Elsevier Masson SAS on behalf of Socié té française d'anesthé sie et de ré animation (Sfar).

Despite the most modern treatment efforts, the maternal mortality was 36%. Scheduled cesarean delivery during combined spinal-epidural anesthesia seemed to be an attractive approach, but there was no evidence of actual benefit. Therefore, pregnancy must still be discouraged in patients with severe PH.

Laparoscopic surgery technology continues to advance. However, much less attention has been focused on how alteration of the laparoscopic surgical environment might improve clinical outcomes. We conducted a randomized, 2 × 2 factorial trial to evaluate whether low intraperitoneal pressure (IPP) (8 mmHg) and/or warmed, humidified CO2 (WH) gas are better for minimizing the adverse impact of a CO2 pneumoperitoneum on the peritoneal environment during laparoscopic surgery and for improving clinical outcomes compared to the standard IPP (12 mmHg) and/or cool and dry CO2 (CD) gas. Herein we show that low IPP and WH gas may decrease inflammation in the laparoscopic surgical environment, resulting in better clinical outcomes. Low IPP and/or WH gas significantly lowered expression of inflammation-related genes in peritoneal tissues compared to the standard IPP and/or CD gas. The odds ratios of a visual analogue scale (VAS) pain score >30 in the ward was 0.18 (95% CI: 0.06, 0.52) at 12 hours and 0.06 (95% CI: 0.01, 0.26) at 24 hours in the low IPP group versus the standard IPP group, and 0.16 (95% CI: 0.05, 0.49) at 0 hours and 0.29 (95% CI: 0.10, 0.79) at 12 hours in the WH gas group versus the CD gas group.

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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.

SummaryWe studied the potentiation of analgesia for labour by the addition of clonidine to epidural low-concentration levobupivacaine with sufentanil in a randomised, double-blinded study. We enrolled primiparous women who were in spontaneous labour. The study solutions, made of 100 ml levobupivacaine 0.0625% plus sufentanil 0.45 lg.ml )1 and either 150 lg clonidine or no clonidine, were used for induction of analgesia, and for its maintenance with self-administered boluses and a continuous background infusion. The need for additional epidural boluses during labour was lower and analgesia and maternal satisfaction were better in the clonidine (n = 57) than in the control group (n = 58). Blood pressure was lower and the rate of instrumental delivery higher in the clonidine group. Clonidine (1.36 lg.ml) added to the epidural solution of lowconcentration levobupivacaine improves the quality of analgesia. The relevance of the haemodynamic effects should be explored in larger validation studies. To relieve pain during labour with the fewest side effects possible, different solutions have been proposed. These include lowering the concentration of local anaesthetics and ⁄ or adding opioids to the anaesthetic solution, and developing less toxic drugs than bupivacaine [1]. We recently studied the effects of two formulations of levobupivacaine (0.0625% and 0.125%) for analgesia during labour in primiparous women, both with sufentanil 0.45 lg.ml )1 [2]. The solution was patient-administered after a first injection of 15-20 ml for induction. With low-concentration levobupivacaine, analgesia was sometimes insufficient, while high-concentration levobupivacaine provided better analgesia, but doses sometimes exceeded recommended limits. We hypothesised that addition of low-dose clonidine to low-concentration levobupivacaine would improve the quality of analgesia without exceeding recommended dose limits. Clonidine is known to potentiate epidural analgesia through inhibition of nociceptive transmission in the spinal cord via a2 receptors and through local anaesthetic effects [3,4]. Although epidural clonidine for labour is usually administered as a single injection [5,6], the addition of clonidine in epidural infusions has also been shown to improve analgesia during labour [7][8][9][10][11]. However, as concentrations over 2 lg.ml )1 may lead to more side effects [8,[10][11][12], we chose a safer dose of 150 lg of clonidine, diluted in our prefilled bags,

A standard and validated tool to assess MS in clinical research on analgesia for labor is still to be developed. Power should be improved by acting on sample sizes or sensitivity of the outcome.

Prenatal diagnosis of Blake's pouch cyst following first-trimester observation of enlarged intracranial translucencyA 27-year-old primigravida with no relevant medical history was seen for her first prenatal appointment and first-trimester ultrasound scan at 12 + 1 weeks' gestation. The crown-rump length (CRL) was 57.8 mm and the nuchal translucency thickness was 1.3 mm. First-trimester evaluation for combined risk did not indicate that the pregnancy was at high risk for aneuploidy, with a risk of 1/10 000.Following the publications by Chaoui and Nicolaides et al. 1 -3 , we systematically measure intracranial translucency (IT) at the first-trimester scan. For this fetus the IT was 3.5 mm (Figure 1), which is well above the 95 th percentile for CRL according to established reference ranges 1 . The patient was examined again at 23 and 32 weeks' gestation. Examination of fetal anatomy at 23 weeks showed a large cyst connecting the fourth ventricle with the retrocerebellar space. The vermis was present, along with otherwise normal fetal morphology and biometry. We noted an enlargement of the fourth ventricle and an elevation of the lower part of the vermis, which was shifted away from the posterior part of the brainstem in an anticlockwise rotation (Figure 2). Using the methodology described by Guibaud and des Portes 4 for the diagnosis of anomalies of the posterior fossa, we concluded that the fetus had a persistent Blake's pouch (or Blake's pouch cyst). At the time of writing the infant was 1 month old with normal findings on neurological examination and on transfontanellar ultrasound examination performed 2 weeks after birth (Figure 3).