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Objective: To assess the benefits and safety of early human fibrinogen concentrate in postpartum haemorrhage (PPH) management.Design: Multicentre, double-blind, randomised placebo-controlled trial.Setting: 30 French hospitals.Population: Patients with persistent PPH after vaginal delivery requiring a switch from oxytocin to prostaglandins.Methods: Within 30 minutes after introduction of prostaglandins, patients received either 3 g fibrinogen concentrate or placebo.Main Outcome Measures: Failure as composite primary efficacy endpoint: at least 4 g/dl of haemoglobin decrease and/or transfusion of at least two units of packed red blood cells within 48 hours following investigational medicinal product administration. Secondary endpoints: PPH evolution, need for haemostatic procedures and maternal morbidity-mortality within 6 ± 2 weeks after delivery.Results: 437 patients were included: 224 received FC and 213 placebo. At inclusion, blood loss (877 ± 346 ml) and plasma fibrinogen (4.1 ± 0.9 g/l) were similar in both groups (mean ± SD). Failure rates were 40.0% and 42.4% in the fibrinogen and placebo groups, respectively (odds ratio [OR] = 0.99) after adjustment for centre and baseline plasma fibrinogen; (95% CI 0.66-1.47; P = 0.96). No significant differences in secondary efficacy outcomes were observed. The mean plasma FG was unchanged in the Fibrinogen group and decreased by 0.56 g/l in the placebo group. No thromboembolic or other relevant adverse effects were reported in the Fibrinogen group versus two in the placebo group.Conclusions: As previous placebo-controlled studies findings, early and systematic administration of 3 g fibrinogen concentrate did not reduce blood loss, transfusion needs or postpartum anaemia, but did prevent plasma fibrinogen decrease without any subsequent thromboembolic events.Tweetable Abstract: Early systematic blind 3 g fibrinogen infusion in PPH did not reduce anaemia or transfusion rate, reduced hypofibrinogenaemia and was safe. [ABSTRACT FROM AUTHOR]

Objective: To evaluate in which anatomical layer (above the fascia or below the fascia) continuous wound infusion of local anesthetic, combined with nonsteroidal antiinflammatory drugs, through a multiorifice catheter has the best effectiveness during the first 48 hours on postoperative pain intensity after elective cesarean delivery.Methods: Fifty-six women undergoing elective cesarean delivery under spinal anesthesia were randomly allocated to receive 48-hour continuous wound infusion either above the fascia or below the fascia using ropivacaine and ketoprofene through a multiholed wound catheter. No other systemic analgesics were used, except for rescue patient-controlled intravenous morphine. Evaluation by a blinded investigator included visual analog scale scores at rest and at movement, morphine consumption, patient satisfaction, residual pain at 1 and 6 months, and undesirable side effects.Results: Continuous wound infusion below the fascia resulted in significantly reduced pain at rest and total postoperative morphine consumption (15.7 mg, 95% confidence interval 9.7-20.7 mg) compared with wound administration above the fascia (26.4 mg, 95% confidence interval 18.1-34.7). No undesirable side effects or residual pain requiring treatment were recorded in both groups, whereas analgesia and satisfaction were excellent.Conclusion: After cesarean delivery, continuous wound infusion over 48 hours with ropivacaine and ketoprofene through a multiholed wound catheter inserted below the fascia results in better analgesia when compared with administration above the fascia.Clinical Trial Registration: ClinicalTrials.gov, www.clinicaltrials.gov, NCT01160913.Level Of Evidence: I. [ABSTRACT FROM AUTHOR]

Objective: To provide recommendations on the management of urgent obstetrical emergencies outside the maternity ward., Design: A group of 24 experts from the French Society of Emergency Medicine (SFMU), the French Society of Anaesthesia and Intensive Care Medicine (SFAR) and the French College of Gynaecologists and Obstetricians (CNGOF) was convened. Potential conflicts of interest were formally declared at the outset of the guideline development process, which was conducted independently of industry funding. The authors followed the GRADE (Grading of Recommendations Assessment, Development and Evaluation) method to assess the level of evidence in the literature. The potential drawbacks of strong recommendations in the presence of low-level evidence were highlighted. Some recommendations with an insufficient level of evidence were not graded., Methods: Eight areas were defined: imminent delivery, postpartum haemorrhage (prevention and management), threat of premature delivery, hypertensive disorders in pregnancy, trauma, imaging, cardiopulmonary arrest, and emergency obstetric training. For each field, the expert panel formulated questions according to the PICO model (population, intervention, comparison, outcomes) and an extensive literature search was conducted. Analysis of the literature and formulation of recommendations were conducted according to the GRADE method., Results: Fifteen recommendations on the management of obstetrical emergencies were issued by the SFMU/SFAR/CNGOF panel of experts, and 4 recommendations from formalised expert recommendations (RFE) established by the same societies were taken up to answer 4 PICO questions dealing with the pre-hospital context. After two rounds of voting and several amendments, strong agreement was reached for all the recommendations. For two questions (cardiopulmonary arrest and inter-hospital transfer), no recommendation could be made., Conclusions: There was significant agreement among the experts on strong recommendations to improve practice in the management of urgent obstetric complications in emergency medicine., (Copyright © 2022. Published by Elsevier Masson SAS.)

Objectives: To describe the best practices for management of postpartum hemorrhage (PPH) after vaginal delivery at its initial stage by anesthesiologists., Methods: Medline, the Cochrane Library, and international guidelines have been exhaustively analyzed, graded, and discussed by the members of the scientific committee., Results: Early recognition of PPH relies on either a perceived or a quantified blood loss of 500mL and over (using a collecting bag), or the presence of clinical signs of shock (hypotension, tachycardia, tachypnea, altered mental status) (professional consensus). Precise timing of the diagnosis of PPH must be annotated (professional consensus). Once the diagnosis is established, appropriate senior professionals, including the anesthesiologist at the early stage, must be called in. The cornerstones of initial resuscitation are restoration of blood volume and oxygen carrying capacity, achieved, with adequate intravenous access, initially with crystalloids, associated with oxygen by facemask (professional consensus). Initial resuscitation is performed, and its efficiency is assessed by continuous monitoring and hemoglobin bedside tests (Hemocue(®)). Adequate anesthetic technique must be performed to enable the obstetricians to perform a diagnostic procedure (manual removal of placenta, uterine revision), and to most frequently obtain the cessation of bleeding. Hemodynamic stability is required for loco-regional anesthesia, while on the other hand, general anesthesia with rapid sequence induction and intubation is recommended (professional consensus). Anesthesiologists must anticipate in case of failure of initial measures, including in alerting the blood transfusion service and calling for additional help (professional consensus)., Conclusions: Adequate management of postpartum hemorrhage (PPH) requires multidisciplinary combined and simultaneous actions. After early recognition, five components are undertaken simultaneously: communication, resuscitation, monitoring, investigating the cause of bleeding, and controlling or stopping the bleeding. Bleeding is usually stopped within 30min in 70 to 80% of cases., (Copyright © 2014. Published by Elsevier Masson SAS.)

Background: Postpartum hemorrhage is the leading cause of maternal death worldwide. Recent data from trauma patients and patients with hemorrhagic shock have suggested that an increased fresh frozen plasma:red blood cell (FFP:RBC) ratio may be of benefit in massive bleeding. We addressed this issue in cases of severe postpartum hemorrhage., Methods: We reviewed data from all patients diagnosed with severe postpartum hemorrhage during a 4-year period (2006-2009). Patients who were treated with sulprostone and required transfusion within 6 hours of delivery were included in the study and were divided into 2 groups according to their response to sulprostone: bleeding controlled with sulprostone alone (sulprostone group) and bleeding requiring an additional advanced interventional procedure including arterial angiographic embolization and/or surgical procedures (arterial ligation, B-Lynch suture, or hysterectomy; intervention group). The requirement or no requirement for advanced procedures constituted the primary end point of the study. Propensity scoring was used to assess the effect of a high FFP:RBC ratio on bleeding control., Results: Among 12,226 deliveries during the study period, 142 (1.1%) were complicated by severe postpartum hemorrhage. Bleeding was controlled with sulprostone alone in 90 patients (63%). Advanced interventional procedures were required for 52 patients (37%). Forty-one patients were transfused with both RBCs and FFP. The FFP:RBC ratio increased over the study period (P < 0.001), from 1:1.8 at the start to 1:1.1 at the end of the study period. After propensity score modeling (inverse probability of treatment weighting), a high FFP:RBC ratio was associated with lower odds for advanced interventional procedures (odds ratio [95% confidence interval], 1.25 [1.07-1.47]; P = 0.008). There were no deaths, severe organ dysfunction, or other complications as a consequence of severe postpartum hemorrhage., Conclusions: In this retrospective study, a higher FFP:RBC ratio was associated with a lower requirement for advanced interventional procedures in the setting of postpartum hemorrhage. The benefits of transfusion using a higher FFP:RBC ratio should be confirmed by randomized-controlled trials.

Obstructive sleep apnea (OSA) is associated with impaired airway reflexes. Cough is the main airway defense mechanism but the effect of OSA on cough is unknown. Thirty-two female obese patients scheduled to undergo bariatric surgery were studied. They were classified as presenting OSA (20 patients) when the apnea-hypopnea index (AHI) was greater than 5h. Cough sensitivity was measured with citric acid. Increasing concentrations of nebulized citric acid were delivered until cough was elicited. The concentrations eliciting one (C1) and two coughs (C2) were recorded and log transformed (log C1 and log C2). log C1 and log C2 (median (interquartile)) were 1.90 mg/mL (0.90) and 2.2mg/mL (0.30) in OSA patients and 1.60 mg/mL (0.45) and 1.60 mg/mL (0.45) in non-OSA patients, respectively (comparison between groups: p=0.0372 for log C1 and p=0.0227 for log C2). A significant relationship was observed between AHI and log C1 and log C2. Cough sensitivity is therefore, decreased in female obese OSA patients and this decreased sensitivity is positively correlated with disease severity.