[Prevalence, severity, and predictors of bronchopulmonary dysplasia in a cohort of very preterm infants]. / Prévalence, gravité et facteurs prédictifs de la dysplasie bronchopulmonaire dans une cohorte ultramarine de grands prématurés.

OBJECTIVES: The aim of this retrospective cohort study was to determine the prevalence and severity of BPD and its predictors in a regional cohort of very preterm (VP) infants in Reunion Island. METHODS: All autochthonous VP infants, live-born before the 33rd week of gestation (WG) between 1st January 2008 and 31st December 2009, were eligible for the study. Only VP infants surviving at least 28 days, for whom the parameters were known from birth, were included in the case-control study of predictors of moderate to severe BPD (BPDmo/s). RESULTS: In VP infants less than 33 WG, the rate of overall BPD (3 grades of severity) was 30.7%. Among those who survived 28 days or more, the rate of BPDmo/s was 13.1% (95%CI: 10.2-15.9%). In VP infants less than 32 WG that survived at 36 WG, the prevalence of BPDmo/s was 18.2% (95% CI: 14.2-22.1%). In a fixed-effect logistic model, adjusted for gestational age, postnatal growth, and the mode of ventilation at 24h, 4 key factors were predictive of BDPmo/s: small for gestational age, surfactant, delayed energy intake, and late-onset neonatal infection. In a mixed-effect logistic model adjusted for these same cofactors, the site was associated with BPDmo/s, in line with a center-effect. CONCLUSION: The prevalence of BPDmo/s in the mixed-race population of Reunion Island is consistent with those observed in Europe but were site-specific. In our setting, predictors of individual BPDmo/s are similar to those already identified.

Obstetrical and neonatal outcomes in obese women / Resultados obstétricos y neonatales en las mujeres obesas

OBJECTIVE: To compare the incidence of antenatal and intrapartum complications and neonatal outcomes among pre-pregnant obese women. METHODS: At the Sud-Reunion Hospital's maternity, Reunion Islands, France, over a 54-month period, each obese pregnant woman (BMI > or = 30 kg/m2) delivering a singleton after 22-weeks gestation was compared to the next age and parity-matched woman of normal pre-pregnancy weight (BMI 18.5-25 kg/m2), who delivered after the index case. The Students t test, Mann and Whitney test, Chi-square test and logistic regression model were used for statistical analysis. RESULTS: The study enrolled 2081 obese women and 2081 controls. The incidences of pre-eclampsia, chronic and pregnancy-induced hypertension, chronic and gestational diabetes mellitus were increased in the obese women group. Prenatal care in obese women required a high rate of hospitalizations as well as a high rate of insulin treatment. Obese women were more likely to be delivered by Caesarean section. The rate of in utero fetal death, neonatal and perinatal death was significantly higher in the obese women group. The high BMI in relation with both pre-eclampsia and in utero fetal death remained unchanged after adjustment of other risk factors. CONCLUSION: Obese women were more likely to present several obstetric complications and to be delivered by Caesarean section. Obstetricians who decide on a first Caesarean section in an obese woman should be aware of the cumulated obesity and uterine scar risks that could threaten any subsequent Caesarean section.

OBJETIVO: Comparar la incidencia de las complicaciones antenatales e intraparto, y los resultados neonatales entre las mujeres obesas pre-embarazadas. MÉTODOS: Por un periodo de más de 54 meses, cada mujer obesas embarazadas (IMC $ 30 kg/m2) dando a luz singletons después de 22 semanas de gestación, en el Hospital de Maternidad de Sud-Reunion, Reunion Island, Francia, fue comparados con la mujer de peso normal pre-embarazada siguiente, pareada por edad y paridad (IMC 18.5-25 kg/m2) dando a luz después del caso del índice. Para el an álisis estadístico se usó la prueba T de Student, la prueba de Mann-Whitney, la prueba de chi-cuadrado, y el modelo de regresión logística. RESULTADOS: El estudio enroló a 2081 mujeres obesas y 2081 controles. Las incidencias de pre-eclampsia, hipertensión inducida por el embarazo y crónica, así como la diabetes mellitus gestacional y crónica, aumentaron en el grupo de mujeres obesas. El cuidado prenatal en las mujeres obesas requirió una alta tasa de hospitalizaciones así como una alta tasa de tratamiento de insulina. Las mujeres obesas eran m ás propensas a tener el parto por ces área. La tasa de muerte fetal in útero, muerte neonatal y perinatal fue significativamente m ás alta en el grupo de mujeres obesas. El alto IMC en relación tanto con la pre-eclampsia como con la muerte fetal en útero permaneció igual después del ajuste de otros factores de riesgo. El alto IMC tanto en relación con la pre-eclampsia como con respecto la muerte fetal in útero permaneció igual después del ajuste de otros factores de riesgo. CONCLUSIÓN: Las mujeres obesas tuvieron mayor propensión a presentar varias complicaciones obstétricas y tener el parto mediante cesárea. Los obstetras que deciden practicar una primera cesárea en una mujer obesa deben tener conciencia de la obesidad acumulada y los riesgos de cicatriz uterina que podrían amenazar cualquier cesárea posterior.

[Herpetic neonatal hepatitis]. / Les hépatites herpétiques néonatales.

Herpes simplex virus (HSV) infection can affect various organs-systems in the neonatal period. Herpetic hepatitis was seldom reported in the literature. We report on 2 cases. Firstly, a 16 day-old newborn infant was admitted because of haemorrhagic syndrome and shock. Biological assessment showed a severe hepatic insufficiency. Antibiotic and aciclovir therapy was started as HSV infection was suspected. Five days later, the herpetic attack was confirmed by polymerase chain reaction (PCR) in blood and cerebrospinal fluid (CSF). The genotye of the virus in the CSF was HSV1. Treatment included aciclovir for 21 days intravenously and 2 months orally. At 10 months, the clinical and biological examinations were normal. Secondly, a 4 day-old newborn was hospitalised because of fever and polypnea. Pulmonary X rays showed heterogeneous opacities of the right base. Serum C reactive protein was 30 mg/l. Antibiotic therapy was started. Two days later, the fever persisted while a severe hepatic insufficiency developed. The diagnosis of herpetic hepatitis was evoked and the child was given aciclovir. Forty-eight hours later, the PCR confirmed a HSV in blood, while viral culture of a mouth swab found HSV 2. Evolution was favourable after 21 days of specific and symptomatic treatment. Aciclovir treatment was continued orally for six months. Herpetic hepatitis is rare in the neonatal period. Diagnosis must be evoked early when facing severe neonatal hepatic insufficiency. Provided specific treatment, prognosis is good.

[Clinical aspects and genetic specificities of cystic fibrosis in Reunion Island]. / Aspects cliniques et spécificités génétiques de la mucoviscidose à l'île de la Réunion.

OBJECTIVES: Evaluation of the phenotype-genotype correlation of a specific mucoviscidosis mutation, "Y122X", in Reunion Island. This mutation represents 25% of our cases. PATIENTS AND METHODS: Retrospective study of a cohort of 84 children presenting cystic fibrosis (CF) during a 5-year period (1994-1998). Diagnosis was based on one or two identified genetic mutations and/or minimum two abnormal chloride sweat tests (Cl > 70 mmol/l). Follow-up of this cohort was performed in the two referral centers of the Island following the French national guidelines (INSERM U 155). RESULTS: In our population, we identified 10 mutations, of which three of them represented more than 80% of the cases: Delta F508 (51.8%), Y122X (24.4%) and 3120 + 1G --> A (4.8%). The authors report clinical significant differences in children with the homozygote mutation Y122X as compared with children presenting the Delta F508 CF-mutation: failure to thrive affecting mainly the height with, paradoxically, a relatively normal weight development, and a better pulmonary function. CONCLUSION: The frequent Y122X CF-mutation reported in "la Reunion" seems to affect mainly height in children with a relatively good nutritional outcome. This failure to thrive does not seem to be of digestive origin. These results suggest that growth gene(s) located nearby the cystic fibrosis transmembrane conductance regulator (CFTR) may have suffered the same segregation than the Y122X mutation or that clusters of this specific Caucasian population known as "petits blancs" in la Reunion are smallest for ethnic reasons.

Evaluation of neonatal sepsis screening in a tropical area. Part II: Evaluation of intrapartum chemoprophylaxis protocol.

The authors report on an analysis of a chemoprophylaxis protocol at the University Hospital of Guadeloupe in the Caribbean. This study comprised 6,060 consecutive deliveries and was initiated to assess the application of an intrapartum chemoprophylaxis protocol, evaluate its results, and try to identify possible necessary modifications to the existing protocol. Although more than 90% of women had at least one bacterial screening (vaginal or urinary) during the last trimester of pregnancy, approximately 75% of mothers who were heavily colonized group B streptococcus (GBS) at delivery were not detected by this systematic screening. As is also reported in other tropical areas where a great proportion of neonatal sepsis occurs in term babies, low birthweight was not a specific risk factor in this study when controlling for other major risk factors such as fever and premature rupture of membranes. Intrapartum chemoprophylaxis was associated with an approximate threefold decrease in the risk of GBS neonatal bacteraemia among at risk deliveries. The results suggest that, in our tropical context, prolonged rupture of membranes of at least 12 hours' duration should be considered as a cause for intrapartum chemoprophylaxis as it accounted for the majority of cases of neonatal bacteraemia that escaped the existing protocol.

Evaluation of neonatal sepsis screening in a tropical area Part III: Neonatal sepsis in meconium stained deliveries

Of the 6,060 consecutive live births delivered at the University Maternity Unit of Guadeloupe (French West Indies) during a 30-month period, 635 newborns (10.4) presented with meconium stained (MS) amniotic fluid, of which 595 (94) received bacteriological screening at birth (light MS, n = 543; thick MS, n = 52). Thirty (5) of MS newborns had a bacteraemia (n = 13, group B streptococcus, GBS), and 128 (21.5) a bacterial positive gastric aspirate (n = 54, GBS). Sixty-six newborns among MS babies needed tracheal suctioning (11) in the delivery room for meconium inhalation. Among these 595 screened MS newborns, 286 (48) presented clinical signs of postmaturity at birth, having therefore an explanation for their MS condition. For the other MS newborns without the postmaturity explanation, we experienced twofold increased risk of neonatal sepsis (OR 1.88 for bacteraemia and 2.61 for external carriage p < 0.02, Chi square) as compared with their MS postmature counterparts. We conclude that when meconium stained deliveries are associated with postmaturity signs, one may not need to initiate prophylactic antibiotic treatment at birth unless they present with other traditional risk factors for neonatal sepsis such as intrapartum fever and prolonged rupture of membranes.

Evaluation of neonatal sepsis screening in a tropical area. Part II: Evaluation of intrapartum chemoprophylaxis protocol

The authors report on an analysis of a chemoprophylaxis protocol at the University Hospital of Guadeloupe in the Caribbean. This study comprised 6,060 consecutive deliveries and was initiated to assess the application of an intrapartum chemoprophylaxis protocol, evaluate its results, and try to identify possible necessary modifications to the existing protocol. Although more than 90 of women had at least one bacterial screening (vaginal or urinary) during the last trimester of pregnancy, approximately 75 of mothers who were heavily colonized group B streptococcus (GBS) at delivery were not detected by this systematic screening. As is also reported in other tropical areas where a great proportion of neonatal sepsis occurs in term babies, low birthweight was not a specific risk factor in this study when controlling for other major risk factors such as fever and premature rupture of membranes. Intrapartum chemoprophylaxis was associated with an approximate threefold decrease in the risk of GBS neonatal bacteraemia among at risk deliveries. The results suggest that, in our tropical context, prolonged rupture of membranes of at least 12 hours' duration should be considered as a cause for intrapartum chemoprophylaxis as it accounted for the majority of cases of neonatal bacteraemia that escaped the existing protocol.

Evaluation of neonatal sepsis screening in a tropical area. Part I: Major risk factors for bacterial carriage at birth in Guadeloupe

This prospective study reports on screening for neonatal sepsis among 3,372 live births out of 6,060 consecutive deliveries at the University Hospital of Pointe-Ó-Pitre, Guadeloupe, during a 30-month period. Group B Streptococcus (GBS) was the most common pathogen, representing 46 (89/194) of positive blood cultures and 52 (335/637) of positive gastric aspirates. Although only 3,372 (55) of all live births were screened, 637 (10) had gastric bacterial carriage at birth; of those, 335 (5.5) involved GBS. Similarly, there were 194 (3.2) positive blood cultures, of which 89 (1.5) involved GBS. In this report, all newborns who presented with a positive GBS blood culture had at least one of the external tests positive for GBS (gastric, ear canal, rectum and placenta). Thirty-seven per cent (14/38) of positive neonatal blood cultures occurred in newborns with foetid liquor while in deliveries with intrapartum fever 16.5 (32/195) of blood cultures were positive. In our clinical practice, characteristics that were evident in the delivery room (without knowledge of prenatal follow-up) such as foetid liquor, intrapartum fever, prolonged rupture of membranes, foetal tachycardia and meconium staining were associated with the great majority of neonatal sepsis.

Lipid intake during pregnancy in developing countries: possible effect of essential fatty acid deficiency on fetal growth.

There is a strong epidemiological association between poor nutritional status and low-birthweight (LBW) newborns. According to the World Health Organization (WHO), 95% of total LBW in the world are born in developing countries. Nevertheless, the nutritional etiology of intra uterine growth retardation (IUGR) is still controversial and not yet established largely because of contradictory nutritional studies in pregnancy. In 1981 Menon et al described an animal model of IUGR due to mild deficiency in essential fatty acids (EFA, linoleic and alpha linolenic acids), with a strong correlation between EFA intake during pregnancy and fetal growth. According to the WHO reports in the last decade, there was a dramatic deficiency of lipid intakes (less than 10% of total caloric amounts) in the majority of developing countries while the EFA requirements alone of normal nourished women are evaluated at 6% of total caloric amounts during pregnancy. A mild deficiency in dietary EFA may be a limiting factor in fetal growth processes in humans as it has been shown in animals. Such a mechanism could be easily verified. Research proposals are made in an attempt to test this hypothesis in developing countries with possible applications in further nutritional interventions in pregnancy.

PIP: This literature review presents the hypothesis that low birthweights (LBW) common in developing countries may be related to a low intake of essential fatty acids (EFA). There are 19 million babies with LBW born yearly in developing countries, most categorized as intrauterine growth retardation (IUGR). Smoking and pregnancy-induced hypertension are the only known risk factors for IUGR. EFAs are fatty acids that are like vitamins, because humans do not have enzymes to make them and require them in the diet. Mild EFA deficiency caused 25-30% LBW in rats. EFAs are needed for formation of all cell membranes and, particularly, for nervous system development in the last trimester of pregnancy and early postnatal growth. Excess saturated fats, high ambient temperatures, and high carbohydrate diets, all prevalent in many tropical developing countries, compete for EFAs in metabolism. Many women in developing countries subsist on diets with 15% or fewer calories from lipids, far lower than the 30% recommended by WHO, or the calculated 14 grams/day of EFA in a 2000 calorie diet recommended in pregnancy. Of about 30 studies reported on attempts to improve birth weights, 4 studies achieved weight gains by feeding pregnant women nutritional supplements containing EFAs. 2 types of research studies were suggested: determining red cell membrane lipid content in LBW infants and their mothers in developing countries and a controlled trial of nutritional supplements with protein, carbohydrate, and EFAs.

Hyaline membrane disease: the role of ethnicity and maternal risk characteristics.

OBJECTIVE: Our objective was to explore the association between maternal ethnicity and maternal antepartum complications of pregnancy, maternal sociodemographic factors, and newborn characteristics with the incidence of hyaline membrane disease. STUDY DESIGN: By using a retrospective cohort analysis the incidence of hyaline membrane disease was determined for 2295 preterm infants. The study population consisted of all live, inborn infants delivered vaginally from 1982 to 1987. Statistical differences were assessed by use of chi 2 and Student's t tests. A logistic regression procedure determined the relationship of ethnicity and hyaline membrane disease after the study was controlled for all other significant population differences. RESULTS: The differences between black and white populations in marital status, were statistically significant years of education, prolonged rupture of membranes, anemia, and chronic hypertension were statistically significant. Infants of black mothers were diagnosed with hyaline membrane disease less often than infants of white mothers (overall and at each gestational age interval). After the study was controlled for population differences, infants of black mothers were still found to experience hyaline membrane disease less often. CONCLUSION: These data suggest that hyaline membrane disease occurs less frequently, is less severe, and is accompanied by fewer related complications in black preterm infants.

Congenital heart disease diagnosed in Guadeloupe.

An epidemiologic survey of congenital heart disease was performed in Guadeloupe, French West Indies, during the 3-year period 1988-1990. This survey, the first on congenital heart disease from the Caribbean, found an overall rate of 6.08 congenital heart disease cases per 1,000 live births, a high rate of hypoplastic left heart disease, and a rate of coarctation of the aorta similar to rates reported in developed countries.

PIP: Between January 1988 and December 1990 health workers referred 139 infants suspected of heart disease to a skilled pediatric cardiologist at the University Hospital of Pointe-a-Pitre, Guadeloupe. The physicians considered patent ductus arteriosus of prematurity to be a congenital heart disease if it still existed after the neonatal period. The incidence of congenital heart disease was 6.08 cases/1000 live births with a sex ratio of 1:1. 12% of chromosomal abnormalities, especially Down's syndrome. Physicians diagnosed 92% of all cases in the 1st year of life. 35% (49 infants) went to the Pediatric Cardiologic Department of Hospital Necker in Paris, France, to undergo catheterizations. 32 of these infants also underwent chest surgery. Prevalence of coarctation of the aorta (3.1/10,000 live births) essentially equalled that of developed countries. The prevalence of hypoplastic left heart disease was considerably higher than the rate in the literature (3.5/10,000 live births vs. 0.5-2.7/10,000 live births). It was the 4th ranking congenital heart disease in this population (5.7% of all cases). All the infants with hypoplastic left heart disease died.