (≥ 500 ml) was always identified but severe PPH (≥ 1000 ml) was identified in less than half of the cases. The difficulty of the EVPS must be emphasized during the initial training of the students and during professional’s trainings. Part 2: DPP, anxiety, and PTSD are common in the postpartum period including women who have not had PPH. The occurrence of PTSD is to be monitored at M2 in women with PPH. It is important to identify these disorders in all postpartum women in order to implement adapted and individualized follow-up of these women and thus to promote the mother-child bond

VARIATION OF DELTA HEMOGLOBIN BEFORE AND AFTER VAGINAL DELIVERY WITH AN IMMEDIATE POST-PARTUM HEMORRHAGE: A FRENCH PROSPECTIVE MULTICENTRE COHORT STUDY - HERA STUDY

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Change in Hemoglobin Was Not a Reliable Diagnostic Screening Test for Postpartum Hemorrhage: A French Prospective Multicenter Cohort Study (HERA Study)

International audienceChanges between pre- and postpartum hemoglobin might be useful for optimizing the postpartum diagnosis of postpartum hemorrhage (PPH), defined as a blood loss exceeding 500 mL. This study’s principal objective was to estimate the mean change in hemoglobin (between pre/post-delivery hemoglobin) among women with vaginal deliveries and PPH. The secondary objectives were to analyze: hemoglobin changes according to blood volume loss, the appropriateness of standard thresholds for assessing hemoglobin loss, and the intrinsic and extrinsic performances of these threshold values for identifying PPH. French maternity units (n = 182) participated in the prospective HERA cohort study. Women with a vaginal delivery at or after a gestation of 22 weeks with a PPH (n = 2964) were eligible. The principal outcome was hemoglobin loss in g/L. The mean hemoglobin change was 30 ± 14 g/L among women with a PPH. Overall, hemoglobin decreased by at least 10% in 90.4% of women with PPH. Decreases ≥ 20 g/L and ≥40 g/L were found, respectively, in 73.9% and 23.7% of cases. Sensitivity and specificity values for identifying PPH were always <65%, the positive predictive values were between 35% and 94%, and the negative predictive values were between 14% and 84%. Hemoglobin decrease from before to after delivery should not be used as a PPH diagnostic screening test for PPH diagnosis for all vaginal deliveries

Prevalence of maternal psychological disorders after immediate postpartum haemorrhage: a repeated cross-sectional study - the PSYCHE* study protoco

Introduction The main objective of this study is to assess the prevalence of depression at 2, 6 and 12 months postpartum in women who have had an immediate postpartum haemorrhage (PPH) (blood loss ≥500 mL within 24 hours of delivery). The secondary objectives are to assess the prevalence of anxiety and post-traumatic stress disorder among these women and to evaluate the prevalence of psychological disorders according to the severity of the PPH. Methods and analysis This repeated, cross-sectional, single-centre study will take place at the Clermont-Ferrand University Hospital (France). The population will comprise a cohort of women giving birth at a term ≥22 weeks of gestation. For each woman with a PPH (exposed), two women without PPH (unexposed) will be included: the women who give birth immediately before and immediately after her. The PPH will be managed according to French guidelines. The principal endpoint is the prevalence of depression, measured by the Edinburgh Postnatal Depression Scale (EPDS). The intervention will consist of four surveys including various self-completed questionnaires: the first during the immediate postpartum (Post-Delivery Perceived Stress Inventory (PDPSI), Spielberger'sState-Trait Anxiety Inventory (STAI)-Y-A and Y-B and Mini-International Neuropsychiatric Interview (M.I.N.I.) 5.0.0), then at 2 months (EPDS, STAI-Y-A, Generalised Anxiety Disorder (GAD-7) and Revised Impact of Event Scale (IES-R)), and finally at 6 months and 1 year postpartum (EPDS, STAI-Y-A, GAD-7, M.I.N.I. 5.0.0 and IES-R). The study will include 1542 women — 514 with PPH. Ethics and dissemination The institutional review board (IRB) approved the study on 14 February 2017 (IRB Sud Est VI: N°AU1243). Results will be reported in peer-reviewed journals and at scientific meetings. Findings from the study will be useful for individualising medical follow-up after childbirth, especially for woman who experienced a PPH, but also more generally in increasing birth professionals' awareness of effects of trauma. The evidence obtained might also lead to modifying practices and including this recommendation in French guidelines on PPH. Trial registration number NCT03120208

Opti’care protocol: a randomised control trial to evaluate the impact of a mobile antenatal care clinic in isolated rural areas on prenatal follow-up

International audienceIntroduction Rural residence appears to be a factor of vulnerability among pregnant women with poor clinical antenatal care. Our principal objective is to assess the impact of an infrastructure for a mobile antenatal care clinic on the completion of antenatal care for women identified as geographically vulnerable in a perinatal network. Methods and analysis Controlled cluster-randomised study in two parallel arms comparing an intervention group with an open-label control group. This study will concern the population of pregnant women who must live in one of the municipalities covered by the perinatal network and considered to be an area of geographic vulnerability. The cluster randomisation will take place according to the municipality of residence. The intervention will be the implementation of pregnancy monitoring by a mobile antenatal care clinic. The completion of antenatal care between the intervention and control groups will be a binary criterion: 1 will be attributed to each antenatal care that includes all visits and supplementary examinations. Sample size has been estimated to be 330 at least with an 80% participation rate. The univariate analyses will compare the follow-up rates (with Fisher’s exact test), and all individual characteristics collected (Fisher’s exact test, Student’s t-test) between the two groups. The multivariate analysis will use a mixed linear model analysis and consider the cluster effect as random; the initial model will include known confounders from the literature, confounders identified in univariate analyses, and the clinically relevant prognostic factors. All of these factors will be taken into account in the model as a fixed effect. Ethics and dissemination The Patient Protection Committee North-West II approved this study on 4 February 2021 (IRB 2020-A02247-32). The results will be the subject of scientific communications and publications. Trial registration number NCT04823104

Do estimates of blood loss differ between student midwives and midwives? A multicenter cross-sectional study

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Conservative management or cesarean hysterectomy for placenta accreta spectrum: the PACCRETA prospective study

BackgroundPlacenta accreta spectrum is a life-threatening condition that has increased dramatically in recent decades along with cesarean rates worldwide. Cesarean hysterectomy is widely practiced in women with placenta accreta spectrum; however, the maternal outcomes after cesarean hysterectomy have not been thoroughly compared with the maternal outcomes after alternative approaches, such as conservative management.ObjectiveThis study aimed to compare the severe maternal outcomes between women with placenta accreta spectrum treated with cesarean hysterectomy and those treated with conservative management (leaving the placenta in situ).Study DesignFrom a source population of 520,114 deliveries in 176 hospitals (PACCRETA study), we designed an observational cohort of women with placenta accreta spectrum who had either a cesarean hysterectomy or a conservative management (the placenta left in situ) during cesarean delivery. Clinicians prospectively identified women meeting the inclusion criteria and included them at delivery. Data collection started only after the women had received information and agreed to participate in the study in the immediate postpartum period. The primary outcome was the transfusion of >4 units of packed red blood cells within 6 months after delivery. Secondary outcomes were other maternal complications within 6 months. We used propensity score weighting to account for potential indication bias.ResultsHere, 86 women had conservative management and 62 women had cesarean hysterectomy for placenta accreta spectrum during cesarean delivery. The primary outcome occurred in 14 of 86 women in the conservative management group (16.3%) and 36 of 61 (59.0%) in the cesarean hysterectomy group (risk ratio in propensity score weighted model, 0.29; 95% confidence interval, 0.19–0.45). The rates of hysterectomy, total estimated blood loss exceeding 3000 mL, any blood product transfusion, adjacent organ injury, and nonpostpartum hemorrhage-related severe maternal morbidity were lower with conservative management than with cesarean hysterectomy (all adjusted, P≤.02); but, the rates of arterial embolization, endometritis, and readmission within 6 months of discharge were higher with conservative management than with cesarean hysterectomy.ConclusionAmong women with placenta accreta spectrum who underwent cesarean delivery, conservative management was associated with a lower risk of transfusion of >4 units of packed red blood cells within 6 months than cesarean hysterectomy