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La mortalité maternelle est considérée depuis quelques années comme un problème de santépublique au Sénégal ; ce qui a engendré pendant ces dernières décennies, un ensemble d’actionsparfois pertinentes, mais dont la mise en oeuvre est très souvent discutée, comme c’est le cas dansde nombreux pays africains.En 2010, le ratio de mortalité maternelle du pays est estimé à 392 décès maternels pour 100 000naissances vivantes selon le rapport de l’enquête démographique et de santé (EDS). Ce niveau resteélevé en dépit d’une hausse considérable du recours à l’assistance à l’accouchement.L’assistance médicale à l’accouchement qualifiée, définie comme « le processus par lequel unefemme reçoit des soins adéquats durant le travail, l’accouchement et le post-partum précoce », estapparue dans plusieurs études comme un déterminant-clé dans le processus de réduction de la mortalitématernelle.Deux conclusions principales sont obtenues à partir de nos analyses.D’une part, la très forte hausse du recours à l’assistance médicale à l’accouchement observée aucours de la première décennie des années 2000 a été sanctionnée par une baisse régulière, mais modérée,de la mortalité maternelle. D’autre part, cette faible baisse s’explique par une offred’assistance médicale à l’accouchement excessivement centrée sur des sages-femmes dont les qualificationssont hétérogènes et trop souvent limitées. Elle s’explique aussi par des infrastructures encoretrop peu adaptées à la gestion des urgences obstétricales.En effet, malgré tous les progrès accomplis dans ce domaine, il reste encore une marge importantepour poursuivre l’accès à un accouchement assisté. C’est en particulier le cas dans les campagnes,chez les femmes les plus jeunes, celles qui ont reçu une faible instruction et qui dépendent exagérémentde leurs conjoints. De ce fait, il serait intéressant de mener des politiques de sensibilisationdu côté des hommes.Au final, les enjeux futurs de l’assistance médicale à l’accouchement au Sénégal continuent à combinerdes problèmes d’offre et des problèmes de demande malgré les progrès accomplis dans cedomaine. / Maternal mortality is considered for several years as a public health problem in Senegal; which resultedin recent decades of a set of relevant actions sometimes, but the implementation is very oftendiscussed, as is the case in many African countries.In 2010, the maternal mortality ratio in the country is estimated at 392 maternal deaths per 100,000live births according to the report of the Demographic and Health Survey (DHS). This level remainshigh despite of a significant increase in the use of Delivery Assistance.The qualified medical assistance in childbirth, defined as "the process by which a woman receivesadequate medical care during labor, delivery and the early postpartum," has appeared in severalstudies as a key determinant in the maternal mortality reduction process.We can note two main conclusions from our analysis.First, the very strong increase in the use of medical assistance in delivery which has been observedin the first decade of the 2000s was sanctioned by a regular but moderate decline in maternal mortality.Then, this small decrease is due to a medical assistance in childbirth entirely performed bymidwives whose qualifications are heterogeneous and often limited. It is also explained by infrastructureswhich are not adapted to the management of obstetric emergencies.In fact, despite all the progress made in this field, there still are significant things to do before accessingto assisted delivery. This is particularly the case in rural areas, among younger women,those who received low education and who depend excessively on their husbands. Therefore, itwould be interesting to make aware of men on this issue.In the end, the future challenges of Assisted Reproduction Technology (ART) in Senegal continueto combine problems of supply and demand problems despite the progress made in this field.

Problématique : Quelle est l’association entre la pratique traditionnelle du lit de feu et la dépression post-partum chez les femmes lao? Considérant que les répercussions de la dépression post-partum peuvent affecter tant la femme que le nouveau-né et la famille, cette étude vise à contribuer à la connaissance que l’on a de cette condition. Pour ce faire, elle s’interroge sur le rôle thérapeutique d’un rituel traditionnel pratiqué par plus de la majorité des femmes en RDP Lao. Méthodologie : Cette étude transversale vise à explorer la relation entre la dépression post-partum et la pratique du lit de feu. Pour ce faire, 105 femmes ont été interrogées à l'hôpital central Mahosot de Vientiane (en RDP Lao) à l’aide de deux questionnaires. Résultats : 13,33 % des femmes ont des symptômes dépressifs importants et 90,48 % des femmes ont pratiqué le lit de feu. Les analyses suggèrent que le soutien social, la grossesse non désirée et l’histoire de dépression pendant la grossesse ont une association significative avec la dépression postnatale. Le modèle multivarié faisant interagir ces trois variables permet d’expliquer 22,5% de la variance de la variable dépendante (valeur-p de 0,0003). En raison d’un manque de variabilité dans les données obtenues, il est impossible d’étudier l’association entre les deux variables principales (pratique du lit de feu et dépression postnatale). Conclusion : Bien que les résultats obtenus supposent que le support social mobilisé par la pratique du lit de feu contribue positivement à la santé psychologique des nouvelles mères, il est impossible de confirmer l’effet protecteur global de la pratique sur la dépression postnatale. Pour répondre à une telle hypothèse, des études ultérieures seraient à encourager. Mots-clés : dépression post-partum ; pratiques traditionnelles ; lit de feu ; RDP Lao ; culture ; support social ; santé mentale / Problematic: What is the association between the traditional hot bed practice and postpartum depression among Lao women? Considering that the impact of postpartum depression can affect the woman, the newborn and the family, this study aims to contribute to the knowledge of this condition. To do so, the study explores the therapeutic role of a traditional ritual, still practiced by more than the majority of women in Lao PDR. Methodology: This cross-sectional study aims to explore the relationship between postpartum depression and the hot bed practice. 105 women were interviewed at Mahosot Central Hospital in Vientiane (Lao PDR) using two questionnaires. Results: 13.33% of women had significant depressive symptoms and 90.48% of women practiced the hot bed. The analyzes suggest that social support, unwanted pregnancy and the history of depression during pregnancy have a significant association with postnatal depression. The multivariate model, which interacts with these three variables, explains 22.5% of the variance of the dependent variable (p-value of 0.0003). Due to a lack of variability in the data obtained, it is impossible to study the association between the two main variables (hot bed practice and postnatal depression). Conclusion: Although the results obtained indicate that the social support mobilized by the hot bed contributes positively to the psychological health of new mothers, it is impossible to confirm the protective effect of the practice on postnatal depression. To answer such a hypothesis, further studies exploring the components of the practice should be encouraged. Keywords: postpartum depression; traditional practices; hot bed; Lao PDR; culture; social support; mental Health

Diss. (sammanfattning) Stockholm : Karolinska institutet, 2007. / Härtill 4 uppsatser.

Hibiscus tiliaceus L. (Malvaceae) é usado popularmente em desordens do pós-parto. O extrato metanólico de flores de H. tiliaceus apresentou atividade antidepressiva-like nos testes de nado forçado e de suspensão da cauda, ambos são amplamente usados como modelos animais preditivos da atividade antidepressiva. Além disso, o extrato demonstrou uma tendência de aumento do tempo gasto nos braços abertos no labirinto em cruz elevado. Considerando que o extrato de H. tiliaceus, que contém fitoesteróis como o estigmasterol, o stigmastadienol e o stigmastadienone, pode ser útil no tratamento ou prevenção da depressão pós-parto relacionadas à retirada crônica de altos níveis de hormônios associados à gestação. Nosso objetivo foi avaliar o efeito de extratos de H. tiliaceus em modelo animal de depressão pós-parto e ansiedade. Utilizamos ratas Wistar fêmeas submetidas ao modelo de depressão pós-parto induzido por hormônios (estradiol e progesterona), administrados por via subcutânea. Após período gestacional induzido, os animais receberam água, veiculo ou extrato de H. tiliaceus nas doses de 100 e 400mg/kg, via oral (gavagem). No período pós-parto, as ratas foram submetidas a testes comportamentais de nado forçado, o labirinto em cruz elevado e de preferência claro-escuro como modelos preditivo de depressão e ansiedade. Foi obsevado um aumento no tempo de imobilidade associado a uma diminuição na tentativa de fuga, no teste do nado forçado, em animais submetidos ao modelo de depressão pós-parto comparado ao grupo controle, sugerindo que este modelo é capaz reproduzir sintomas de depressão pós-parto. Não houve diferença significativa nos testes de ansiedade entre os animais submetidos ao modelo de depressão pós-parto comparado aos controles. A administração de extrato metanólico de H. tiliaceus não foi capaz de alterar o comportamento relacionado à depressão e ansiedade em ratas Wistar. / Postpartum affective disorders are rarely modeled. The depressive-like behavior of hormone withdrawal following hormone-simulated "pregnancy" was described in Long-Evans and Sprague Dawley rats. Our aim was to evaluate the validity of hormone withdrawal following hormonesimulated "pregnancy" method in Wistar rats as a model of depression and/or anxiety. Recently, it was demonstrated an antidepressant-like profile of methanol extract of Hibiscus tiliaceus L., a plant used in postpartum disorders, in adult male Swiss albino mice, then, we also investigated the antidepressant and anxiolytic-like activities of the methanol extract of H. tiliaceus flowers using this animal model of postpartum disorder. Ovariectomized rats received daily injections of the vehicle or hormones (estradiol and progesterone) to simulate the 23-day gestational period in the rat. Days 24-27 were considered the ''post-partum'' period, where the methanolic extract of H. tiliaceus or vehicle were administered by gavage. Rats were submitted to forced swimming, elevated plus-maze test and lightdark box tests. Rats submitted to ''post-partum depression model'' increased the immobility time in forced swimming. The methanolic extract of H. tiliaceus administration did not alter the immobility time in the forced swim test. In the light-dark box test, rats submitted to post-partum depression model showed decreases in number of rearing in dark compartment. In conclusion, our data indicate that Wistar rats may be an adequate model postpartum affective disorders, showing ''depressive-like'' symptoms in the forced swim test without any anxiogenic effect. Besides, we could suggest that decrease on number of rearing in the dark compartment may indicate the motivational state.

Made available in DSpace on 2014-12-17T14:03:29Z (GMT). No. of bitstreams: 1 DanielleSB.pdf: 977139 bytes, checksum: 8435c2a5e1927080b529352e7ed8ae63 (MD5) Previous issue date: 2008-07-03 / Coordena??o de Aperfei?oamento de Pessoal de N?vel Superior / Vitamin A deficiency (VAD) is a serious public health problem in developing countries, and as a therapeutic and prophylactic measure retinil palmitate is being supplemented. Nevertheless its efficacy has been questioned. The objective of the study was to evaluate the supplementation of two retinil palmitate megadosis on the serum retinol levels of post partum healthy mothers from Dr. Jos? Pedro Bezerra (Hospital Santa Catarina) hospital, Natal - RN. The enrolled women (n=199) were randomly distributed into three studied groups and supplemented with retinil palmitate immediately after delivery with a single 200,000 IU dose (group S1), two 200,000 IU dose (group S2) with 24h difference between the doses, or no supplementation (group C). Among women selected, 143 remained until the end of the study. The influence of vitamin A dietary intake was evaluated during pregnancy and after 30 days of delivery. The average intake of the population was reasonable, but a high prevalence of inadequate intake was found. Retinol in colostrums and mature milk was determined by high performance liquid chromatography (HPLC). The retinol average in colostrums and mature milk in the supplemented and control groups were adequate according to the reference values. In colostrums, women from groups C, S1 and S2 presented retinol averages by milk volume of 94.8 ? 40.2 ?g/dL, 92.2 ? 50.0 ?g/dL and 91.8 ? 53.7 ?g/dL, respectively. No difference was found between these averages (p=0.965), this was also seen when the values where expressed as ?g/g of fat (p=0.905). After 30 days of delivery, retinol per milk volume differed between the control group (36.6 ? 17.5 ?g/dL) and groups supplemented with 200,000 IU (51.0 ? 28.8 ?g/dL) or 400,000 IU (55.2 ? 31.6 ?g/dL) of retinil palmitate (p<0,05). Nevertheless, when S1 and S2 groups where compared, no significant difference was found (p=0.97). Considering retinol/g of fat, the means were 12.7 ? 6.7 ?g/g, 15.6 ? 8.3 ?g/g and 17.2 ? 8.9 ?g/g for groups C, S1 and S2, respectively, with significant difference between groups S2 and C (p=0,01). Subclinical VAD prevalence showed a serious public health problem in the study population (32% in colostrums and 31.5% in mature milk). When analyzing the groups separately, the group which received two doses (200,000 IU + 200,000 IU) presented the lowest VAD prevalence (20.7%). Retinil palmitate supplementations of 200,000 IU and 400,000 IU (divided in two doses) in the immediate post partum showed no significant difference. Nevertheless, the 400,000 IU (divided in two doses) supplementation showed a reduction in VAD / A defici?ncia de vitamina A (DVA) ? um grave problema de sa?de p?blica nos pa?ses em desenvolvimento e por este motivo tem-se implementado a suplementa??o com retinil palmitato como medida terap?utica e profil?tica. Entretanto, a sua efic?cia tem sido questionada. O estudo objetivou avaliar o efeito da suplementa??o materna de duas megadoses de retinil palmitato (200.000 UI cada uma) no p?s-parto, sobre os n?veis de retinol no leite materno de lactantes saud?veis do hospital Dr. Jos? Pedro Bezerra (Hospital Santa Catarina), Natal - RN. As mulheres recrutadas (n=199) foram distribu?das aleatoriamente em tr?s grupos de estudo e suplementadas com retinil palmitato no p?s-parto imediato com dose ?nica de 200.000 UI (grupo S1), dose dupla de 200.000 UI espa?adas de 24h (grupo S2) ou n?o receberam suplementa??o (grupo C). Dentre as mulheres originalmente selecionadas, 143 permaneceram at? o fim do experimento. Foi verificada a influ?ncia do consumo alimentar de vitamina A durante a gesta??o e ap?s 30 dias do parto. O consumo m?dio da popula??o foi satisfat?rio, por?m ainda foi encontrada uma expressiva preval?ncia de consumo inadequado. O retinol no leite colostro e no leite maduro de 30 dias foi determinado por Cromatografia L?quida de Alta Efici?ncia (CLAE). As m?dias de retinol nos leites colostro e maduro dos grupos suplementados e controle, apresentaram-se adequadas em rela??o aos valores de refer?ncia. No leite colostro, as mulheres dos grupos C, S1 e S2 apresentaram m?dias de retinol por volume de leite de 94,8 ? 40,2 ?g/dL; 92,2 ? 50,0 ?g/dL e 91,8 ? 53,7 ?g/dL, respectivamente, n?o sendo encontrada diferen?a entre estas (p=0,965), o que tamb?m ocorreu quando expresso em ?g/g gordura (p=0,905). No p?s-parto de 30 dias, o retinol por volume de leite diferiu entre o grupo controle (36,6 ? 17,5 ?g/dL) e os grupos suplementados com 200.000 UI (51,0 ? 28,8 ?g/dL) ou 400.000 UI (55,2 ? 31,6 ?g/dL) de retinil palmitato (p<0,05). Por?m, quando S1 e S2 foram comparados entre si, n?o foi encontrada diferen?a significativa (p=0,97). Considerando-se o retinol/g de gordura, as m?dias foram 12,7 ? 6,7 ?g/g; 15,6 ? 8,3 ?g/g e 17,2 ? 8,9 ?g/g para os grupos C, S1 e S2, respectivamente, havendo diferen?a significativa entre S2 e C (p=0,01). A preval?ncia de defici?ncia subcl?nica de Vitamina A revelou um grave problema de sa?de p?blica (32% no leite colostro e 31,5% no leite maduro) na popula??o. Analisando-se os grupos separadamente, aquele que recebeu dose dupla (200.000 UI + 200.000 UI) apresentou o menor percentual de DVA (20,7%). As suplementa??es de 200.000 UI e 400.000 UI de retinil palmitato (dividida em duas doses) no p?s-parto imediato, n?o mostraram diferen?a significativa. Entretanto, considerando o ?ltimo tratamento, foi observada uma diminui??o da preval?ncia de DVA

Hibiscus tiliaceus L. (Malvaceae) é usado popularmente em desordens do pós-parto. O extrato metanólico de flores de H. tiliaceus apresentou atividade antidepressiva-like nos testes de nado forçado e de suspensão da cauda, ambos são amplamente usados como modelos animais preditivos da atividade antidepressiva. Além disso, o extrato demonstrou uma tendência de aumento do tempo gasto nos braços abertos no labirinto em cruz elevado. Considerando que o extrato de H. tiliaceus, que contém fitoesteróis como o estigmasterol, o stigmastadienol e o stigmastadienone, pode ser útil no tratamento ou prevenção da depressão pós-parto relacionadas à retirada crônica de altos níveis de hormônios associados à gestação. Nosso objetivo foi avaliar o efeito de extratos de H. tiliaceus em modelo animal de depressão pós-parto e ansiedade. Utilizamos ratas Wistar fêmeas submetidas ao modelo de depressão pós-parto induzido por hormônios (estradiol e progesterona), administrados por via subcutânea. Após período gestacional induzido, os animais receberam água, veiculo ou extrato de H. tiliaceus nas doses de 100 e 400mg/kg, via oral (gavagem). No período pós-parto, as ratas foram submetidas a testes comportamentais de nado forçado, o labirinto em cruz elevado e de preferência claro-escuro como modelos preditivo de depressão e ansiedade. Foi obsevado um aumento no tempo de imobilidade associado a uma diminuição na tentativa de fuga, no teste do nado forçado, em animais submetidos ao modelo de depressão pós-parto comparado ao grupo controle, sugerindo que este modelo é capaz reproduzir sintomas de depressão pós-parto. Não houve diferença significativa nos testes de ansiedade entre os animais submetidos ao modelo de depressão pós-parto comparado aos controles. A administração de extrato metanólico de H. tiliaceus não foi capaz de alterar o comportamento relacionado à depressão e ansiedade em ratas Wistar. / Postpartum affective disorders are rarely modeled. The depressive-like behavior of hormone withdrawal following hormone-simulated "pregnancy" was described in Long-Evans and Sprague Dawley rats. Our aim was to evaluate the validity of hormone withdrawal following hormonesimulated "pregnancy" method in Wistar rats as a model of depression and/or anxiety. Recently, it was demonstrated an antidepressant-like profile of methanol extract of Hibiscus tiliaceus L., a plant used in postpartum disorders, in adult male Swiss albino mice, then, we also investigated the antidepressant and anxiolytic-like activities of the methanol extract of H. tiliaceus flowers using this animal model of postpartum disorder. Ovariectomized rats received daily injections of the vehicle or hormones (estradiol and progesterone) to simulate the 23-day gestational period in the rat. Days 24-27 were considered the ''post-partum'' period, where the methanolic extract of H. tiliaceus or vehicle were administered by gavage. Rats were submitted to forced swimming, elevated plus-maze test and lightdark box tests. Rats submitted to ''post-partum depression model'' increased the immobility time in forced swimming. The methanolic extract of H. tiliaceus administration did not alter the immobility time in the forced swim test. In the light-dark box test, rats submitted to post-partum depression model showed decreases in number of rearing in dark compartment. In conclusion, our data indicate that Wistar rats may be an adequate model postpartum affective disorders, showing ''depressive-like'' symptoms in the forced swim test without any anxiogenic effect. Besides, we could suggest that decrease on number of rearing in the dark compartment may indicate the motivational state.

Hibiscus tiliaceus L. (Malvaceae) é usado popularmente em desordens do pós-parto. O extrato metanólico de flores de H. tiliaceus apresentou atividade antidepressiva-like nos testes de nado forçado e de suspensão da cauda, ambos são amplamente usados como modelos animais preditivos da atividade antidepressiva. Além disso, o extrato demonstrou uma tendência de aumento do tempo gasto nos braços abertos no labirinto em cruz elevado. Considerando que o extrato de H. tiliaceus, que contém fitoesteróis como o estigmasterol, o stigmastadienol e o stigmastadienone, pode ser útil no tratamento ou prevenção da depressão pós-parto relacionadas à retirada crônica de altos níveis de hormônios associados à gestação. Nosso objetivo foi avaliar o efeito de extratos de H. tiliaceus em modelo animal de depressão pós-parto e ansiedade. Utilizamos ratas Wistar fêmeas submetidas ao modelo de depressão pós-parto induzido por hormônios (estradiol e progesterona), administrados por via subcutânea. Após período gestacional induzido, os animais receberam água, veiculo ou extrato de H. tiliaceus nas doses de 100 e 400mg/kg, via oral (gavagem). No período pós-parto, as ratas foram submetidas a testes comportamentais de nado forçado, o labirinto em cruz elevado e de preferência claro-escuro como modelos preditivo de depressão e ansiedade. Foi obsevado um aumento no tempo de imobilidade associado a uma diminuição na tentativa de fuga, no teste do nado forçado, em animais submetidos ao modelo de depressão pós-parto comparado ao grupo controle, sugerindo que este modelo é capaz reproduzir sintomas de depressão pós-parto. Não houve diferença significativa nos testes de ansiedade entre os animais submetidos ao modelo de depressão pós-parto comparado aos controles. A administração de extrato metanólico de H. tiliaceus não foi capaz de alterar o comportamento relacionado à depressão e ansiedade em ratas Wistar. / Postpartum affective disorders are rarely modeled. The depressive-like behavior of hormone withdrawal following hormone-simulated "pregnancy" was described in Long-Evans and Sprague Dawley rats. Our aim was to evaluate the validity of hormone withdrawal following hormonesimulated "pregnancy" method in Wistar rats as a model of depression and/or anxiety. Recently, it was demonstrated an antidepressant-like profile of methanol extract of Hibiscus tiliaceus L., a plant used in postpartum disorders, in adult male Swiss albino mice, then, we also investigated the antidepressant and anxiolytic-like activities of the methanol extract of H. tiliaceus flowers using this animal model of postpartum disorder. Ovariectomized rats received daily injections of the vehicle or hormones (estradiol and progesterone) to simulate the 23-day gestational period in the rat. Days 24-27 were considered the ''post-partum'' period, where the methanolic extract of H. tiliaceus or vehicle were administered by gavage. Rats were submitted to forced swimming, elevated plus-maze test and lightdark box tests. Rats submitted to ''post-partum depression model'' increased the immobility time in forced swimming. The methanolic extract of H. tiliaceus administration did not alter the immobility time in the forced swim test. In the light-dark box test, rats submitted to post-partum depression model showed decreases in number of rearing in dark compartment. In conclusion, our data indicate that Wistar rats may be an adequate model postpartum affective disorders, showing ''depressive-like'' symptoms in the forced swim test without any anxiogenic effect. Besides, we could suggest that decrease on number of rearing in the dark compartment may indicate the motivational state.

Contexte : La pré-éclampsie (PE) est une pathologie ischémique placentaire se manifestant par un syndrome materno-fœtal pendant la grossesse, et dont seul l’accouchement peut interrompre la progression. La PE peut survenir dans le post-partum et cette forme atypique de PE n’est pas expliquée par notre compréhension actuelle de la maladie. L’objectif de ce travail est de formuler des hypothèses physiopathologiques et de les explorer par l’étude des facteurs de risques, des potentiels facteurs déclencheur et de les corréler à l’étude de l’histopathologie des placentas. Méthode : Il s’agit d’une étude cas-témoins, comparant les caractéristiques démographiques et obstétricales des cas de PE du post-partum (n=50), à celles des cas de PE ante-partum précoce (n=100) et tardive (n=100), et à des grossesses normotensives (n=100). Pour l’étude de l’histopathologie placentaire, 30 placentas par groupe ont été étudiés. Les patientes ont été recrutées sur la base de registres de patientes avec troubles hypertensifs, tenus par les centres participants et sur la base des codes diagnostiques issus de la classification internationale des maladies (CIM). Résultats : Aucune différence statistiquement significative n’a été observée entre les groupes en terme d’âge, d’indice de masse corporelle, de primiparité, de recours aux techniques de procréation médicalement assistée et de décès néonataux. La PE du post-partum est associée à l’ethnie afro-caribéenne (OR 3.0, IC 95% 1.3-6.7 ; p <0.01), l’hypertension artérielle (HTA) pré-gestationnelle (OR 46.3, IC 95% 7.4-∞; p <0.01), la gémellité (OR 7.7, IC 95% 1.4-78.7) ; p<0.01), un état infectieux péri-partum (OR 6.5, IC 95% 1.8-29.7 ; p<0.01), la provocation du travail (OR 6.0, IC 95% 1.8-21.4 ; p <0.01), et des valeurs de tension artérielle (TA) avant la sortie de la maternité normales-hautes, tant pour la valeur systolique (OR 10.2, IC 95% 4.3-25.4 ; p<0.01) que pour la valeur diastolique (OR 30.2, IC 95% 8.3-168.3 ; p<0.01). Au niveau placentaire, 40% des placentas des cas de PE post-partum présentaient une déciduite aiguë (PE précoce: 5.7% (2), p<0.01; PE tardive: 16.7% (5), p=0.046; normotendues: 3.2% (1), p<0.01), 39.4% (13) démontraient une anomalie de la maturité villositaire (PE précoce: 77.2% (27), p<0.01; PE tardive: 26.7% (8), p=0.3; normotendues: 3.2% (1), p<0.01), 18.2% (6) montraient une vasculopathie déciduale (PE précoce: 34.3% (12), p=0.13; PE tardive: 10% (3), p=0.35; normotendues: 9.7% (3), p=0.33) et 9.1% (3) présentaient des signes d’ischémie et d’infarctus (PE précoce: 51.4% (18), p<0.01; PE tardive: 13.3% (4), p=0.6; normotendues: 16.1% (5), p=0.4). Conclusions : Les résultats de nos travaux suggèrent que les patientes présentant une PE dans le post-partum ont un profil de risque similaire à celui de la PE typique de l’ante partum, en particulier des PE tardives survenant au delà de 34 SA. La modification de la date de l’accouchement par l’intervention médicale et la provocation du travail pourrait agir comme facteur déclencheur de la PE dans le post-partum, de même qu’une infection aiguë. Les premiers signes de PE post-partum peuvent être détectés par la mesure de la TA avant la sortie de la maternité. Aucune différence significative n’a été observée au niveau placentaire, en terme de vasculopathie déciduale et de signes d’ischémie placentaire. Le taux de déciduite aiguë était plus important dans la PE du post-partum. Au total, la PE du post-partum semble être une pathologie maternelle, survenant dans un contexte d’état inflammatoire accru, possiblement déclenchée par une infection aiguë, où la maladie ischémique placentaire joue peu ou aucun rôle. / Background: Pre-eclampsia (PE) is an ischemic placental disease that is clinically expressed by a maternal-fetal syndrome. Only delivery can stop the progression of the disease. PE can occur after delivery and this atypical from of PE is not explained by our current understanding of the physiopathology. The objective of this work was to formulate physiopathological hypotheses for post-partum PE, to explore them by identifying the risk factors, potential triggers and to correlate them to a histological study of the placenta of women who would later present with post-partum pre-eclampsia. Methods: This is a case-control study, comparing the demographic and obstetrical characteristics of cases of post-partum PE (n=50) with cases of early-onset PE (n=100), late-onset PE (n=100) and normotensive pregnancies (n=100). For the pathological study, 30 placentas per group were included. Patients were identified on a registry of hypertensive disorders of pregnancy and through the codification of the International Classification of Diseases (ICD). Results: There was no difference in term of age, body mass index, primiparity, use of reproductive technology and neonatal death between groups. Post-partum PE was associated with Afro-Caribbean ethnicity (OR 3.0, CI 95% 1.3-6.7; p <0.01), pre-gestationnal hypertension (OR 46.3, CI 95% 7.4-∞; p <0.01), twin pregnancies (OR 7.7, CI 95% 1.4-78.7); p<0.01), peri-partum infectious diseases (OR 6.5, IC 95% 1.8-29.7; p<0.01), induction of labor (OR 6.0, IC 95% 1.8-21.4; p <0.01), and normal-high blood pressure value before discharge of the maternity ward, for the systolic value (OR 10.2, IC 95% 4.3-25.4; p<0.01) as well as for the diastolic value (OR 30.2, IC 95% 8.3-168.3 ; p<0.01). Forty percent of placenta of post-partum PE had acute deciduitis (early PE: 5.7% (2), p<0.01; late PE: 16.7% (5), p=0.046; normal: 3.2% (1), p<0.01), 39.4% (13) had abnormal maturation of the villi (early PE: 77.2%(27), p<0.01; late PE: 26.7%(8), p=0.3; normal: 3.2 %(1), p<0.01), 18.2% (6) had decidual arteriolopathy (early PE: 34.3% (12), p=0.13; late PE: 10% (3), p=0.35; normal: 9.7% (3), p=0.33) and 9.1% (3) had villous ischemia and infarction (early PE: 51.4% (18), p<0.01; late PE: 13.3% (4), p=0.6; normal: 16.1% (5), p=0.4). Conclusions: Our work suggests that patients presenting with post-partum PE have similar risk profile than the typical antepartum PE, in particular with late-onset PE (after 34 weeks of gestation). Modification of the delivery date by medical intervention and induction of labor, might act as a trigger, as well as an acute infection. First signs of post-partum PE can be detected through measurement of blood pressure before discharge of the maternity. There were no significant differences in the placentas in terms of decidual arteriolopathy and villi ischemic changes between post-partum PE, late onset PE and the controls. There was a higher level of acute deciduitis in the placenta of post-partum PE. Altogether, our results suggests that post-partum preeclampsia is more of a maternal disease, characterized by an increased inflammatory state, potentially triggered by infection, and in which placental ischemic disease has little or no role to play.

Le ratio de mortalité maternelle en Afrique de l’Ouest est le plus élevé au monde et l’hémorragie du post-partum (HPP) y est la principale cause directe de mortalité maternelle. L’objectif général de ce travail était d’apporter des connaissances pour améliorer la prise en charge des HPP dans les structures hospitalières en Afrique de l’Ouest. Tout d’abord, nous avons montré que les facteurs de risques maternels de morbi-mortalité liée à l’HPP retrouvés dans les pays à ressources élevées étaient généralisables au contexte de l’Afrique de l’Ouest. Par ailleurs, nos analyses suggèrent que la qualification du médecin en charge du service de maternité (médecin généraliste versus gynécologue-obstétricien) a un impact déterminant sur la survie des femmes présentant une HPP dans ce contexte. Ensuite, nous avons montré que l'injection d'ocytocine dans les dix minutes qui suivent le diagnostic d’HPP était un facteur déterminant pour améliorer la santé maternelle au Bénin et au Mali. Le diagnostic rapide de l’HPP et une meilleure surveillance du post-partum immédiat étaient également importants. Enfin, nous avons mis en place une étude pilote pour évaluer la faisabilité d’un essai contrôlé randomisé (ECR) dont l’objectif est de tester l’efficacité du tamponnement utérin par condom catheter dans la prise en charge des hémorragies du post-partum dans cette région. Les résultats ont montré que la mise en place d’un ECR était faisable et ont apporté des connaissances supplémentaires pour optimiser le protocole de recherche. Ainsi, nous avons identifié un certain nombre de facteurs sur lesquels des actions doivent être menées pour améliorer la qualité de la prise en charge de l’HPP. / The maternal mortality ratio in West Africa is the highest in the world and postpartum hemorrhage (PPH) is the leading direct cause of maternal mortality. The general objective of this work was to provide knowledge to improve the management of PPH in hospitals in West Africa. Firstly, we have highlighted that maternal risk factors for morbidity and mortality related to the PPH found in high-resource countries were generalizable to the context of West Africa. Furthermore, our analysis suggests that the qualification of the doctor in charge of the maternity unit (general practitioner versus obstetrician) has a decisive impact on the maternal issue in this context. Then, we showed that injection of oxytocin within ten minutes after the diagnosis of PPH was a key factor for improving maternal health in Benin and Mali. Rapid diagnosis of PPH and better monitoring of the immediate postpartum period were also important. Finally, we set up a pilot study to assess the feasibility of a randomized controlled trial (RCT), which aims to test the effectiveness of uterine tamponade with condom catheter in the postpartum hemorrhage management in this region. The results showed that f a RCT was feasible and provided additional knowledge to optimize the research protocol. Thus, we have identified a number of factors on which action should be taken to improve the quality of PPH management.