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Fibrinogen concentrate is used to treat severe postpartum hemorrhage despite limited evidence of its effectiveness in obstetric settings. We aimed to explore the association between its administration and maternal outcomes in women with severe postpartum hemorrhage.This secondary analysis of the EPIMOMS prospective population-based study, exploring severe maternal morbidity, as defined by national expert consensus (2012-2013, 182,309 deliveries, France), included all women with severe postpartum hemorrhage and transfused with red blood cells during active bleeding.The primary endpoint was maternal near-miss or death, and the secondary endpoint the total number of red blood cells units transfused.We studied fibrinogen concentrate administration as a binary variable and then by the timing of its administration. We used multivariable analysis and propensity score matching to account for potential indication bias.Among the 730 women with severe postpartum hemorrhage and transfused, 313 (42.9%) received fibrinogen concentrate, and 142 (19.5%) met near-miss criteria or died. The risk of near-miss or death was not significantly lower among the women treated with fibrinogen concentrate than among those not treated, in either the multivariable analysis (adjusted RR = 1.03; 95% CI, 0.72-1.49; P = 0.855) or the propensity score analysis (RR = 0.85; 95% CI, 0.55-1.32; P = 0.477). Among women treated with fibrinogen concentrate, administration more than three hours after red blood cell transfusion started was associated with a higher risk of near-miss or death than administration before or within 30 min after the transfusion began (adjusted RR = 2.07; 95% CI, 1.10-3.89; P = 0.024). Results were similar for the secondary endpoint.The use of fibrinogen concentrate in severe postpartum hemorrhage needing red blood cell transfusion during active bleeding is not associated with improved maternal outcomes.

Transfusion is a major therapy for severe postpartum hemorrhage but there are few population-based descriptions of practice. The objective of this retrospective French population-based study was to describe transfusion practices in women with severe postpartum hemorrhage and the compliance with guidelines.Study data were sourced from a prior prospective population-based study of 182 309 deliveries in France between 2012 and 2013. Transfusion practices and compliance with French national guidelines were described for all women with severe postpartum hemorrhage who had been transfused with red blood cells.In 1495 women with severe postpartum hemorrhage (0.8% of all deliveries), 35.1% were not transfused, 50.0% were transfused during active bleeding and 14.9% exclusively after control of bleeding. Among 697 women with a hemoglobin level7 g/dL, 21.4% were not transfused. In 747 women transfused during active bleeding, 68.8% also received fresh frozen plasma (fresh frozen plasma to red blood cell ratio between 0.5 and 1 in 80.4%). Forty-four percent received fibrinogen concentrate (including 37.4% with a plasma fibrinogen level2 g/L) and 8.6% had a massive transfusion. Among 223 women transfused after bleeding was controlled, 5.4% received fresh frozen plasma and 13% had a hemoglobin level7 g/dL.One in five women with severe postpartum hemorrhage and a low hemoglobin concentration did not receive blood transfusion, which does not comply with French national recommendations. Over-transfusion occurred in women in whom bleeding had been controlled. The use of tools to help clinicians with transfusion decision-making should be developed.

Objective To analyse whether prenatal care trajectories among women with hypertensive disorders during pregnancy in France differ between immigrants from sub-Saharan Africa (SSA) and native French women. Design Qualitative interview study. Setting Three public maternity units in the Paris region. Population Women born in SSA or in France of French parents and treated for hypertension or pre-eclampsia during their pregnancy. Methods A sociologist conducted semi-structured in-depth interviews of 33 women during their postpartum hospitalisation and collected data from their medical files. n'vivo 10 (QSR International) was used for line-by-line coding of the transcriptions, to identify emerging themes. Strauss's concept of illness trajectories was then applied to these data. Main outcome measures Themes derived from interviews. Results Women reported during the interviews that the blood pressure measurement procedures used by hospital staff varied between the two groups, and their medical records supported this finding. Repeated urinary dipstick testing of proteinuria before laboratory testing was more frequent for African women, as was the failure to further test proteinuria levels requiring additional action. The two groups received similar standardised care after severe complications. Other findings showed that African women were less likely to rely on healthcare services. Conclusions These results suggest non-medically justified differential prenatal care between African and native women that may have helped delay the diagnosis of hypertension or pre-eclampsia. This study suggests hypotheses for further quantitative studies to explore the potential involvement of this differential care in the higher frequency of severe complications in this subgroup, concordantly reported in European countries hosting SSA migrants. Tweetable abstract Differential prenatal care may delay diagnosis of pre-eclampsia among African compared with native French women.

ObjectivesMost indicators proposed for assessing quality of care in obstetrics are process indicators and do not directly measure health effects, and cannot always be identified from routinely available databases. Our objective was to propose a set of indicators to assess the quality of hospital obstetric care from maternal morbidity outcomes identifiable in permanent hospital discharge databases.MethodsVarious maternal morbidity outcomes potentially reflecting quality of obstetric care were first selected from a systematic literature review. Then a three-round Delphi consensus survey was conducted online from 11/2016 through 02/2017 among a French panel of 37 expert obstetricians, anesthetists-critical-care specialists, midwives, quality-of-care researchers, and user representatives. For a given maternal outcome, several definitions could be proposed and the indicator (i.e. corresponding rate) could be applied to all women or restricted to specific subgroup(s).ResultsOf the 49 experts invited to participate, 37 agreed. The response rate was 92% in the second round and 97% in the third. Finally, a set of 13 indicators was selected to assess the quality of hospital obstetric care: rates of uterine rupture, postpartum hemorrhage, transfusion incident, severe perineal lacerations, episiotomy, cesarean, cesarean under general anesthesia, post-cesarean site infection, anesthesia-related complications, postpartum pulmonary embolism, maternal readmission and maternal mortality. Six were considered in specific subgroups, with, for example, the postpartum hemorrhage rate assessed among all women and also among women at low risk of PPH.ImplicationsThis Delphi process enabled us to define consensually a set of indicators to assess the quality of hospital obstetrics care from routine hospital data, based on maternal morbidity outcomes. Considering 6 of them in specific subgroups of women is especially interesting. These indicators, identifiable through codes used in international classifications, will be useful to monitor quality of care over time and across settings.

Introduction L’hospitalisation en reanimation et en unite de soins intensifs (USI) des femmes dans le contexte obstetrical est encore peu exploree en France et pourrait dependre non seulement de la severite du tableau clinique, mais aussi de l’offre de soins [1] . L’objectif principal de ce travail etait de decrire en population le taux d’admissions obstetricales en reanimation et en USI, ainsi que l’organisation des soins, globalement et en fonction des regions francaises. Materiel et methodes Nous avons realise une etude prospective en population sur la morbidite maternelle severe–etude EPIMOMS–dans 6 regions de France (Alsace, Auvergne, Basse-Normandie, Ile-de-France, Lorraine, Rhone-Alpes, 183 000 accouchements, mai 2012–mai 2013). Ceci nous a permis de decrire l’incidence des admissions obstetricales en reanimation et en USI pour l’ensemble des regions, puis separement par region et par type de service (reanimation ou USI). La proportion par region des maternites disposant d’une unite de soins continus (USC) a ete egalement rapportee. Nous avons enfin decrit globalement et par region la proportion des admissions pour hemorragie obstetricale en reanimation ou en USI. Resultats Parmi les 2708 femmes ayant presente un evenement maternel morbide severe et qui ont ete incluses dans EPIMOMS, 521 ont ete admises en reanimation et/ou en USI, soit 2,9 femmes pour 1000 accouchements. Ce taux d’incidence etait plus eleve en Alsace (4,4/1000) et en Ile-de-France (3,3/1000) et plus faible en Auvergne (1,5/1000) et Lorraine (1,6/1000). Seulement 18 % (93/521) des femmes ont ete hospitalisees en USI. Cette proportion etait plus faible en Ile-de-France (12 %) et en Rhone-Alpes (13 %) et plus elevee en Auvergne et en Lorraine (37 % et 33 % respectivement). Dans ces 2 dernieres regions, la quasi-totalite des maternites etaient associees a une USC contre 60 % en Alsace, 77 % en Rhone-Alpes et 79 % en Ile-de-France. Globalement, l’indication la plus frequente d’admission obstetricale en reanimation ou en USI etait l’hemorragie obstetricale (45 % des admissions obstetricales en reanimation ou en USI, 1,3/1000 accouchements). Cette proportion etait plus faible en Auvergne (37 %) et en Lorraine (28 %) qu’en Ile-de-France (45 %) et en Rhone-Alpes (56 %). Discussion Le taux d’admissions obstetricales en reanimation et USI varie beaucoup d’une region a l’autre et est plus faible dans les regions ou les maternites sont associees a une USC, notamment les hospitalisations pour hemorragie obstetricale. Ces resultats suggerent que l’offre de soins disponible localement influence la strategie de prise en charge des femmes presentant une complication obstetricale grave. L’analyse des circuits de soins permettrait de preciser l’effet de l’offre sur la sante des femmes.