Global implications of evidence ‘biased’ practice: management of the third stage of labour

Increasing attention is being paid to the promotion of clinical and cost-effective care informed by the highest level of evidence to ensure health outcomes are optimised and access to health care is equitable. There are obvious advantages to these approaches, including increased awareness of the importance of rigorous methodology when conducting primary and secondary research, utilising methods which are systematic, robust, transparent and explicit. Evidence-based practice was introduced to replace the traditional approach of ‘this is how we have always done it’ as an underpinning for clinical practice. Ironically, however, the transition has not been straightforward and there have been criticisms of the way ‘evidence’ to support some areas of practice is perceived and applied in clinical settings. Anecdotally and based on personal experience, there are two main criticisms: 1. Acceptance of evidence without critique: Too much faith (or blind faith) in the process by which ‘evidence’ (authoritative or systematic) is produced. 2. Lack of holistic insight in the application of evidence: Employing ‘one size fits all’ policies ignoring individual needs for required care in conveyor-like processed care provision. To explore these criticisms, the example of management of the third stage of labour is used.</p

Anaphylaxis in pregnancy : a population-based multinational European study

Anaphylaxis in pregnancy is a rare but severe complication for both mother and infant. Population-based data on anaphylaxis in pregnancy are lacking from mainland European countries. This multinational study presents the incidence, causative agents, management and maternal and infant outcomes of anaphylaxis in pregnancy. This descriptive multinational study used a combination of retrospective (Finnish medical registries) and prospective population-based studies (UK, France, Belgium and the Netherlands) to identify cases of anaphylaxis. Sixty-five cases were identified among 4,446,120 maternities (1.5 per 100,000 maternities; 95%CI 1.1-1.9). The incidence did not vary between countries. Approximately three-quarters of reactions occurred at the time of delivery. The most common causes were antibiotics in 27 women (43%), and anaesthetic agents in 11 women (17%; including neuromuscular blocking drugs, 7), which varied between countries. Anaphylaxis had very poor outcomes for one in seven mothers and one in seven babies; the maternal case fatality rate was 3.2% (95%CI 0.4-11.0) and the neonatal encephalopathy rate was 14.3% (95%CI 4.8-30.3). Across Europe, anaphylaxis related to pregnancy is rare despite having a multitude of causative agents and different antibiotic prophylaxis protocols.Peer reviewe

Maternal mortality in the context of political free health care on pregnancy and birth to the Treichville teaching hospital, Abidjan-Côte d’Ivoire

Background: Maternal mortality continues to be a drama in the countries of Sub Saharan Africa. Despite the efforts of the world through the millennium development goals (MDGs) 5 and 6, the situation remains very worrying in this region. If in developed countries, maternal mortality is an indicator of the quality of obstetric care, for poor countries, it is an indicator of social and economic development.Methods: Our study was designed to assess the impact of free support of pregnancy and childbirth on maternal mortality at treichville teaching hospital in Abidjan. We conducted a retrospective descriptive study of deaths of our service over the period September 2012 to August 2013 taking into account the hospital data.Results: During this period, we recorded 32 deaths per 3173 live births. Eight out of ten patients were younger than 35 years. And half had no education. 93.75% of patients were evacuated to another structure and more than half of the deaths occurred less than two hours after admission to our service. Bleeding causes dominate with 37.50% of postpartum haemorrhage.Conclusions: Maternal death rates in our service remain high despite the policy of free care and factors of this mortality remain unchanged for decades

Nouvelle approche des fibroses par microscopie multiphotonique avec génération de second harmonique [New approach of fibrosis by multiphoton microscopy with second harmonic generation]

La fibrose est une réponse adaptative pathologique qui détruit non spécifiquement les tissus. Il s'agit d'un processus universel de réparation des tissus qui survient en réaction à de nombreux types d'agressions telles les contraintes mécaniques, les brûlures, les radiations ionisantes, l'ischémie, l'inflammation. Ces agressions concourent de manière intriquée à la physiopathologie des maladies infectieuses, tumorales ou auto-immunes, de l'hypertension artérielle et des maladies cardio-vasculaires. Le terme de fibrose décrit précisément l'accumulation nouvelle de protéines de la matrice extra-cellulaire selon un arrangement spatial fibrillaire caractéristique. Il s'agit essentiellement de molécules de collagènes de type I et III (voire de type II, V ou XI) synthétisées sous forme de triples hélices elles-mêmes assemblées en fibrilles par les cellules fibroblastiques. L'apparition des collagènes fibrillaires marque un changement qualitatif et quantitatif de composition des collagènes des tissus. Réciproquement, ces changements de la matrice extracellulaire influencent le phénotype des cellules qui y résident. Ainsi dans le rein normal, le collagène de type I n'existe que dans l'adventice artériel. Son apparition au sein des autres structures de cet organe marque une fibrose tubulo-interstitielle qui constitue le meilleur marqueur pronostic défavorable d'une évolution vers l'insuffisance rénale terminale, et ce quelle que soit la maladie causale. Ainsi, comme lors des fibroses compliquant les hépatopathies et les pneumopathies chroniques, les séquelles de brûlures ou d'abrasions cutanées-muqueuses ou encore le remodelage cardiaque et vasculaire, le réarrangement de la géométrie de la matrice extracellulaire altère l'organisation fonctionnelle du tissu considéré. De ce fait, ce processus de réparation a des effets fonctionnels délétères qui constituent un enjeu médical majeur. Les fibrilles de collagène ont des capacités d'auto-assemblage qui sont aussi catalysées et stabilisées ou au contraire empêchées par les enzymes de la matrice extracellulaire. Le développement de la fibrose ou sa régression dépend donc ainsi du bilan des équilibres biologiques de ces mécanismes. Il est donc crucial de caractériser les changements extracellulaires et cellulaires qui font du restutio ad integrum de l'architecture et de la fonction tissulaire un défi biomédical

Anaphylaxis in pregnancy : a population-based multinational European study

Funding Information: M‐P B, OA, and GV had equal contributions to this study. We thank T. Schapp, J. Zwart and E. Overtoom in the NethOSS team; C. Daoui from the French SFAR Research Network; the B.OSS team and Belgian maternity units involved in this study. The work was funded by the Medical Research Council (MRC) and the Nuffield Department of Population Health. The views expressed in this publication are those of the authors and not necessarily those of the MRC. The funders had no role in the study design, data collection and analysis, decision to publish or preparation of the article. Permission for the use and sharing of registry and medical records was obtained from the National Institute for Health and Welfare (THL), Finland. Approval was acquired from the B.OSS and NethOSS steering committee for the data collection and sharing of anonymous data for this anaphylaxis study. The French Data Protection Authority approved the collection of the data (CNIL 1985389). All the women in France were informed of anonymised data collection during the study. B.oSS gained approval for data collection from the Ghent University Ethics Committee as central EC (2015/1470, amendment 23/06/2016, B670201526875), and gained informed consent of all women included in the study. The Central University Research Ethics Committee, University of Oxford gave approval to complete this prospective observational study (Reference R46400/RE001). Data sharing statement: Data cannot be shared publicly due to confidentiality issues arising from small numbers of cases in mainland European countries. Requests for access to the UK dataset will be considered by the National Perinatal Epidemiology Unit Data Sharing committee. Access to the data can be requested from [email protected] . No other external funding or competing interests declared. Publisher Copyright: © 2020 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists Copyright: Copyright 2020 Elsevier B.V., All rights reserved.Peer reviewedPublisher PD