Grossesse et addictions : mettre en place un réseau de soins personnalisés à partir d’un accueil en maternité

Women under psychoactive substances, once pregnant, don’t seek help spontaneously from addictology services. Even if they don’t have a specific demand for themselves, they do want their infant’s well-being. The innovation has been to propose to them an obstetrical consultation in the maternity unit with the referent midwife who liaises with all the different professionals inside and outside the hospital. In parallel, the gynaecologist-obstetrician ensures a follow-up of pregnancies at risk and this framework becomes the axis of all the network actions: coordination of care provided, health education, follow-up monitoring, hospitalisation preparation, team support in every step, postpartum organisation, father’s inclusion. The midwife has a clinical supervision once a week with a child psychiatrist. This workflow won the trust of future parents, enhanced the visibility of addiction within maternities (from 2 situations in 1994 to 80 in 2013) and reduced the adoption percentage in case of opioid addictions (from 60% to 4%).     

Proposition d’une stratégie de prévention du risque fracturaire en début de ménopause

Postmenopausal osteoporosis is a chronic disease, which justifies long-term treatment in those women with an increased risk of fracture. The current disponibility of various drugs, which have demonstrated their efficacy in reducing the incidence of fracture, has raised the question of the best treatment strategy in a woman who would begin her postmenopausal period with an increased risk for fracture. Indeed, for most treatments (with the exception of hormonal replacement therapy [HRT]), their efficacy in reducing the risk of fracture has been mainly demonstrated in higher risk elderly women (above 65 years) with prevalent vertebral fractures. There is uncertainty concerning their cost-effectiveness in younger women for a true primary prevention of the risk of fracture. Furthermore, current guidelines recommend a 5-year period of treatment which has led us to considering treatment strategies which would be based on various sequential treatment periods over time, the selection of each specific sequence being determined by the clinical situation of the woman, the level of her fracture risk and the expected skeletal (in terms of spectrum of bone effects) and potential extraskeletal benefits of drugs. In this regard, HRT or raloxifene, which allows a more global approach of the menopause-induced consequences of estrogen deficiency than the sole prevention of osteoporosis, should be privileged within the first 10 years of treatment or so in those youngest women at increased risk for subsequent fracture. Use of bisphosphonate or strontium ranelate should be thus reserved at a more advanced age, when the prevention of hip fracture becomes mandatory.     

Les naissances des grands prématurés en dehors des maternités de type III sont-elles évitables ? Expérience du réseau Grand Lyon

ObjectiveThe main objective of this study was to calculate the percentage of preterm births before 28 weeks gestational age (weeks GA) outside level-3 maternity wards and determine how many could have been prevented.MethodsThis was an observational, multicenter, retrospective cohort study, which included all the deliveries that occurred between 24 and 27 weeks GA + 6 days in the Greater Lyon perinatal network (France) occurring between first of March 2008 and first of March 2009. In utero transfers (IUTs) and newborn transfers (NBTs) which were carried out outside the network, medical abortions, and foetal deaths in utero were excluded. The duration between patient's arrival in the level 1 and 2 maternity and birth was compared at the 97^th percentile of the mother's transfer time in level-3 maternity. Births that occurred outside of level-3 maternity wards were considered avoidable each time the first duration was more than the second.ResultsDuring the study period, 113 infants were born alive between 24 and 27 weeks GA + 6 days in the network. They were all included in the study. Ninety were born in a level-3 maternity ward and 23 were born in level-1 and 2 maternity wards (20%). There were 35 requests for IUT and 28 were carried out (80%). In 65% of non-level 3 births, no IUT was requested. In 17% of cases, an IUT request could have prevented births in level 1/2 maternity wards. If twin pregnancies had been transferred to a level-3 maternity ward, 26% of non-level 3 births would have been avoided. If all high-risk pregnancies had been transferred to a level-3 maternity ward, 40% of non-level 3 births would have been avoided.Discussion and conclusionAny time a pregnant woman is hospitalized in a type 1/2 maternity ward before 28 weeks GA, doctors should consider an in utero transfer to a level-3 maternity ward. It may be possible to lower the birth-rate of non-level 3 births by a targeted increase in in utero transfers and by transferring high-risk pregnancies to a level-3 maternity ward.     

Implication d’un réseau de périnatalité dans l’harmonisation régionale de l’évaluation de l’état fœtal pendant le travail

The perinatal care network of Aquitaine, aiming for a regional harmonization and improvement of security conditions during birth, proposed a regional project of training program on the theme “the analysis of the fetal heart rate in direction of 28 maternities of Aquitaine”. It included a new physiopathological approach and the promotion of intrapartum fetal scalp sampling for a better prevention of adverse outcomes such as asphyxia or inappropriate caesareans.     

Les températures cutanées locales mesurées en pratique clinique sont-elles prédictives de la température cutanée moyenne chez le nouveau-né prématuré ?

Background

Measurement of mean skin temperature (Tsk) is fundamental in quantifying heat exchanges between premature neonates and their environment. The use of an infrared camera provides Tsk measurements, so called TskIR, which is highly accurate, non-invasive and does not impact on the environment of the neonate. However, the cost and time of analysis using this technique cannot be applied in clinical practice. An alternative proposed method is to calculate TskIR from two local skin temperatures, hepatic (Thep) and peripheral (Tperiph), which are routinely measured in clinical settings using thermal probes.

Objective

To determine the relationship between TskIR, Thep and Tperiph for premature infants less than 32 weeks of gestational age.

Methods

Thirty-six premature infants were placed in closed incubators regulated and randomly assigned either in air (N = 18) or in skin mode (N = 18). TskIR, Thep and Tperiph (on the calf) were recorded every minute for 10 consecutive hours.

Results

There was no correlation between TskIR and Thep. However, TskIR and Tperiph were significantly correlated (TskIR = 0.34 + 23.41 Tpériph) when the two control modes were combined. In skin mode, the correlation was stronger (R² = 0.55) than in air mode (R² = 0.0004).

Conclusion

Tperiph, routinely recorded in clinical settings on the calf, accurately estimates TskIR.     

Lutte contre l’anémie de la femme enceinte dans l’Ouest guyanais : diagnostic et mise en oeuvre d’actions par le réseau Périnat Guyane autour d’une évaluation des pratiques professionnelles

In Western French Guiana, 70% of pregnant women have anemia. Périnat Guyane network coordinated a practice review using a clinical pathway in order to improve prevention, screening, and care for anemia during pregnancy. Before implementation of actions, 54 medical records were audited. After implementation, 82% of practitioners reported to have changed their professional practice.     

Élaboration et diffusion dans un réseau de santé en périnatalité de recommandations concernant les « Soins au nouveau-né normal dans les deux premières heures »

Perinatal “Sécurité naissance-Pays de la Loire” (France) network organized together with paediatricians and midwives of the 24 maternity units in the region of meetings to propose, in 2005 and 2006, recommendations on the care of healthy newborns in the six first hours. This theme was chosen because of new attitudes have for the good treatment of children, once their safety assured. Consensus points which have been identified: definition of normality at birth, limiting the introduction of oral and nasal pharynx suction, the environment of the newborn, delayed actions, clinical examination at birth… Other discussion points were made and were left to the discretion of teams: the time of cord clamping, testing of atresia of the esophagus by the introduction of a gastric suctioning, indications and modalities and skin to skin and eye care. Sending telematics days and at regular scientific network with pediatricians, midwives and gynecologists-obstetricians ensured dissemination. These recommendations have been assessed by an audit statement shows good acceptability and good feasibility of those who responded to the audit (15/24). An audit observation practices birth room should be provided.