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International audience; War is back in Europe. With all its horrific pictures and live videos.In its report issued on the 24th of March 2022, the World Health Organization (WHO) [1] states that the Ukrainian conflict has involved 18 million persons so far, with 3.4 million refugees in bordering countries and 6.4 million persons internally displaced (Fig. 1). In this report, 1,035 deaths and 1,650 civilian injuries were reported in Ukraine without any reported data from Russia.

Background Pregnant women are at increased risk of hypoxaemia during general anaesthesia. Our aim was to determine the incidence and the risk factors that contribute to hypoxaemia in this setting. Methods Every woman 18 yr or older who underwent a non-elective Caesarean section under general anaesthesia was eligible to participate in this multicentre observational study. The primary endpoint was the incidence of hypoxaemia defined as the SpO2 ≤95%. The secondary endpoint was the incidence of difficult intubation defined as more than two attempts or failed intubation. Results During the study period, 895 women were prospectively included in 17 maternity hospitals, accounting for 79% of women who had general anaesthesia for non-elective Caesarean section. Maternal hypoxaemia was observed in 172 women (19%; confidence interval [CI], 17–22%). Risk factors associated with hypoxaemia in the multivariate analysis were difficult or failed intubation (adjusted odds ratio [aOR]=19.1 [8.6–42.7], P 35 kg m−2 (aOR=0.53 [0.28–0.998], P=0.0495). Intubation was difficult in 40 women (4.5%; CI, 3.3–6%) and failed intubation occurred in five women (0.56%; CI, 0.1–1%). In the multivariate analysis, use of a hypnotic drug other than propofol was associated with difficult or failed intubation (aOR=25 [2–391], P=0.02). A propensity score confirmed that propofol was associated with a significant decreased risk of difficulty or failure to intubate (P Conclusions Hypoxaemia during Caesarean sections was observed in 19% of women and was significantly associated with difficult or failed intubation. The use of propofol may protect against the occurrence of difficult intubation.

Resume De plus en plus de parturientes ont recours a une analgesie peridurale pour l’accouchement. Plusieurs facteurs de realisation difficile ont ete mis en evidence : un indice de masse corporel eleve, une palpation difficile des reperes osseux anatomiques, des anomalies structurales du rachis et une incapacite a adopter une position convexe du rachis lombaire. Ces 3 derniers facteurs ont ete compiles dans un score de 0 a 4, afin d’anticiper les difficultes a venir. De plus, la consistance du ligament jaune (limite posterieure de l’espace peridural) peut etre modifiee au cours de la grossesse et de fausses pertes de resistance peuvent percues. La resonnance acoustique et la transmission de la resistance opposee par le ligament jaune par compression de fluide semblent bien identifier l’entree dans l’espace peridural. L’echographie determine de facon fiable le niveau de ponction, l’inclinaison des processus epineux ainsi que la distance entre la peau et l’espace peridural. Elle peut egalement permettre de confirmer la bonne mise en place du catheter d’analgesie. Enfin, la peri-rachianesthesie combinee ou la realisation d’une « dural puncture epidural » (ou DPE, consistant a faire une rachicenthese, avec une ponction durale seule, sans injection intrathecale) pourraient permettre de verifier, par reflux de liquide cephalo-rachidien, le caractere median de l’abord peridural.

Epidural blood patch is commonly used for management of post-dural puncture headache after accidental dural puncture. The primary aim was to determine factors associated with failed epidural blood patch.In this prospective, multicentre, international cohort study, parturients ≥18 yr receiving an epidural blood patch for treatment of post-dural puncture headache were included. Failed epidural blood patch was defined as headache intensity numeric rating scale (NRS) score ≥7 in the upright position at 4, 24, or 48 h, or the need for a second epidural blood patch, and complete success by NRS=0 at 0-48 h after epidural blood patch. All others were considered partial success. Multinominal logistic regression was used for statistical analyses with P0.01 considered statistically significant.In all, 643 women received an epidural blood patch. Complete data to classify failure were available in 591 (91.9%) women. Failed epidural blood patch occurred in 167 (28.3%) patients; 195 (33.0%) were completely successful and 229 (38.7%) partially successful. A total of 126 women (19.8%) received a second epidural blood patch. A statistically significant association with failure was observed in patients with a history of migraine, when the accidental dural puncture occurred between lumbar levels L1/L3 compared with L3/L5 and when epidural blood patch was performed48 h compared with ≥48 h after accidental dural puncture. In patients having radiological investigations, three intracranial bleeds were diagnosed.Failed epidural blood patch occurred in 28.3% of women. Independent modifiable factors associated with failure were higher lumbar level of accidental dural puncture and short interval between accidental dural puncture and epidural blood patch. A history of migraine was associated with a higher risk of second epidural blood patch.NCT02362828.

International audience; No abstract available

BACKGROUND: Several randomised controlled trials show that maintenance of labour epidural analgesia with programmed intermittent epidural bolus reduces the maternal motor block compared with maintenance with a continuous infusion. However, these trials were usually restricted to healthy nulliparous parturients. To assess the generalisability of these randomised controlled trials to ‘real-world’ conditions, we compared maternal motor function (modified Bromage score) over time between healthy nulliparous and parous women using routinely collected quality-control data. METHODS: After ethical approval, all parturients receiving programmed intermittent epidural bolus labour analgesia between June 2013 and October 2014 were included in this prospective cohort study. Bupivacaine 0.1% with fentanyl 2 μg ml(−1) was used allowing for patient-controlled bolus every 20 min. The maternal motor function (primary outcome) was regularly assessed from insertion of the epidural catheter until delivery. RESULTS: Of the 839 parturients included, 553 (66%) were nulliparous and 286 (34%) were parous. The parous women had a shorter median duration of epidural analgesia (3 h 59 min vs 5 h 45 min) and a higher incidence of spontaneous delivery (66% vs 37%). The probability of being in a certain Bromage category at birth was similar in nulliparous and parous women in a general additive model adjusting for duration of epidural analgesia, number of rescue top-ups, and number of catheter manipulations (cumulative odds ratio: 1.18; 95% confidence interval: 0.98–1.41). Parous women required a higher time-weighted number and volume of rescue top-ups. CONCLUSIONS: The results of the randomised controlled trials on a reduced motor block with programmed intermittent epidural bolus seem generalisable to parturients typically not included in these trials.

Objective To compare maternal complications and describe neonatal outcomes in women with severe preeclampsia at ≤ 26+0 weeks in two countries with different management policies: expectant management (Brazil) versus termination of pregnancy (France). Methods We conducted a retrospective comparative study by reviewing the medical records of women with severe preeclampsia at ≤ 26+0 weeks, from January 2010 to June 2018, in two centers: Hospital das Clínicas da Faculdade de Medicina, in Sao Paulo, Brazil (where medical abortion is forbidden in this indication) and Hôpital Antoine-Béclère, Clamart, France (where medical termination is accepted). We collected information on maternal characteristics, laboratory tests, maternal complications and fetal and newborn characteristics. We used Student’s t-test and the Mann-Whitney U nonparametric test to compare quantitative variables, and Chi-square test or Fisher's exact test to evaluate the associations between the qualitative variables. Results There was no between-group difference in maternal complications during hospitalization (p = 0.846). In Brazil, the rate of cesarean section was 66.7%, and 20% of patients had vertical incision. The rate of spontaneous fetal death was 35.6% and among the live-born infants 26.6% were discharged from hospital. In France, one patient had a cesarean section with vertical incision. Conclusion When comparing termination of pregnancy to expectant management in severe preeclampsia before 26 weeks, maternal complications were equivalent but maternal reproductive future might have been compromised in 20% of cases due to a higher risk of uterine rupture in subsequent pregnancies for patients having classic cesarean (vertical incision). 26.6% of children survived the neonatal period when pregnancy was pursued, however we lack information on their long-term follow-up.

Background Hypotension is the main side effect of spinal anaesthesia (SA) for elective caesarean delivery (CD). An increased in heart rate in response to inferior vena cava (IVC) compression has been reported to be predictive of hypotension and vasopressor requirements in this setting. The objective of the study was to evaluate the prevalence of an increase in heart rate in response to IVC compression and its potential effect on hypotension and phenylephrine requirements. Methods Healthy parturients scheduled for elective CD under SA were preoperatively investigated for a positive supine stress test (SST). It was defined as an increase in heart rate (HR) > 10 beats/min after 5 min of supine position. A crystalloid coload and prophylactic phenylephrine infusion were systematically used to maintain systolic arterial pressure (SAP) between 90–100% of baseline. Hypotension was defined as SAP Results Among 100 women, 26% had a positive SST. There was no significant difference in the incidence of hypotension: 38% versus 24.3% (p = 0.17) in women with positive SST or without, respectively. The cumulative dose of phenylephrine (450 µg [325–625] versus 350 µg [250–500], p = 0.09) was not significantly different between the two groups. Incidences of reactive hypertension, bradycardia, nausea or vomiting and neonatal outcomes were comparable. Conclusions A positive SST to IVC compression was found in a quarter of term women scheduled for elective CD under SA. This condition has no significant impact on hypotension and phenylephrine requirements when using a crystalloid coload and a phenylephrine infusion targeted at maintaining SAP close to baseline.

Invasive therapies (surgery or radiological embolization) are used to control severe post-partum hemorrhage. The intra-uterine tamponade balloon is a potential alternative, well documented after vaginal delivery. However, available data on its use after cesarean delivery remain scarce. This study assessed the efficacy of the intra-uterine tamponade balloon during post-partum hemorrhage in a cesarean delivery setting. Using a retrospective impact design, post-partum hemorrhage-related outcomes before (&ldquo, pre-balloon&rdquo, period) versus after implementation of intra-uterine tamponade balloon (&ldquo, post-balloon&rdquo, period) were compared. All women with post-partum hemorrhage requiring potent uterotonic treatment with prostaglandins after cesarean delivery over a 9-year period were eligible. The primary outcome was the rate of invasive procedure (conservative surgery, radiological embolization and/or hysterectomy). p &lt, 0.05 was considered statistically significant. A total of 279 patients were included (140 vs. 139). Most baseline characteristics were comparable between the two studied periods. The success rate of the intra-uterine tamponade balloon was 82%, and no related complications occurred. Rates of invasive procedures and transfusion were significantly reduced (28.6% vs. 11.5%, p &lt, 0.001 and 44.3% vs. 28.1%, p = 0.006 respectively) during the &ldquo, period, and length of hospital stay was shorter (p &lt, 0.001). Implementation of intra-uterine tamponade balloon during post-partum hemorrhage after cesarean delivery appears to be safe and effective, with a decrease in both invasive procedures and transfusion rates.

Thromboembolic events may occur both during and after pregnancy Pregnancy in itself increases the thromboembolic risk, which is even greater during the postpartum period Due to additional coagulation changes induced by COVID-19 infection, this risk may even be greater

An important variability of anaesthetic standards of care was discovered in the obstetric departments of many European Union countries. After discussing this issue in various meetings of the European Society of Anaesthesiology (ESA) board and its obstetric subcommittee, European Board of Anaesthesiology of the European Union of Medical Specialists (EBA-UEMS) executive members, ESA obstetric subcommittee members and European experts in obstetric anaesthesiology have participated in the elaboration of this document. This experts' opinion is focused mainly on obstetric patients and safety concerns in terms of minimum standards of practice. An initial bibliographical search was performed in medical databases and general literature, searching for obstetric anaesthesiology standards to select the most important safety issues. After the initial presentation of the project during EBA-UEMS and ESA obstetric subcommittee meetings, participants were asked to review the document; several rounds of revisions were performed by the experts, to reach a common opinion concerning the topics considered central to patient safety in the obstetric setting. After three rounds of revision, a consensus was reached and is presented in this document, which includes the list of topics considered relevant by the involved areas, and the respective recommendations. These recommendations covered some EBA-UEMS strategic key areas, in addition to several clinical aspects of common obstetric practice.

Resume La rachianesthesie pour cesarienne elective s’accompagne d’une hypotension potentiellement deletere a la fois pour la mere et l’enfant a naitre. Le choix et les modalites d’administration de vasopresseurs dans cette indication particuliere et cette population specifique ont beneficie de nombreux progres ces dernieres annees.

Resume Le syndrome d’apnee/hypopnee obstructive du sommeil (SAHOS) est plus frequent au cours de la grossesse particulierement en cas d’obesite. Il comporte un risque d’hypertension et de diabete gestationnel. Il peut etre depiste a l’aide du STOP-BANG. En post-partum, l’analgesie par morphine intrathecale n’est pas recommandee dans ce contexte. Les patients ayant un SAHOS doivent etre appareilles avec une CPAP durant l’hospitalisation.

Resume En raison d’une mortalite maternelle importante et malgre des progres therapeutiques manifestes, l’hypertension pulmonaire (HTP) reste une contre-indication formelle a la grossesse. Des strategies de prevention de la grossesse incluant la prise d’une contraception adequate doivent etre proposees a toute patiente porteuse d’une HTP. Toute grossesse impose une prise en charge dans un centre de reference de l’HTP. Une interruption therapeutique de grossesse doit etre systematiquement proposee et pratiquee le plus tot possible. Si la grossesse est poursuivie, un suivi multidisciplinaire regulier est necessaire afin d’adapter le traitement de fond, depister les complications respiratoires, hemodynamiques et obstetricales. L’accouchement par voie basse ou par cesarienne requiert la presence d’une equipe dediee et doit etre programme. La cesarienne, realisee entre 34 et 36 semaines d’amenorrhee, reste le mode d’accouchement preferentiel car elle permet de s’affranchir des contraintes hemodynamiques liees a la douleur pendant le travail et aux efforts expulsifs. L’accouchement par voie basse est neanmoins possible sous certaines conditions de monitorage et de surveillance et permet de diminuer le risque de saignement, d’infection et de maladie veineuse thromboembolique par rapport a la cesarienne. L’anesthesie locoregionale est a privilegier, independamment de la voie d’accouchement, car l’anesthesie generale est probablement associee a une surmortalite. Une surveillance etroite, en unite de soins continu ou en reanimation, est necessaire durant plusieurs jours en post-partum du fait du risque de decompensation.

Severe infections during pregnancy and postpartum are rare, despite a high frequency of bacteraemia, but remain on of the leading cause of maternal death. Therapeutic guidelines validated in general population should be applied to pregnant women, with regards to their specificities: insidious clinical signs and rapid onset, clinical presentation often as respiratory failure due to physiological changes during pregnancy; most frequent causes: pneumonia, pyelonephritis, genitary tract infections; sensibility to virus, Listeria, malaria, due to immunological changes during pregnancy; caesarean section is the single most important risk factor of postpartum infection; aggressive treatment should be started promptly, including fluid infusion and early administration of vasoactive agents (Norepinephrine); broad-spectrum intravenous empirical antibiotic therapy must be established immediately (within the first hour), and chosen according to frequent microorganisms involved in sepsis during pregnancy; infectious source, mostly pelvic, is often accessible to surgery; if foetal extraction does not improve maternal outcomes, it remains necessary for obstetrical or foetal reasons and mandatory if chorioamnionitis is confirmed; specific attention should be drawn to streptococcus A invasive infection which experiments a recent resurgence and is correlated to a high morbidity and mortality for both the mother and the foetus; protocols should be written in every maternity.

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.

Background Postpartum haemorrhage (PPH) remains the leading cause for maternal mortality worldwide. Hypofibrinogenaemia has been identified as a major risk factor for progress towards severe PPH. The efficacy of fibrinogen concentrate supplementation in PPH has been shown in various clinical settings but the level of evidence is not sufficient to prove the benefit, evaluate the risks, and determine the value, timing and dose of fibrinogen supplementation in PPH. The FIDEL trial objective is to evaluate the impact of a therapeutic strategy based on the early administration of human fibrinogen concentrate compared to the current practice based on late administration in severe PPH patients requiring second line uterotonics. Methods/design This is a prospective multicentre, randomised, double-blind, placebo-controlled trial. A total of 412 patients will be randomised if they meet the following criteria: female patients ≥ 18 years old, vaginal delivery, PPH requiring IV administration of prostaglandins (sulprostone) after 20 to 30 minutes of oxytocin failure. The participants are assigned to receive either fibrinogen 3 g or placebo infusions. The primary endpoint is a composite endpoint defined as the percentage of patients losing at least 4 g/dL of Hb, and/or requiring a transfusion of at least 2 units of packed red blood cells, within the 48 hours following fibrinogen administration. Discussion The purpose of this study is to demonstrate the efficacy and safety of an early fibrinogen concentrate infusion in uncontrolled active PPH.

Postpartum haemorrhage (PPH) is defined as blood loss >= 500 mL after a delivery and severe PPH as blood loss >= 1000 mL, regardless of the a route of delivery (professional consensus). The preventive a administration of uterotonic agents just after delivery is effective in a reducing the incidence of PPH and its systematic use is recommended, a regardless of the route of delivery (Grade A). Oxytocin is the first a line prophylactic drug, regardless of the route of delivery (Grade A); a a slowly dose of 5 or 10 IU can be administered (Grade A) either IV or IM a (professional consensus).After vaginal delivery, routine cord drainage a (Grade B), controlled cord traction (Grade A), uterine massage (Grade a A), and routine bladder voiding (professional consensus) are not a systematically recommended for PPH prevention. After caesarean delivery, a placental delivery by controlled cord traction is recommended (grade B). a The routine use of a collector bag to assess postpartum blood loss at a vaginal delivery is not systematically recommended (Grade B), since the a incidence of severe PPH is not affected by this intervention. In cases a of overt PPH after vaginal delivery, placement of a blood collection bag a is recommended (professional consensus). The initial treatment of PPH a consists in a manual uterine examination, together with antibiotic a prophylaxis, careful visual assessment of the lower genital tract, a a uterine massage, and the administration of 5-10 IU oxytocin injected a slowly IV or IM, followed by a maintenance infusion not to exceed a a cumulative dose of 40 IU (professional consensus). If oxytocin fails to a control the bleeding, the administration of sulprostone is recommended a within 30 minutes of the PPH diagnosis (Grade C). Intrauterine balloon a tamponade can be performed if sulprostone fails and before recourse to a either surgery or interventional radiology (professional consensus). a Fluid resuscitation is recommended for PPH persistent after first line a uterotonics, or if clinical signs of severity (Grade B). The objective a of RBC transfusion is to maintain a haemoglobin concentration (Hb) >8 a g/dL. During active haemorrhaging, it is desirable to maintain a a fibrinogen level >= 2 g/L (professional consensus). RBC, fibrinogen and a fresh frozen plasma (FFP) may be administered without awaiting a laboratory results (professional consensus). Tranexamic acid may be used a at a dose of 1 g, renewable once if ineffective the first time in the a treatment of PPH when bleeding persists after sulprostone administration a (professional consensus), even though its clinical value has not yet a been demonstrated in obstetric settings. It is recommended to prevent a and treat hypothermia in women with PPH by warming infusion solutions a and blood products and by active skin warming (Grade C). Oxygen a administration is recommended in women with severe PPH (professional a consensus). If PPH is not controlled by pharmacological treatments and a possibly intra-uterine balloon, invasive treatments by arterial a embolization or surgery are recommended (Grade C). No technique for a conservative surgery is favoured over any other (professional a consensus). Hospital-to-hospital transfer of a woman with a PPH for a embolization is possible once hemoperitoneum is ruled out and if the a patient's hemodynamic condition so allows (professional consensus). (C) a 2015 Elsevier Ireland Ltd. All rights reserved.

Resume L’objectif est d’analyser les effets de l’analgesie peridurale et de ses differentes modalites d’administration sur la mecanique obstetricale : travail obstetrical (stade 1 et 2) et modalites d’accouchement. Les articles anglais et francais publies sur le sujet dans la banque de donnees Medline ont ete analyses, en se focalisant principalement sur la derniere decennie. Les effets de l’analgesie par voie peridurale sont fonction de la nature et de la concentration des produits administres. L’analgesie peridurale moderne (APDM) n’augmente pas le taux de cesarienne et ne ralentit pas la dilatation cervicale, meme en debut de travail. Le critere d’initiation d’une APDM doit donc etre l’intensite douloureuse et non la dilatation cervicale. Le taux d’extraction instrumentale est peu ou pas augmente avec l’APDM. La peridurale deambulatoire ameliore l’autonomie et la satisfaction des parturientes mais pas directement la mecanique obstetricale. La rachianalgesie-peridurale combinee n’ameliore pas non plus la mecanique obstetricale par rapport a l’APDM, mais elle est utile chez les parturientes ayant une dilatation rapide, avancee, ou une douleur tres intense. La PCEA ( Patient Controlled Epidural Analgesia ) diminue la dose analgesique recue et/ou le nombre d’interventions pour defaut d’analgesie par rapport a une perfusion continue peridurale classique « CEI » ( Continuous Epidural Infusion ). Le mode PIEB ( Programmed Intermittent Epidural Bolus ) fournit une meilleure diffusion de la solution et une meilleure analgesie par rapport au mode CEI. Le nouveau mode PIEB + PCEA reduit le bloc moteur et peut etre aussi le taux d’extraction instrumental.

Background A comparison of the effective dose in 50% of patients (ED50) has suggested that the potency of levobupivacaine lies between that of bupivacaine and ropivacaine. However, for clinical purposes, knowledge and use of doses close to the ED95 are more relevant. This study was designed to determine the EC80 (effective concentration) for both epidural levobupivacaine and ropivacaine using the Continual Reassessment Method (CRM) during obstetric analgesia. Methods In this double-blind randomised study, term parturients were included by cohorts of 6 if cervical dilatation was ≤ 5 cm and visual analogue pain score (VAPS) > 30 mm. Efficacy was defined by a decrease of VAPS to a value ≤ 10, thirty minutes after epidural injection of 20 mL of levobupivacaine or ropivacaine. The first cohort received the lowest dose. Every next cohort received a dose according to the response's probability calculated using a Bayesian method, incorporating data from all consecutive previous patients. In addition, a logistic equation was fitted a posteriori to the whole data set to determine the whole dose-probability curve. Results Fifty-four patients were enrolled. Levobupivacaine 0.17% and ropivacaine 0.2% gave probabilities of success of 82% and 72% respectively. By fitting the logistic model to the data, the concentration leading to a probability of 0.8 (EC80) was 0.14% for levobupivacaine and 0.24% for ropivacaine while the EC50 were 0.09% for levobupivacaine and 0.17% for ropivacaine, respectively. Conclusion This study suggests that epidural levobupivacaine used as the sole drug for labour analgesia has an EC80 lower than that of ropivacaine.

Resume L’âge maternel avance (35 ans ou plus) est un facteur de risque de naissance prematuree, de retard de croissance intra-uterin, de morbidite/mortalite perinatale et de cesarienne. Malgre les risques qui croissent exponentiellement avec l’âge maternel, la morbidite et la mortalite maternelles et perinatales demeurent globalement basses. Les femmes donnant naissance a un âge avance prennent souvent grand soin de leur sante et jouissent frequemment d’une tres bonne qualite de soins, ce qui amoindrit l’effet de l’âge sur le deroulement de leur grossesse et de leur accouchement. Les parturientes tres âgees (45 ans ou plus) ont aussi un devenir globalement satisfaisant, peut-etre en partie parce qu’elles ont recours au don d’ovocyte. Cependant, le taux de cesarienne et la mortalite maternelle sont franchement accrus. L’anesthesiste-reanimateur doit donc rechercher les comorbidites antenatales chez ces patientes et doit etre pret a assurer l’anesthesie pour une cesarienne en cours de travail ainsi que la gestion des eventuelles complications aigues du peripartum.

« L'anesthesie pour cesarienne » et « l'arret cardiorespiratoire (ACR) chez la femme enceinte » traites dans ce premier numero de notre nouvelle Revue Anesthesie & Reanimation constituent deux des grands sujets a bien connaitre pour qui pratique l'anesthesie obstetricale, que ce soit regulierement ou plus episodiquement en particulier durant les periodes de garde. Les raisons qui doivent conduire a maitriser ces deux themes sont pourtant bien differentes. L'anesthesie pour cesarienne fait partie « du pain quotidien » de l'anesthesiste de maternite. Ne pas bien connaitre ce domaine est a l'evidence incompatible avec la pratique de l'anesthesie obstetricale. A l'inverse, l'ACR est heureusement un evenement exceptionnel chez la femme enceinte et beaucoup d'anesthesistes ne rencontreront jamais cette situation stressante, voire traumatisante, durant la totalite de leur carriere. Pourtant, les specificites de prise en charge et les consequences potentielles sur le pronostic final sont telles qu'il est indispensable de s'etre bien prepare a faire face a cet evenement improbable et a pouvoir ainsi coordonner l'action et le comportement des multiples intervenants souvent deroutes, voire incoherents. L'article de Chassard et Bouvet [1] porte sur l'anesthesie pour cesarienne et nous fourni les elements developpes dans la Conference d'essentiel du Pr Dominique Chassard lors du congres de la Sfar en septembre dernier. Douze points essentiels sont listes en debut d'article. L'objectif n'est donc pas d'effectuer ici une redite, mais plutot de souligner les elements nouveaux et/ou marquants par rapport a la precedente Conference d'essentiel que j'avais presentee quatre ans auparavant en 2010.

Anaesthetists often stand in the front line to manage postpartum neurological deficits, although epidural analgesia is rarely responsible for these complications. An epidural analgesia was performed to relieve pain during spontaneous labor in a 34-year-old parturient. An emergency C-section was subsequently required due to fetal heart rate abnormalities. Twelve hours after catheter removal, the parturient developed a severe right leg motor and sensory neurological deficit, predominant on L5 and S1 roots and diagnosed by a neurologist as a central nerve root injury. Lumbar MRI identified a non-compressive epidural bleeding in front of the L5 vertebral body. Epidural bleeding after labor epidural analgesia is a rare complication that may jeopardize the functional prognosis. It may be difficult in some cases to differentiate an upper plexus injury due to labor and delivery from a central epidural analgesia-related nerve root lesion. Fetal head compression at the pelvic brim may induce neurological deficits in several well-differentiated nervous territories, thus mimicking an anaesthetic-induced perimedullar radiculopathy.

Resume Nous rapportons le cas d’une patiente de 30 ans, avec une preeclampsie severe, ayant presente des cephalees et des cervicalgies gauches a 27 semaines d’amenorrhee, accompagnees d’un flou visuel avec engourdissement de l’hemiface gauche spontanement resolutif en deux heures. Une semaine plus tard, malgre la bitherapie antihypertensive instauree, les pressions arterielles restaient mal controlees et l’apparition d’un HELLP syndrome conduisait a la realisation d’une cesarienne en urgence pour engagement du pronostic maternel et fœtal. A j5 post-partum, la patiente presentait au reveil un syndrome de Claude Bernard-Horner droit accompagne d’acouphenes ipsilateraux invalidants. L’angio-TDM des troncs supra-aortiques, realisee en urgence et confirmee secondairement par une angio-IRM, retrouvait une dissection arterielle carotidienne bilaterale sans accident vasculaire cerebral d’aval. La patiente etait transferee en urgence dans une unite de soins intensifs neurovasculaires ou un traitement anticoagulant a dose curative etait instaure afin de prevenir les lesions ischemiques cerebrales et retiniennes d’aval. L’evolution etait rapidement favorable et permettait un retour a domicile de la patiente a j7 post-partum. L’imagerie de controle realisee a quatre mois montrait la regression totale de la dissection arterielle bilaterale et conduisait a l’arret du traitement anticoagulant.

Evaluating the clinical significance of blood cultures positive for coagulase-negative staphylococci (CoNS) is of critical importance since these microorganisms represent both the first contaminants of blood cultures and one of the leading causes of bloodstream infection (BSI). This prospective 2-centre study aimed to compare a previously reported algorithm to a clinical algorithm based on our experience. We identified 84 patients with CoNS-positive blood cultures. Twenty-seven (32%) were considered to have BSI according to our study algorithm. Thirty-seven (44%) patients were considered to have CoNS BSI according to the previously reported algorithm. The 2 algorithms isolated patients with similar rates of recurrences and hospital mortality. Our algorithm seemed to result in less diagnoses of CoNS BSI without harmful consequences compared to the previously reported algorithm. The impact on patient outcome and the inappropriate use of antibiotics deserves further investigation.

Resume La thrombopenie gestationnelle concerne environ 10 % des femmes enceintes. Dans 75 % des cas, il s’agit d’une thrombopenie gestationnelle benigne, sans consequence et sans risque hemorragique. Cependant, elle peut reveler des pathologies graves comme la preeclampsie, le hemolysis elevated liver enzyme and low platelets (HELLP) syndrome et les redoutables microangiopathies thrombotiques. Elle peut aussi s’inscrire dans le cadre d’un purpura thrombopenique auto-immun ou d’une autre affection auto-immune comme le lupus ou le syndrome des anticorps antiphospholipides. Le risque hemorragique et les consequences fœtomaternels sont variables en fonction de ces pathologies, ce qui impose un diagnostic etiologique precis. Les examens complementaires ne sont pas systematiques et doivent etre orientes en fonction des signes associes. Le diagnostic differentiel entre purpura thrombopenique auto-immun et thrombopenie gestationnelle n’est pas biologique, mais clinique et anamnestique. La strategie therapeutique et l’attitude vis-a-vis de la realisation de l’anesthesie/analgesie locoregionale est fonction de chaque pathologie.

Resume Les infections severes sont rares au cours de la grossesse ou en postpartum, malgre une forte incidence de bacteriemies chez les femmes enceintes. Les germes les plus souvent en cause sont l’ Escherichia coli et le streptocoque B, mais les infections sont souvent polymicrobiennes. Une recrudescence des infections graves a streptocoque A est responsable d’une augmentation recente de la part relative des infections impliquees dans la mortalite maternelle des pays industrialises. Le statut physiologique et la faible incidence des comorbidites expliquent la rarete du choc septique chez la femme enceinte ; en l’absence de donnees specifiques au cours de la grossesse, la prise en charge initiale s’appuie sur les principes de reanimation precoce en tenant compte des modifications hemodynamiques et pulmonaires, responsables notamment d’une defaillance respiratoire. L’antibiotherapie a large spectre doit etre ultraprecoce. L’extraction fœtale peut etre indiquee pour des motifs obstetricaux mais ne modifie pas le pronostic maternel, excepte en cas d’arret cardiorespiratoire.

Major obstetric hemorrhage is a challenge for anesthesiologists because it remains responsible for over 10% of maternal deaths in high-income countries. A standardized multidisciplinary management, described in locally validated protocols and based on international guidelines is mandatory to prevent these deaths. The first difficulty relies on the systematic underestimation of the bleeding. Collection bags must be used to facilitate the diagnosis and therefore rapid management. The etiologies in antenatal or postpartum must be well-known in order to be treated adequately. A rapid recourse to prostaglandins (sulprostone in France) may reverse uterine atony. Invasive approach with surgery or radiology should be promptly implemented (uterine artery or internal iliac artery ligations±uterus plication) and hysterectomy should then be timely considered. Simultaneously, early and aggressive resuscitation with large-bore venous accesses should be implemented for rapid and massive transfusion (4:4:1 RBC:FFP:platelets ratio), along with an early use of fibrinogen concentrates and tranexamic acid. This transfusion strategy may be then guided by thromboelastography or thromboelastometry and bedside hemoglobin measurements. Activated factor VII remains indicated only before or after hysterectomy in case of uncontrolled bleeding. Management of placentation abnormalities (placenta previa, accreta, increta, percreta) must be well mastered as these etiologies may generate cataclysmic hemorrhages that can be and have to be anticipated.

International audience; Postpartum haemorrhage (PPH) is defined as blood loss ≥500mL after delivery and severe PPH as blood loss ≥1000mL, regardless of the route of delivery (professional consensus). The preventive administration of uterotonic agents just after delivery is effective in reducing the incidence of PPH and its systematic use is recommended, regardless of the route of delivery (Grade A). Oxytocin is the first-line prophylactic drug, regardless of the route of delivery (Grade A); a slowly dose of 5 or 10 IU can be administered (Grade A) either IV or IM (professional consensus). After vaginal delivery, routine cord drainage (Grade B), controlled cord traction (Grade A), uterine massage (Grade A), and routine bladder voiding (professional consensus) are not systematically recommended for PPH prevention. After caesarean delivery, placental delivery by controlled cord traction is recommended (grade B). The routine use of a collector bag to assess postpartum blood loss at vaginal delivery is not systematically recommended (Grade B), since the incidence of severe PPH is not affected by this intervention. In cases of overt PPH after vaginal delivery, placement of a blood collection bag is recommended (professional consensus). The initial treatment of PPH consists in a manual uterine examination, together with antibiotic prophylaxis, careful visual assessment of the lower genital tract, a uterine massage, and the administration of 5-10 IU oxytocin injected slowly IV or IM, followed by a maintenance infusion not to exceed a cumulative dose of 40IU (professional consensus). If oxytocin fails to control the bleeding, the administration of sulprostone is recommended within 30minutes of the PPH diagnosis (Grade C). Intrauterine balloon tamponade can be performed if sulprostone fails and before recourse to either surgery or interventional radiology (professional consensus). Fluid resuscitation is recommended for PPH persistent after first line uterotonics, or if clinical signs of severity (Grade B). The objective of RBC transfusion is to maintain a haemoglobin concentration (Hb) >8g/dL. During active haemorrhaging, it is desirable to maintain a fibrinogen level ≥2g/L (professional consensus). RBC, fibrinogen and fresh frozen plasma (FFP) may be administered without awaiting laboratory results (professional consensus). Tranexamic acid may be used at a dose of 1 g, renewable once if ineffective the first time in the treatment of PPH when bleeding persists after sulprostone administration (professional consensus), even though its clinical value has not yet been demonstrated in obstetric settings. It is recommended to prevent and treat hypothermia in women with PPH by warming infusion solutions and blood products and by active skin warming (Grade C). Oxygen administration is recommended in women with severe PPH (professional consensus). If PPH is not controlled by pharmacological treatments and possibly intra-uterine balloon, invasive treatments by arterial embolization or surgery are recommended (Grade C). No technique for conservative surgery is favoured over any other (professional consensus). Hospital-to-hospital transfer of a woman with a PPH for embolization is possible once hemoperitoneum is ruled out and if the patient's hemodynamic condition so allows (professional consensus).