Relationships between placental GH concentration and maternal smoking, newborn gender, and maternal leptin: possible implications for birth weight.

The control of fetal growth depends on multiple hormones, including both IGF-I and placental GH (PGH) in the mother, and IGF-I rather than pituitary GH (pitGH) in the fetus. Leptin, which is produced by adipocytes and syncitiotrophoblast cells, has also been thought to influence fetal growth by an as yet unknown mechanism. This study assessed the relationships between the GH-IGF-I axis in mothers and newborns, and maternal smoking, neonate gender, and maternal and fetal leptin. We collected blood in 87 mothers at the onset of labor and cord blood immediately after birth in their 87 healthy full-term newborns. GH concentrations were log(10) transformed, and data were expressed as the geometric mean (-1, +1 tolerance factor). PGH was lower in the 30 smoking mothers, as compared with the 57 nonsmoking mothers [18.2 (11.5; 28.6) vs. 27.0 (15.1; 48.2) microg/liter, P < 0.01]. Cord blood IGF-I was lower in neonates from smoking mothers (90 +/- 44 vs. 135 +/- 65 microg/liter, mean +/- SD, P < 0.01), consistent with their lower birth weight percentile (P < 0.01). A gender effect was observed for PGH, which was higher when the newborn was female, and for newborn pitGH and newborn leptin, which were, respectively, lower and higher in females, even after adjustment for birth weight and maternal smoking category (P < 0.05 for all comparisons). Multiple regression analyses identified maternal leptin as a negative predictor of PGH (P < 0.05) and newborn leptin as a positive predictor of newborn IGF-I (P < 0.05). Maternal smoking is associated to decreased maternal PGH and cord blood IGF-I concentrations. A sexual dimorphism for PGH, newborn pitGH, and newborn leptin exists at the time of birth, but its physiological significance remains to be studied. The relationships between maternal leptin and PGH and between cord blood leptin and IGF-I are consistent with the hypothesis that leptin could contribute to the control of fetal growth.

[Bone mineral density in patients with cystic fibrosis by dual-energy X-ray absorptiometry]. / Etude de la minéralisation osseuse de patients mucoviscidosiques par absorptiométrie biphotonique à rayons X.

BACKGROUND: The aim of this study was to assess the bone mineral density of cystic fibrosis patients. PATIENTS AND METHODS: We have retrospectively studied 45 patients with cystic fibrosis, 22 females and 23 males, aged between six and 27 years (mean 13 +/- 5.5 years). Nutritional status, Shwachman score, pulmonary function, serum calcium and 25-hydroxyvitamin D levels and lumbar bone mineral density by dual energy X-ray absorptiometry were assessed. RESULTS: The average height of the patients was 97 +/- 4% (range: 86-106) and body mass index 93 +/- 10% (range 77-114) of the normal values of age. The average Shwachman score was 80 +/- 11/100 (range: 47-96). The forced expiratory volume in 1s was 80 +/- 29% (21-128) and the vital capacity 85 +/- 21% (range: 40-122) of the predicted values. The serum levels of calcium and 25-hydroxyvitamin D were lower than normal values in six cases and one case respectively. Thirty-eight patients had a mean lumbar spine bone mineral Z-score which was -1.35 +/- 1.2 DS and 84.7 +/- 13.5% of the normal values. It was correlated with the height, the body mass index, the Shwachman score, the FEV 1 and the vital capacity. CONCLUSION: Decreased bone density is frequent among cystic fibrosis subjects. It shows a lack of control of the illness. It remains unknown with usual investigation; the dual X-ray absorptiometry should, each time it is possible, take part of investigations in those patients.

[Gravely ill newborns (excluding greatly premature) in 1986 and 1995 in three deparments of Pays de la Loire]. / Les nouveau-nés gravement malades (grande prématurité exclue) en 1986 et en 1995 dans trois départements des Pays de la Loire.

AIM: Evaluation of the progress in the treatment of seriously ill newborn infants under hospital care over the nine-year period from 1986 to 1995 in three departments of the Pays de la Loire region in France. POPULATION AND METHODS: The category of seriously ill newborn infants included only infants born after at least 32 weeks of gestation and having a Cullen severity score higher than 2. The two groups of seriously ill newborn infants at risk in 1986 and 1995 were first compared to a control group of healthy newborn babies delivered during the same years. The two groups were then compared with each other. RESULTS: In 1986 and 1995, the numbers of births were respectively 32,876 and 29,446, and the numbers of seriously ill newborn infants under hospital care were respectively 307 and 245. However, between 1986 and 1995 the risk factors as well as the causes of morbidity had changed. The average period of hospitalization decreased by five days. The mortality rate dropped from 0.16% to 0.09% (P < 0.05) and the number of serious complications decreased from 0.07% to 0.03% (P < 0.05). CONCLUSION: The improvement in the care of seriously ill newborn infants between the two reference periods, 1986 and 1995, may be attributed not only to technical progress but also to a better organization of the perinatal care in our region.

[Fetal and neonatal mortality from 22 weeks of amenorrhea in the Loire area]. / La mortalité foetale et néonatale à partir de 22 semaines d'aménorrhée en Pays de la Loire.

BACKGROUND: The Pays de Loire has a low perinatal mortality indicators among French regions but this could be due to under-notification. OBJECTS: To explore this hypothesis we undertook a survey in order to identify all fetal and neonatal deaths occurring at a gestionnal age of 22 weeks or more. We also tried to examine and analyze the causes of death. METHODS: All maternity (26) and neonatal wards (5) in the region took part in the survey in 1995. Clinicians were asked to fill out a questionnaire for all deaths occurring from gestational age (GA) 22 weeks and/or concerning a birthweight of a least 500 g. Only perinatal deaths related to parents living in the Pays de Loire were included in the study. RESULTS: Two hundred and sixty seven perinatal deaths were identified out of a total 29,440 births (9.1 /1000). Eighty three (2.8 /1000) were termination of pregnancy for medical reasons, of which 82% were motivated by chromosomic illness. Ninety-nine stillbirths fell (3.4 /1000) into two GA periods: 24 to 27 weeks (20%) and 38 to 41 weeks (2%). The cause of stillbirths remained unknown in 50% of cases despite a post-mortem examination rate of 87%. There were 29 deaths (1 /1000) in the immediate per and post-partum, 40% of which occurred at GA 22 to 25 weeks. Another 38% occurred at GA 36 to 40 weeks and these were related to undectected malformations or infections. Neonatal and intensive care units reported 56 neonatal deaths (1.9 /1000). GA was under 33 weeks for 44% of them. Deaths were caused by usual complications of severe prematurity, neurologic diseases and malformations. Thirty-two percent of total deaths were not notified to the French Authority: 25% of deaths for termination of pregnancy for medical reasons and 7% for stillbirths and per and post partum deaths. CONCLUSION: This survey suggests that the Pays de Loire perinatal mortality indicators remained low compared with other French regions, even after adjustment for this under notification. This casts doubts on the validity of perinatal mortality monitoring based on official notifications. The cause may lie in the inadequacy of legislation of the particular circumstances of perinatal deaths.

[Evaluation of the impact and efficiency of high-fidelity simulation for neonatal resuscitation in midwifery education]. / Évaluation de la simulation haute-fidélité dans la formation initiale à la réanimation en salle de naissance chez les étudiants sages-femmes.

BACKGROUND: Prompt initiation of appropriate neonatal resuscitation skills is critical for the neonate experiencing difficulty transitioning to extra-uterine life. Expertise in neonatal resuscitation is essential for personnel involved in the care of newborns, above all for midwives who are sometimes alone to initiate the first resuscitation. The use of simulation training is considered to be an indispensable tool to address these challenges, not only in continuing education but also in midwifery education. OBJECTIVE: The aim of this study was to evaluate the impact and efficiency of high-fidelity simulation for neonatal resuscitation in midwifery education. METHODS: This was a prospective monocentric study conducted in the Angers university hospital between October and December 2012 and included two groups of midwifery students (n=40) who received high-fidelity simulation as part of their basic midwifery education. Participants' perceptions of the knowledge, skills, and confidence gained following training in high-fidelity simulation for neonatal resuscitation were determined using a pre-/post-test questionnaire design completed during the training and also several months after the course, as well as after the students had begun working. A satisfaction survey to evaluate this training was also completed at the same time. RESULTS: With a good participation rate (67.5%), the survey showed a high degree of satisfaction among the participants. This training was described as facilitating their hire in one third of cases. A significant increase in self-assessment of skills scores was observed between the pre-test and post-test (P<0.001), the pre-test and the distance test (P<0.001), and the post-test and distance test (P=0.007). Although a decrease in the median score was observed on the knowledge questionnaire given as a post-test, this median remained significantly higher than that obtained on the pre-test (P=0.03). CONCLUSION: The significant improvement in knowledge during the session and its preservation after a few months confirmed the efficacy of this teaching method. The simulation training increased the participants' perceptions of their knowledge, skills, and confidence in conducting neonatal resuscitation. These preliminary results are very encouraging and argue in favor of generalizing this teaching method. However, this training could be more profitable if it was proposed earlier in the midwifery curriculum and organized with a multidisciplinary team (pediatric and anesthesia residents).

Prenatal diagnosis of pyloric atresia-junctional epidermolysis bullosa syndrome in a fetus not known to be at risk.

Junctional epidermolysis bullosa with pyloric atresia (PA-JEB) is a highly lethal, inherited, autosomal recessive disease. Thus far, prenatal diagnosis of this syndrome was only realized on pregnancies at risk for recurrence. We report the case of a 26-year-old woman, first cousin to her husband, who had undergone amniocentesis for polyhydramnios. The karyotype was normal but the amniotic fluid contained acetylcholinesterase. A targeted scan at 25 weeks' gestation did not find spina bifida, but polyhydramnios with a dilated stomach, and several other anomalies: echogenic particles in the amniotic fluid, a thin skin which closely adhered to the nasal bones, narrow nostrils, abnormal ears, fisted hands, malposition of both first toes, and kidney malformation. Despite no previous case in the family, it was thought that sonographic findings were suggestive of the PA-JEB syndrome. A fetal skin biopsy was carried out at 28 weeks' gestation. The ultrastructural examination of fetal skin displayed JEB. Genetic analysis detected a homozygous mutation in the gene encoding integrin alpha 6. Termination of pregnancy was carried out at 29 weeks' gestation. These results illustrate that in the case of a fetus not known to be at risk, diagnosis of PA-JEB can be achieved by ultrasound findings leading to fetal skin biopsy and ultrastructural examination of blistered epidermis. Some new sonographic signs should raise the possibility of significant cutaneous desquamation and blister formation in a fetus, especially when there is positive amniotic acetylcholinesterase coupled with elevated alpha-fetoprotein or suspected pyloric atresia.