FIGO consensus guidelines on placenta accreta spectrum disorders : Conservative management

Peer reviewe

Placenta accreta spectrum - variations in clinical practice and maternal morbidity between UK and France : a population-based comparative study

SM’s DPhil was funded by the Medical Research Council. PACCRETA was funded by PACCRETA was funded by the French Health Ministry under its Clinical Research Hospital Program (grant number: AOR12156) and by the Angers University Hospital.Peer reviewedPublisher PD

Int J Environ Res Public Health

BACKGROUND: Female surgeons are exposed to physical and mental stressors that differ from those of other specialties. We aimed to assess whether female surgeons are more at risk of pregnancy complications than women in other medical specialties. METHODS: We used a cross-sectional electronic survey of female physicians working in the French Region Nouvelle-Aquitaine who were pregnant between 2013 and 2018. A pregnancy complication was defined as the occurrence of miscarriage, ectopic pregnancy, fetal growth restriction, prematurity, fetal congenital malformation, stillbirth, or medical termination of the pregnancy. Multivariate logistic regression models were used to evaluate the risk of pregnancy complications for female surgeons relative to women practicing in other medical specialties. RESULTS: Among the 270 women included, 52 (19.3%) experienced pregnancy complications and 28 (10.4%) were surgeons. In the multivariate analysis, female surgeons had a higher risk of pregnancy complications: adjusted odds ratio = 3.53, 95% confidence interval [1.27-9.84]. CONCLUSION: Further research is necessary to identify the hazards specifically involved in the practice of surgery to be able to propose preventive actions targeted to female surgeons during their pregnancy

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

Effect of routine controlled cord traction as part of the active management of the third stage of labour on postpartum haemorrhage: multicentre randomised controlled trial (TRACOR).

International audienceOBJECTIVE: To assess the impact of controlled cord traction on the incidence of postpartum haemorrhage and other characteristics of the third stage of labour in a high resource setting. DESIGN: Randomised controlled trial. SETTING: Five university hospital maternity units in France. PARTICIPANTS: Women aged 18 or more with a singleton fetus at 35 or more weeks' gestation and planned vaginal delivery. INTERVENTIONS: Women were randomly assigned to management of the third stage of labour by controlled cord traction or standard placenta expulsion (awaiting spontaneous placental separation before facilitating expulsion). Women in both arms received prophylactic oxytocin just after birth. MAIN OUTCOME MEASURE: Incidence of postpartum haemorrhage ≥500 mL as measured in a collector bag. RESULTS: The incidence of postpartum haemorrhage did not differ between the controlled cord traction arm (9.8%, 196/2005) and standard placenta expulsion arm (10.3%, 206/2008): relative risk 0.95 (95% confidence interval 0.79 to 1.15). The need for manual removal of the placenta was significantly less frequent in the controlled cord traction arm (4.2%, 85/2033) compared with the standard placenta expulsion arm (6.1%, 123/2024): relative risk 0.69, 0.53 to 0.90); as was third stage of labour of more than 15 minutes (4.5%, 91/2030 and 14.3%, 289/2020, respectively): relative risk 0.31, 0.25 to 0.39. Women in the controlled cord traction arm reported a significantly lower intensity of pain and discomfort during the third stage than those in the standard placenta expulsion arm. No uterine inversion occurred in either arm. CONCLUSIONS: In a high resource setting, the use of controlled cord traction for the management of placenta expulsion had no significant effect on the incidence of postpartum haemorrhage and other markers of postpartum blood loss. Evidence to recommend routine controlled cord traction for the management of placenta expulsion to prevent postpartum haemorrhage is therefore lacking. TRIAL REGISTRATION: ClinicalTrials.gov NCT01044082

Occupational Exposure to Ultrafine Particles and Placental Histopathological Lesions: A Retrospective Study about 130 Cases

International audienceUltrafine particles (UFPs) are particles smaller than 100 nanometers that are produced unintentionally during human activities or natural phenomena. They have a higher biological reactivity than bigger particles and can reach the placenta after maternal exposure. One study has shown an association between maternal occupational exposure to UFPs and fetal growth restriction. Yet few studies have focused on the effects of UFP exposure on placental histopathological lesions. The aim of this study was to investigate the association between maternal occupational exposure to UFPs and histopathological lesions of their placenta. The analyses were based on data from the ARTEMIS Center. A job-exposure matrix was used to assess occupational exposure to UFPs. The histopathological placental exam was performed by two pathologists who were blinded to the exposure of each subject. The examination was conducted in accordance with the recommendations of the Amsterdam consensus. The study sample included 130 placentas (30 exposed, 100 unexposed). Maternal occupational exposure to UFPs during pregnancy is significantly associated with placental hypoplasia (the phenomenon affected 61% of the exposed patients and 34% of the unexposed ones, p < 0.01). Further research is needed to explain its pathophysiological mechanisms