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International and French maternal mortality. Maternal mortality, defined as the death of a woman during pregnancy and 42 days following delivery, remains a major challenge to health systems worldwide and a known indicator of development. As did the Millennium Development Goal 5, France health ministry targeted a reduction in maternal mortality ratio. Organizations have been developed through the last decade to reach this objective: a triennial maternal deaths national enquiry analyzes the reported cases and evaluates the evitability of the event. Recommendations are produced regarding the major causes of maternal deaths. French maternal mortality ratio varies from 8 to 12 /100,000 births. The major causes are direct obstetric causes (postpartum hemorrhage, thromboembolism, amniotic fluid embolism and preeclampsia, but also rarely sepsis and anaesthesia). The major indirect obstetric causes are cardiopathies, vascular diseases and miscellaneous. Deaths may be due to non-obstetrical causes such as suicides and trauma. In France, the first cause of maternal death is postpartum hemorrhage that represented 33% of the mortality, two triennium ago. This rate have been reduced to 18% and the factors contributing to this reduction were 2004 PPH prevention and management practice guidelines publication updated in 2014 and their diffusion supported by the French society of Anesthesia Intensive Care (SFAR) and the French National Society of Gynecologists and Obstetricians (CNGOF) as well as the midwifes organizations. The perinatal health care networks were actors of this improvement in medical care practices and organization. However a large improvement margin exists to better reduce the maternal mortality ratio in our country.Mortalité maternellle en France et dans le Monde. La mortalité maternelle est définie comme le décès d’une femme pendant la grossesse et dans les 45 jours suivant l’accouchement. Elle représente un indicateur de santé publique et de performance du système de soins dans le monde. À l’image de l’Organisation mondiale de la santé, la France s’est fixé pour objectif de réduire le taux de ces décès. Les moyens mis en oeuvre sont l’analyse des dossiers par une enquête nationale triennale, l’organisation des maternités en réseaux, l’édition et la diffusion de recommandations par les sociétés savantes et l’évaluation des pratiques professionnelles. Le taux de la mortalité maternelle en France se situe entre 8 et 12 pour 100 000 naissances. Les causes de ces décès peuvent être obstétricales directes (hémorragie du post-partum, maladie thromboembolique, prééclampsie, embolie amniotique, sepsis et complications anesthésiques). Elles peuvent être obstétricales indirectes (cardiopathies, accidents vasculaires cérébraux et autres causes diverses) ou non obstétricales (traumatismes ou suicides). La première cause de mort maternelle est l’hémorragie. Le taux de morts par hémorragie a été réduit de 33 à 18 %. Les facteurs qui ont contribué à réduire le nombre de ces décès sont l’édition en 2004 des recommandations de pratique clinique et la diffusion de ces recommandations par les sociétés savantes et les réseaux de santé en périnatalité, organisation créée à partir des décrets dits de périnatalité de 1998. Une marge de progrès reste possible en termes d’organisation des soins et de pratique clinique pour réduire la mortalité évitable.

Unlike propofol, the self-administration of remifentanil for sedation in gastrointestinal endoscopies has never been evaluated formally. We wanted to compare the efficacy and tolerance of patient self-administration of remifentanil vs propofol during gastrointestinal endoscopy.This prospective randomized, single-blinded study, included 77 patients undergoing gastrointestinal endoscopy. Patients were divided into two groups: group R received remifentanil (5 microg.kg(-1).hr(-1) infusion, 25 microg boli, refractory period of five minutes) and group P received propofol (2 mg.kg(-1).hr(-1) infusion, 0.5 mg.kg(-1) boli, refractory period of ten minutes). A 1 mg.kg(-1) bolus of propofol was administered before the procedure began in cases of marked anxiety. Additional boli of 25 microg of remifentanil or 0.5 mg.kg(-1) of propofol were administered when patients complained during the refractory period. The evaluation targeted analgesic efficacy during the procedure and patient satisfaction. The degree of sedation during the procedure and the occurrence of adverse reactions were analyzed.Patient satisfaction was high and comparable in both groups, with the number of awake and oriented patients being significantly higher in group R. Hemodynamic and respiratory tolerance was comparable in both groups, despite two episodes of desaturation in group R. The incidence of nausea was significantly higher in group R.The self-administration of remifentanil for sedation during gastrointestinal endoscopies is as effective as the self-administration of propofol and can be offered to patients, especially when it is desirable that they remain conscious during the procedure.