Introduction En France, l’organisation des soins périnataux et son impact sur la morbi-mortalité des nouveau-nés à bas risque suscitent des interrogations. Cette étude évalue la capacité du Système nationale des données de santé (SNDS) à identifier ces naissances à bas risque telles que définies par la Joint Commission pour l’indicateur de qualité « Complications inattendues chez les nouveau-nés à terme ». Méthodes Les séjours d’accouchement des mères, de naissance des nouveau-nés, d’hospitalisation néonatale en cas de transfert, ainsi que les certificats de décès néonatal ont été chainés (1,2) pour toutes les naissances vivantes en France métropolitaine en 2015-2016 et 2020-2021(N=2893399). Les critères d’exclusion étaient : naissances extrahospitalières, multiples, prématurées, poids<2500 g, anomalies congénitales, autre affections fœtales, exposition à des substances. Résultats 80,8% des naissances vivantes étaient classées à bas risque : 86,9% en type 1, 83,1% en type 2a, 81,4% en type 2b et 73,1% en type 3, avec une variabilité marquée (55,5–97,2 % en type 1, 53,0-93,5% en type 2a, 54,3-90,1% en type 2b, et 54,0-86,0% en type 3). Plus de 99% des exclusions étaient identifiées lors du séjour naissance.Parmi les 8170 décès néonatals, 9,6% concernaient des nouveau-nés à bas risque. Chez ces derniers, 79,3% des critères d’exclusions étaient identifiés lors du séjour naissance; les autres n’apparaissaient qu’après transfert ou sur les certificats de décès, particulièrement pour les enfants nés en types 1 et 2a. Discussion/Conclusion La forte hétérogénéité du taux de naissances classées à bas risque entre maternités souligne la nécessité d’améliorer le codage et la sélection de la population et avant toute comparaison de morbi-mortalité. L’intégration de l’ensemble des hospitalisations et certificats de décès est essentielle, car une documentation incomplète peut fausser les taux de morbi-mortalité, notamment dans les maternités de niveau inférieur où transferts et anomalies non détectées sont plus fréquents.
[This corrects the article DOI: 10.3389/fped.2023.1198016.].
Objectives:Among women with severe PPH (sPPH) in France and the Netherlands, we compared incidence of adverse maternal outcome (major obstetric hemorrhage (≥2.5L blood loss) and/or hysterectomy and/or mortality) by mode of delivery. Second, we compared use and timing of resuscitation and transfusion management, second-line uterotonics and uterine-sparing interventions (intra-uterine tamponade, compression sutures, vascular ligation, arterial embolization) by mode of delivery.Methods:Secondary analysis of two population-based studies of women with sPPH in France and the Netherlands. Women were selected by a harmonized definition for sPPH: (total blood loss ≥ 1500 ml) AND (blood transfusion of ≥ 4 units packed red blood cells and/or multicomponent blood transfusion).Findings:Incidence of adverse maternal outcome after vaginal birth was 793/1002, 9.1 % in the Netherlands versus 88/214, 41.1 % in France and 259/342, 76.2% versus 160/270, 59.3% after cesarean. Hemostatic agents such as fibrinogen were administered less frequently (p < 0.001) in the Netherlands (vaginal birth: 83/1002, 8.3% versus 105/2014, 49.5% in France; cesarean: 47/342, 13.7% and 152/270, 55.6%). Second-line uterotonics were started significantly later after PPH-onset in the Netherlands than France (vaginal birth: 46 versus 25 min; cesarean: 45 versus 18 min). Uterine-sparing interventions were less frequently (p < 0.001) applied in the Netherlands after vaginal birth (394/1002,39.3 %, 134/214, 62.6%) and cesarean (133/342, 38.9 % and 155/270, 57.4%), all initiated later after onset of refractory PPH in the Netherlands.Interpretation:Incidence of adverse maternal outcome was higher among women with sPPH in the Netherlands than France regardless mode of birth. Possible explanatory mechanisms are earlier and more frequent use of second-line uterotonics and uterine-sparing interventions in France compared to the Netherlands.
OBJECTIVE:To compare guidelines from eight high-income countries on prevention and management of postpartum haemorrhage (PPH), with a particular focus on severe PPH.DESIGN:Comparative study.SETTING:High-resource countries.POPULATION:Women with PPH.METHODS:Systematic comparison of guidance on PPH from eight high-income countries.MAIN OUTCOME MEASURES:Definition of PPH, prophylactic management, measurement of blood loss, initial PPH-management, second-line uterotonics, non-pharmacological management, resuscitation/transfusion management, organisation of care, quality/methodological rigour.CONCLUSIONS:Our study highlights areas where strong evidence is lacking. There is need for a universal definition of (severe) PPH. Consensus is required on how and when to quantify blood loss to identify PPH promptly. Future research may focus on timing and sequence of second-line uterotonics and non-pharmacological interventions and how these impact maternal outcome. Until more data are available, different transfusion strategies will be applied. The use of clear transfusion-protocols are nonetheless recommended to reduce delays in initiation. There is a need for a collaborative effort to develop standardised, evidence-based PPH guidelines.RESULTS:Definitions of (severe) PPH varied as to the applied cut-off of blood loss and incorporation of clinical parameters. Dose and mode of administration of prophylactic uterotonics and methods of blood loss measurement were heterogeneous. Recommendations on second-line uterotonics differed as to type and dose. Obstetric management diverged particularly regarding procedures for uterine atony. Recommendations on transfusion approaches varied with different thresholds for blood transfusion and supplementation of haemostatic agents. Quality of guidelines varied considerably.
