Impact of prenatal estimation of the risk of respiratory distress in neonates with congenital pulmonary malformations on the choice of delivery site.

BACKGROUND: The vast majority of prenatally diagnosed congenital pulmonary malformations (CPM) remain asymptomatic at birth. The maximal value of the CPM volume ratio (CVRmax) predicts the risk of neonatal respiratory distress (NRD), and should allow for better assessment of the level of expertise needed at the delivery site. AIM: This study evaluated the level of maternity units currently chosen for the delivery of CPMs, and determined the impact of the choice of delivery site based on the CVRmax, with a threshold of 0.4 cm2. METHODS: Data were extracted from the French prospective MALFPULM cohort, with inclusion between March 2015 and June 2018. RESULTS: The final study population consisted of 383 women. Deliveries in level 1 or 2 maternity units (n = 98, 25%) involved CPMs with lower CVRmax (p<0.001), causing fewer signs of prenatal compression (p = 0.025). Among the 62 children (16%) who presented with NRD, only seven (11%) were born in level 1 or 2 units (p = 0.0078). Choosing the maternity level according to the CVRmax would have increased the number of births in level 1 or 2 maternity hospitals by 70%. In these maternity units, the percentage of children with NRD would have increased from 8% in the actual distribution to 10% in the new strategy. CONCLUSION: Our results showed an overuse of level 3 maternity hospitals for the delivery of newborns with a prenatal diagnosis of CPM. The use of CVRmax should enable a reduction in the use of expertise centers without an adverse impact on newborns.

Respiratory morbidity in children with congenital heart disease.

OBJECTIVE: To evaluate the respiratory outcome in children with congenital heart disease (CHD), considering recent management procedures and the CHD pathophysiology. DESIGN AND SETTING: Clinical and functional respiratory outcome were evaluated in 8-year-old children with isolated CHD followed up from birth in the prospective population-based EPICARD cohort. PATIENTS: Children were assigned to two groups, based on the pathophysiology of the CHD: CHDs with left-to-right shunt (n = 212) and CHDs with right outflow tract obstruction (n = 113). RESULTS: Current wheezing episodes were observed in 15% of the children with isolated CHD and left-to-right shunt, and 11% of the children with isolated CHD and right outflow tract obstruction (not significant). Total lung capacity (TLC) was the only respiratory function parameter that significantly differed between the two groups. It was lower in children with left-to-right shunt (88.72 ± 0.65% predicted) than in those with right outflow tract obstruction (91.84 ± 0.96, p = 0.006). In multivariate analysis, CHD with left-to-right shunt (coeff. [95% CI]: -3.17 [-5.45; -0.89]) and surgery before the age of 2 months (-6.52 [-10.90; -2.15]) were identified as independent factors associated with significantly lower TLC values. CONCLUSION: Lower TLC remains a long-term complication in CHD, particularly in cases with left-to-right shunt and in patients requiring early repair. These findings suggest that an increase in pulmonary blood flow may directly impair lung development.

[Factors associated with inadequate folic acid supplementation for the prevention of neural tube defects in eight Parisian maternity units]. / Facteurs associés à un défaut de supplémentation en acide folique pour la prévention des anomalies de fermeture du tube neural dans huit maternités parisiennes.

OBJECTIVES: Despite the guidelines in effect, too few women in France receive folic acid supplementation. The principal objective of this study was to identify the factors associated with the inadequacy of this supplementation in the periconceptional period. The secondary objective was to assess women's knowledge about the prevention of neural tube defects (NTDs). METHODS: This study included 400 women and took place in 8 Parisian maternity. Folic acid supplementation was inadequate when started after the beginning of the pregnancy. RESULTS: Among the women questioned, 68% had inadequate folic acid supplementation. They were significantly younger (ORa= 1,8; 95% IC [1,1-2,8]), didn't had health insurance (ORa=3,9; 95% IC [1,5-10,1]), had not studied after high school (ORa=2,9; 95% IC [1,2-6,9]) and had regular gynecological care less often than the women with adequate supplementation (ORa=3,0; 95% IC [1,6-5,6]). More than half (55.5%) had insufficient knowledge of the benefits of folic acid; the factors related to this lack of knowledge were the absence of regular gynecological care and of health insurance. CONCLUSION: Individual factors associated with a lack of supplementation have been identified. These results provide health professionals and supervisors with useful information for developing strategies adapted to certain subgroups of women for better prevention of AFTN in these populations.

Prenatal natural history of congenital pulmonary malformations: MALFPULM population-based cohort study.

OBJECTIVES: To assess prenatal changes in the volume of congenital pulmonary malformations (CPM) and examine whether these changes differ in lesions that appear cystic on ultrasound compared with hyperechoic lesions, and to study the relationship between CPM volume and risk of fetal compression. METHODS: We conducted a nationally representative, multicenter, prospective cohort study, which included 579 ultrasound examinations in 176 pregnant women with a diagnosis of fetal CPM, between March 2015 and November 2016. Several ultrasound examinations were performed between diagnosis and delivery, including measurement of CPM volume. We modeled changes in CPM volume ratio (CVR) as a function of gestational age, overall and for cystic/mixed vs hyperechoic malformations, and examined the association between CVR and signs of compression during pregnancy. RESULTS: When modeling CVR changes over time, there was a statistically significant decrease in CVR with increasing gestational age (P < 0.001), but the pattern of change differed according to CPM phenotype at first ultrasound examination: cystic/mixed CPM were characterized by a monotonic decrease in CVR with increasing gestational age (P = 0.002), whereas hyperechoic CPM showed an initial increase in CVR up to 27 weeks of gestation, followed by a decrease thereafter (P < 0.001). Peak CVR values were predicted as early as 21-22 weeks for cystic/mixed CPMs compared with 25-26 weeks for hyperechoic malformations. Regardless of CPM phenotype, fetuses that showed no sign of compression at any point had substantially lower CVR at first CVR measurement, and the CVR remained relatively constant thereafter. Among the subpopulation of fetuses with no sign of compression at first CVR measurement, the odds of a subsequent compression was 7-fold higher (adjusted odds ratio, 7.0; 95% CI, 1.6-29.9) if initial CVR was > 0.4 vs CVR ≤ 0.4 cm2 . CONCLUSIONS: Predicted changes in CVR during pregnancy differ between cystic and hyperechoic malformations. This may be the result of different pathophysiological mechanisms or differences in the timing of occurrence of these different types of CPM. CVR measured at the initial diagnostic ultrasound examination was strongly associated with the odds of subsequent compression. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Screening for fetal spina bifida at the 11-13-week scan using three anatomical features of the posterior brain.

OBJECTIVE: To evaluate the contribution of examination of specific anatomical features of the fetal posterior brain on mid-sagittal first-trimester ultrasound examination to the early detection of open spina bifida. METHODS: Four independent observers reviewed a series of 260 mid-sagittal first-trimester ultrasound images from 52 cases of open spina bifida and 208 normal fetuses. The following analysis was performed by each reviewer for each image: Herman score calculation, intracranial translucency score (CFEF-IT) calculation and determination of presence or absence of three anatomical criteria: intracranial translucency (IT), caudal displacement of the brainstem and cisterna magna. The sensitivity and the false-positive rate for spina bifida detection were calculated for each of the latter three criteria. A secondary analysis was performed on the subset of images achieving a Herman score ≥ 7. RESULTS: The highest detection rate for spina bifida was achieved by non-visualization of the cisterna magna, with associated sensitivity of 50-73% and 39-76%, respectively, for all images and for the subset of images achieving a Herman score ≥ 7. Posterior shift of the brainstem achieved the highest detection rate (86%), but for a single reviewer only. The level of variation in performance between observers was also greatest for this sign. Absence of IT was associated with a lower detection rate for all observers. Overall, an abnormal posterior brain presenting at least one of these three criteria was associated with a detection rate ranging from 50 to 90%. CONCLUSION: In the detection of spina bifida, non-visualization of the cisterna magna achieved the best screening performance. Both non-visualization of the IT and posterior shift of the brainstem were associated with acceptable but lower detection rates. A prospective evaluation of changes in the posterior brain is needed to allow assessment of the most pertinent criteria for first-trimester screening for spina bifida.

Trends in perinatal health in France from 1995 to 2010. Results from the French National Perinatal Surveys.

OBJECTIVE: To study trends in the main indicators of health, medical practices and risk factors in France. POPULATION AND METHOD: We collected data from samples of all births in France during one week in 1995 (n=13318), 1998 (n=13718), 2003 (n=14737) and 2010 (n=14903) and have compared them. RESULTS: Between 1995 and 2010, maternal age and body mass index increased steadily, but tobacco use decreased. In 2010, 39.4% of pregnant women had a visit with a midwife in a maternity unit, versus 26.6% in 2003. Deliveries occurred in large public hospitals more and more frequently. The increase in caesarean sections was no longer significant between 2003 and 2010. In general, medical decisions during pregnancy and delivery were closer to professional recommendations in 2010 than in earlier years. Live births before 37 weeks increased steadily from 5.4% in 1995 to 6.6% in 2010, but the proportion of birth weights below 2500g or the 10th percentile stopped increasing after 2003. CONCLUSION: Routine national perinatal surveys highlight major trends in maternal characteristics, obstetric practices, organisation of services, and perinatal health.

[Trends in perinatal health in France between 1995 and 2010: Results from the National Perinatal Surveys]. / La santé périnatale en France métropolitaine de 1995 à 2010. Résultats des enquêtes nationales périnatales.

OBJECTIVE: To study trends in the main indicators of health, medical practice and risk factors in France. POPULATION AND METHOD: A sample of all births during one week was set-up in 1995 (n=13,318), 1998 (n=13,718), 2003 (n=14,737) and 2010 (n=14,903), and we compared data from these four years. RESULTS: Between 1995 and 2010, maternal age and body mass index increased steadily, but tobacco smoking decreased. In 2010, 39.4% of pregnant women had a visit with a midwife in maternity unit, versus 26.6% in 2003. Deliveries occurred in large public hospitals more and more frequently. The increase in caesarean sections was no longer significant between 2003 and 2010. In general medical decisions during pregnancy and delivery were closer to professional recommendations in 2010 than in the previous years. Live births before 37 weeks increased steadily from 5.4% in 1995 to 6.6% in 2010, but the proportion of births below 2500g or under the 10th percentile stopped increasing since 2003. CONCLUSION: Routine national perinatal surveys highlight major trends in maternal characteristics, obstetric practice, organisation of services and perinatal health.

Visualization of intracranial translucency at the 11-13-week scan is improved after specific training.

OBJECTIVE: To evaluate the ability to confidently identify intracranial translucency (IT) in a clinical practice and following specific training of 10 operators. METHODS: Two experienced observers reviewed 11-13-week nuchal translucency (NT) images for IT visibility in (1) a series of 50 randomly selected images obtained by 10 skilled operators certified by the Collège Français d'Echographie Foetale (CFEF) (retrospective analysis) and (2) a series of 315 images obtained by 10 different operators following specific training for IT visualization (prospective analysis). We calculated proportions of images for which IT was deemed visible and the agreement between the two observers. Data were also stratified by Herman and CFEF quality-score intervals. RESULTS: In the retrospective analysis, IT was visualized by both reviewers in 52% of images, with a moderate level of agreement (κ = 0.63). The rate of IT visualization by both reviewers increased very slightly to 56-58% when only considering images with the best NT quality-control scores. Following specific training of the operators the proportion of images for which both reviewers could identify the fourth ventricle increased to 85%, but the level of agreement remained moderate (κ = 0.66). When considering images with the best NT quality-control scores, IT visualization by both reviewers increased to 91-92%. CONCLUSIONS: In a clinical practice that focuses on NT measurement IT cannot be visualized in a substantial proportion of the images obtained, which limits the utility of this approach for the early prenatal diagnosis of open spina bifida. However, the ability to identify the fourth ventricle significantly increases following specific training.

[Smoking during pregnancy in France between 1972 to 2003: Results from the national perinatal surveys]. / Évolution de la consommation de tabac des femmes pendant la grossesse en France de 1972 à 2003.

OBJECTIVE: To study trends in smoking before and during pregnancy in national samples of pregnant women and changes in characteristics of smokers over time, and describe the current relation between maternal smoking during pregnancy and fetal growth. POPULATION AND METHODS: Five nationally representative samples of singleton live births in metropolitan France (1972, 1981, 1995, 1998 and 2003) were used to study the change in smoking rates during pregnancy over the past 30 years. We further examined changes in smoking rates between 1998 and 2003 according to maternal characteristics. Finally, we estimated the effect of smoking on fetal growth in 2003. RESULTS: Prevalence of smoking decreased over time, but the rate remained high, 21 % in 2003. The decrease was more important among women at low risk of adverse pregnancy outcomes, resulting in increased social disparities. We confirmed the strong dose-response relation between tobacco use during pregnancy and fetal growth. CONCLUSION: It is important to verify that smoking during pregnancy is still decreasing and to develop policies to encourage women to quit smoking during pregnancy, especially for highly exposed groups.

Postpartum return to smoking among usual smokers who quit during pregnancy.

BACKGROUND: Many women stop smoking while they are pregnant, but the majority resume smoking in the postpartum. The objective is to describe postpartum tobacco use of women who quit during pregnancy and factors predicting postpartum smoking relapse. METHODS: Secondary analysis of two surveys of new mothers. Survey A conducted in three maternity hospitals, including 685 women interviewed after birth and who answered a postal questionnaire at 5 months postpartum; survey B conducted in four 'départements' (administrative areas), including 636 women who answered a postal questionnaire at 6 months postpartum. Response rates were respectively 90% and 68%. Smoking status was recorded for three time periods: before pregnancy, during pregnancy, and at 5-6 months. Social characteristics and preventive behaviour were compared for regular smokers who had quit smoking during pregnancy and those who had not, and among quitters, who had resumed smoking postpartum and those who had not. RESULTS: In survey A, 37% were smokers before pregnancy, 34% of them stopped during pregnancy, and among the latter, 48% had resumed smoking 5-6 months after delivery. In survey B, the percentages were respectively 43, 54 and 57%. The most predictive factor of postpartum smoking relapse was the partner's smoking behaviour. CONCLUSION: Return to smoking after delivery is frequent, but nearly half of the regular smokers who had stopped during pregnancy were still non-smokers 5-6 months after the birth. However, to increase this proportion, interventions need to include partners, especially if they are smokers.

Change in alcohol, tobacco and coffee consumption in pregnant women: evolution between 1988 and 1992 in an area of high consumption.

OBJECTIVE: Analyse the evolution of alcohol, tobacco and coffee consumption during pregnancy in a population characterized by a high level of consumption and a low socioeconomic situation. STUDY DESIGN: Data were obtained from two studies done with the same protocol and questionnaire in the Roubaix Public Maternity Hospital in 1988 (176 women) and 1992 (235 women); the two periods were compared using univariate tests and multiple logistic regression to control for social factors. RESULTS: Between 1988 and 1992, there was a clear decrease in alcohol consumption, a slight decrease in coffee consumption and an increase in tobacco use. These changes affected usual consumption as well as consumption during pregnancy. The increase in tobacco use was no longer significant after controlling for social factors. However, the decrease in alcohol consumption affected all women regardless of sociodemographic characteristics, and remained significant after controlling for these characteristics. CONCLUSION: Several factors support the hypothesis that the decrease in the reported alcohol consumption is real, for consumptions in the low to moderate range. However, it is difficult to identify the role of the several factors involved in this evolution: behaviour of the general population, attitude among pregnant women, information and sensitization of prenatal care providers. Besides, one negative aspect needs to be considered: the stability of the incidence of fetal alcohol syndrome, probably reflecting the stability of the proportion of very heavy consumers.

Attitudes and behavior of pregnant women and health professionals towards alcohol and tobacco consumption.

The objective of this study was to identify those factors that influence pregnant women's behavior towards alcohol consumption, so that they could be taken into account when developing alcohol prevention programs in prenatal care. Tobacco use was also studied to identify similarities and differences in attitudes and behavior. A sample of 176 women was interviewed using a structured questionnaire in the prenatal clinics or post-partum wards. Most women were aware that alcohol and tobacco could be harmful to their babies; however heavy drinkers recognized the influence of alcohol in pregnancy less often than the others. Sixty percent of the women, even among the light drinkers, thought that two drinks per day was a reasonable level of consumption during pregnancy. When asked who could be helpful in decreasing their alcohol consumption, most women mentioned their husband, and the doctor or midwife. This is in contrast to our finding that less than 20% of heavy drinkers were advised to reduce alcohol consumption, as compared to 70% of heavy smokers. The results point to the potential for more active interventions on alcohol reduction by health personnel during prenatal care.

Effects of birth weight of alcohol and caffeine consumption during pregnancy.

The aim of this study was to investigate the effect of alcohol and caffeine consumption on birth weight and the possible interaction of these substances with smoking. The sample included 628 women who were interviewed at their first visit to the maternity hospital of Roubaix, France, in 1985-1986. A significant reduction in birth weight was found to be associated with an average daily alcohol consumption of three drinks or more after gestational age, infant sex, maternal age, parity, weight, and height, and cigarette smoking had been controlled for. There was no interaction between smoking and alcohol consumption on birth weight, but a significant relation between alcohol consumption and birth weight was observed among nonsmokers as well as heavy smokers. The relation observed between caffeine and birth weight disappeared after adjustment for smoking. Our results indicate that alcohol reduces birth weight, but do not support the hypothesis of an interaction between smoking and alcohol consumption.

Alcohol use in pregnancy, craniofacial features, and fetal growth.

STUDY OBJECTIVE: The aim was to study the relationship between the level of alcohol consumption in pregnancy and craniofacial characteristics of the neonate. DESIGN: This was a prospective survey of a sample of pregnant women, stratified on prepregnancy level of alcohol consumption. SETTING: The study was carried out at the public antenatal clinic of Roubaix maternity hospital. PARTICIPANTS: During an eight month period, 684 women (89% of those eligible) were interviewed in a standardised way at their first antenatal clinic visit. Of these, all who were suspected of being alcoholic or heavy drinkers (at least 21 drinks per week) were selected for follow up, as was a subsample of light (0-6 drinks per week) and moderate (7-20 drinks per week) drinkers. Of 347 women selected in this way, 202 had their infants assessed by a standardised morphological examination. MEASUREMENTS AND AND MAIN RESULTS: Suggestive craniofacial characteristics of the infants, present either in isolation or in association with growth retardation ("fetal alcohol effects"), were compared in relation to maternal alcohol consumption (alcoholic 12%; heavy drinking 24%; moderate drinking 28%; light drinking 36%). No differences were found between light and moderate drinkers. Infants born to alcoholics had a greater number of craniofacial characteristics and the proportion with features compatible with fetal alcohol effects was higher. There was a similar trend for infants of heavy drinkers. Infants of heavy drinkers who had decreased their alcohol consumption during pregnancy had fewer craniofacial features. Infants of heavy smokers were also found to have increased numbers of craniofacial characteristics. CONCLUSIONS: Craniofacial morphology could be a sensitive indicator of alcohol exposure in utero. Altered morphology is usually considered specific for alcohol exposure, but the relation observed with smoking needs further exploration.

[Maternal consequences of cesarean delivery. Results of a 4-year follow-up]. / Conséquences maternelles de l'accouchement par césarienne. Résultats du suivi à 4 ans.

This study is of a 4-year follow-up of two groups of mothers, the first having had caesarean operations and the second vaginal deliveries. We have already published studies of the results after delivery, after two months and after one year. The purpose of this 4-year follow-up after delivery is to determine the effects of caesarean operation on the numbers of future pregnancies and their results and to look at the long-term consequences for the physical and psychological health of the mothers. Fifty-eight mothers who had had caesarean operations and fifty mothers as controls replied to a postal questionnaire. The response level was 52%. From the social and the medical point of view there was no significant difference between those who replied and those who did not. The results indicate that mothers who had had a caesarean operation were less likely to have another baby or did so in lower numbers. They further had more difficulty in conceiving another pregnancy than did the control mothers (the differences were not statistically significant). After four years they were often more tired than the others, apart from objective medical and social differences. The use of health services was not linked to the method of delivery, but 9% of women who had had a caesarean consulted a psychiatrist in the last three years but none of the controls did. The replies show that caesarean section contributed to or re-awoke a labile psychological state. The data do not make it possible for us to say that women who had had a caesarean operation had particular psychological characteristics.(ABSTRACT TRUNCATED AT 250 WORDS)