Objectifs - Définir les stades du travail spontané, préciser les indications, les modalités et l'efficacité de l'administration d'oxytocine ainsi que décrire les effets indésirables maternels, ...fœtaux et néonataux liés à cette administration. Méthode - Revue systématique de la littérature à partir de la base de données Medline interrogée jusqu'en mars 2016 et complétée par une recherche sur les sites des sociétés savantes. Résultats - Le premier stade débute par une phase de latence, définie par des contractions utérines (CU) entraînant une modification du col jusqu'à 5 cm de dilatation, et se termine par une phase active, de 5 cm à dilatation complète. Le deuxième stade débute par la phase de descente et se termine par la phase d'expulsion. En phase de latence, il est recommandé de ne pas intervenir à titre systématique. Une pose précoce d'analgésie péridurale est possible sans attendre la phase active du travail et, dans ce cas, il est recommandé de ne pas associer de façon systématique une administration d'oxytocine. En phase active du premier stade, une dystocie dynamique est définie par une vitesse de dilation inférieure à 1 cm/4 heures de 5 à 7 cm ou inférieure à 1 cm/2 heures de 7 cm à dilation complète. En cas de dystocie dynamique en phase active, il est recommandé de pratiquer une amniotomie en première intention. En l'absence d'amélioration une heure après l'amniotomie, une administration d'oxytocine peut être réalisée. En cas de prolongation du deuxième stade au-delà de deux heures, il est recommandé d'administrer de l'oxytocine pour corriger une absence de progression de la présentation. En cas de dystocie dynamique, l'oxytocine doit être administrée à un débit initial de 2 mUI/min, augmentée par palier de 2 mUI/min en respectant un délai de 30 minutes, et sans dépasser un débit de 20 mUI/min. Les effets indésirables maternels rapportés concernent l'hyperactivité utérine, la rupture utérine et l'hémorragie du post-partum. Les effets indésirables fœtaux discutés concernent les anomalies du rythme cardiaque fœtal (RCF) liées à une hyperactivité utérine, l'hyponatrémie, l'ictère néonatal, les difficultés de succion et l'autisme. Conclusion - L'administration d'oxytocine durant le travail spontané ne doit pas être considérée comme une prescription anodine. L'état actuel des connaissances doit inciter les acteurs de la périnatalité à la plus grande vigilance. L'administration d'oxytocine durant le travail spontané expose la mère et le fœtus à des effets néfastes pouvant avoir des conséquences à court terme et possiblement à long terme. Ses modalités d'administration doivent faire l'objet d'un protocole. Sa prescription et le consentement de la mère doivent être précisés dans son dossier médical.
Abstract Background and aims The triglyceride (TG)/high-density lipoprotein-cholesterol (HDL-C) ratio has been reported as a useful marker of atherogenic lipid abnormalities, insulin resistance, and ...cardiovascular disease. We evaluated in a large sample of children and adolescents the association of TG/HDL-C ratio with early signs of morphological vascular changes and cardiometabolic risk factors including nonalcoholic fatty liver disease (NAFLD). Methods and results The study population, including 548 children (aged 6–16 years), of whom 157 were normal-weight, 118 overweight, and 273 obese, had anthropometric, laboratory, liver and carotid ultrasonography (carotid artery intima-media thickness-cIMT) data collected. Subjects were stratified into tertiles of TG/HDL-C. There was a progressive increase in body mass index (BMI), BMI-SD score (SDS), waist circumference, blood pressure (BP), liver enzymes, glucose, insulin, homeostasis model assessment of insulin resistance, high-sensitivity C-reactive protein (hsCRP), and cIMT values across TG/HDL-C tertiles. The odds ratios for central obesity, insulin resistance, high hsCRP, NAFLD, metabolic syndrome, and elevated cIMT increased significantly with the increasing tertile of TG/HDL-C ratio, after adjustment for age, gender, pubertal status, and BMI-SDS. In a stepwise multivariate logistic regression analysis, increased cIMT was associated with high TG/HDL-C ratio OR, 1.81 (95% CI, 1.08–3.04); P < 0.05, elevated BP 5.13 (95% CI, 1.03–15.08); P < 0.05, insulin resistance 2.16 (95% CI, 1.30–3.39); P < 0.01, and NAFLD 2.70 (95% CI, 1.62–4.56); P < 0.01. Conclusion TG/HDL-C ratio may help identify children and adolescents at high risk for structural vascular changes and metabolic derangement.
•Knowledge of severe acute maternal morbidity (SAMM) is constantly growing.•Its prevalence and risk factors remain undocumented in low-risk women.•Peripartum SAMM in low-risk women is rare (0.5%) but ...still exists.•Primiparity, IVF pregnancy and migration are associated with increased risk of SAMM.•Gestational anaemia is the only identified modifiable risk factor of SAMM.
Knowledge of severe acute maternal morbidity (SAMM) and its risk factors is constantly growing, but studies have rarely focused on the specific population of low-risk women.
To estimate the prevalence and to identify subgroups at risk of peripartum SAMM in low-risk women
From a population-based cohort-nested case-control study conducted in six French regions, i.e., 182 309 women who gave birth at ≥22 weeks in 119 maternity units, we selected women considered at low risk up to the end of pregnancy before labour according to the NICE guidelines and compared those experiencing peripartum SAMM (during birth and up to 7 days postpartum; n = 489) to a 2% random sample of women without peripartum SAMM from the same units (n = 1800). Risk factors for peripartum SAMM were identified by multivariable logistic regression.
amongst low-risk women, the estimated rate of SAMM was 0.548/100 deliveries (95%CI 0.501–0.599). Severe obstetric haemorrhage was the main cause (83.6% of SAMM cases). Main risk factors for peripartum SAMM were primiparity (aOR 2.4, 95%CI 1.9–3.0), IVF pregnancy (aOR 1.8, 1.0–3.4), third-trimester anaemia (aOR 1.7, 1.3–2.3), being born out of Europe or Africa (aOR 1.9, 1.2–3.0).
amongst women considered at low risk up to the end of pregnancy before labour, peripartum SAMM is rare but still exists. Knowledge of risk factors of SAMM in this population will inform the discussion on peripartum risks and the most appropriate place of birth for each woman.
Objective
To describe and compare the characteristics of women with placenta accreta spectrum (PAS) and their pregnancy outcomes according to the presence of placenta praevia and a prior caesarean ...section.
Design
Prospective population‐based study.
Setting
All 176 maternity hospitals of eight French regions.
Population
Two hundred and forty‐nine women with PAS, from a source population of 520 114 deliveries.
Methods
Women with PAS were classified into two risk‐profile groups, with or without the high‐risk combination of placenta praevia (or an anterior low‐lying placenta) and at least one prior caesarean. These two groups were described and compared.
Main outcome measures
Population‐based incidence of PAS, characteristics of women, pregnancies, deliveries and pregnancy outcomes.
Results
The PAS population‐based incidence was 4.8/10 000 (95% CI 4.2–5.4/10 000). After exclusion of women lost to follow up from the analysis, the group with placenta praevia and a prior caesarean included 115 (48%) women and the group without this combination included 127 (52%). In the group with both factors, PAS was more often suspected antenatally (77% versus 17%; P < 0.001) and more often percreta (38% versus 5%; P < 0.001). This group also had more hysterectomies (53% versus 21%, P < 0.001) and higher rates of blood product transfusions, maternal complications, preterm births and neonatal intensive care unit admissions. Sensitivity analysis showed similar results after exclusion of women who delivered vaginally.
Conclusion
More than half the cases of PAS occurred in women without the combination of placenta praevia and a prior caesarean delivery, and these women had better maternal and neonatal outcomes. We cannot completely rule out that some of the women who delivered vaginally had placental retention rather than PAS; however, we found similar results among women who delivered by caesarean.
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Half the women with PAS do not have both placenta praevia and a prior caesarean delivery, and they have better maternal outcomes.
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Half the women with PAS do not have both placenta praevia and a prior caesarean delivery, and they have better maternal outcomes.
Several studies suggest that a substantial number of patients with normal serum alanine aminotransferase (ALT) levels, defined by current thresholds, have ongoing hepatic necro-inflammation and ...fibrosis, and are at risk of liver disease progression. A major problem lies in the definition of normality. The current upper limit of normal (ULN) for ALT was established in the 1980s when reference populations were likely to include many persons with hepatitis C virus infection and nonalcoholic fatty liver disease. Because ALT may be influenced, not only by liver disease, but also by other medical conditions, changing lifestyle factors and demographic determinants, the current ALT ULN threshold has recently been challenged. This review not only highlights current evidence on why and how ALT ULN should be redefined, but also discusses the current concerns about updating the ULN threshold for ALT.
•Why upper limit of normal (ULN) for alanine aminotransferase (ALT) should be redefined?•How a well-defined healthy group is generated for ALT ULN?•Factors modulating ALT activity•Skepticism concerning the need to update the current ALT ULN
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