[Evaluation of the perinatal network professionals' integration: study about 653 professionals of AURORE network]. / Evaluation de l'intégration des professionnels au sein d'un réseau de périnatalité: enquête auprès de 653 professionnels du réseau AURORE.

OBJECTIVES: Evaluation of the AURORE perinatal network professionals' satisfaction and integration and identification of explanatory factors, three years after implementation. METHOD AND MATERIALS: Transversal study with postal questionnaire sent at 653 AURORE network perinatal professionals. RESULTS: Awareness and participation to network meetings were not associated with the geographic proximity of administrative headquarters (p=0.2) but with consciousness of network website and of network experts identified for each maternity (p<0.001). Patients management was estimated more easy for 92% of professionals. Network impact was evaluated as positive in professional practice (88.2%). Professionals integration were demonstrated by knowledge of network guidelines (94.8%) and their use (96%). CONCLUSION: AURORE perinatal network professionals, three years after implementation, were involved in network maternity. Their participation and interest for this organisation were associated with directs benefits they could get in facilitating their relationship with patients and other health professionals in each day practice.

[Unexpected out-of-hospital deliveries: Management and risk factors]. / Accouchement inopiné extrahospitalier : prise en charge et facteur de risque.

OBJECTIVES: To estimate the frequency of accidental out-of-hospital deliveries (OHDs), to describe the home care and the complications occurred, and to identify risk factors. MATERIALS AND METHODS: A retrospective case-control study from 1st January 2012 to 31 December 2012 in Lyon urban area. Cases were identified from the Emergency Medical Aid Service 69 (SAMU 69) registry and control from the birth registry of the maternity corresponding to the case, recruiting two controls per case. RESULTS: The frequency of the OHDs was 0.3% [0.2-0.4]. At home, the prophylactic administration of oxytocin was performed in 18.3% [9.31-27.3] of cases and prevention of neonatal hypothermia was performed in 45.7% [34.1%-57.3%] of cases. Multiparity [OR: 3.43 (1.65-7.23)], a precarious situation [OR: 37.63 (5.02-7.81)], and lack of antenatal care [OR: 3.36 (2.72-4.15)] were OHDs' risk factors. CONCLUSION: The practical prevention of postpartum hemorrhage, and that of the home neonatal hypothermia could be improved. Points of vigilance for the medical teams to look for during the pregnancy monitoring are precariousness and less than 3 consultations scheduled.

Ventilatory pump failure in premature newborns.

OBJECTIVE: To determine the prevalence of ventilatory pump failure in premature (< 34 weeks gestation) infants. DESIGN: Prospective clinical evaluation of all neonatal intensive care unit (NICU) admissions over a 12 month period in a large, university affiliated hospital. SUBJECTS: A series of 421 consecutive inborn premature infant admissions to the NICU. METHODS: Infants were followed for signs and symptoms of respiratory distress and monitored closely for evidence of respiratory failure requiring intubation and assisted ventilation. The indications for intubation and assisted ventilation were reviewed, and three such indications were considered clear manifestations of ventilatory pump failure, that is, delivery room resuscitation with CXR negative for evidence of parenchymal lung disease [DR/CXR-], hypercapnia (PaCO2 > 55 torr) [increases CO2], and apnea. RESULTS: A total of 192 premature infants (47% of study sample) required intubation and assisted ventilation. Failure of the ventilatory pump to sustain ventilation (DR/CXR-, increases CO2, apnea) accounted for 70 of these 192 (36%) premature infants. CONCLUSIONS: Ventilatory pump failure is a common clinical phenomenon in premature infants. Intensified research on the mechanisms and treatment of ventilatory pump failure might benefit a significant number of such newborns.

Effects of a clinically detectable PDA on pulmonary mechanics measures in VLBW infants with RDS.

We examined the effect of a clinically detectable patent ductus arteriosus (PDA) and its successful treatment with indomethacin on serial measures of pulmonary mechanics in 10 very-low-birthweight (VLBW) intubated infants with respiratory distress syndrome (RDS). Pulmonary mechanics were measured by the passive expiratory flow technique. Total respiratory system compliance (Crs) gradually improved as RDS resolved. However, a significant decrease in mean Crs was associated with the development of a clinically detectable PDA, ranging from 1.51 +/- 0.21 to 0.90 +/- 0.08 mL/cmH2O/m (P less than 0.05). We also noted an increase in mean Crs, from 0.90 +/- 0.08 to 1.49 +/- 0.21 mL/cmH2O/m (P less than 0.05), after successful treatment of a PDA with indomethacin. Total respiratory system resistance (Rrs) did not change. We conclude that a clinically significant PDA is associated with a decreased Crs and that successful treatment of a PDA with indomethacin is associated with an improvement in lung compliance. These findings imply that the development of a clinically detectable PDA and its subsequent treatment complicates the interpretation of pulmonary mechanics data in VLBW infants with RDS.

Measurements of pulmonary mechanics prior to the elective extubation of neonates.

We measured total respiratory system compliance (CRS) and resistance (RRS) by the passive expiratory flow technique prior to the elective extubation of 61 neonates with a history of respiratory distress syndrome. Successful trials of extubation were characterized by a higher mean value of CRS when compared to trials that led to reintubation (1.52 vs. 1.10 mL/cm H2O, P = 0.004). Low values of CRS (0.9 mL/cm H2O or less) were invariably associated with extubation failure, whereas high values of CRS (1.3 mL/cm H2O or greater) were associated with extubation success in 94% of patients. A higher mean value of RRS was recorded in the group of infants who failed extubation when compared to those who were successful (0.22 vs. 0.17 cm H2O/mL/s, P = 0.042). We propose that measurements of pulmonary mechanics, particularly CRS, may be useful in identifying infants who will be at risk for extubation failure.

Prevalence and genotype distribution of human papillomavirus in cytology specimens containing atypical glandular cells: a case-control study.

BACKGROUND: Incidence of glandular cell cancers has risen. While atypical glandular cell (AGC) grade cytology results represent only a small percentage of all Pap test results reported annually in the US, a significant percentage represents a corresponding high-grade lesion on follow-up biopsy. The 2006 ASCCP consensus guidelines for AGC-grade cytology results include colposcopy, endocervical sampling, and high-risk (HR) HPV testing for patient management. OBJECTIVE: Determine HPV prevalence and genotype distribution in AGC-grade cytology specimens (n=53) compared to cytology specimens negative for intraepithelial lesion or malignancy (n=338). STUDY DESIGN: DNA extracted from residual, de-identified liquid-based cytology specimens, using QIAamp MinElute Media Kit was analyzed by PCR using Roche Linear Array HPV Genotyping and Detection Test Kits. Multivariate logistic regression compared HPV prevalence and genotype distribution between cases and controls to generate age-adjusted odds ratios (ORadj) and 95% confidence intervals (CI). RESULTS: HR-HPV DNA was found in 34.0% of cases and 7.4% of controls (ORadj=9.11; 95% CI: 4.08-20.33, p-value<0.001). Limiting analysis to HPV-16 and/or -18 resulted in finding HPV DNA in 20.8% of cases and 1.2% of controls (ORadj=40.10; 95% CI: 10.73-149.88, p-value<0.001). In contrast, prevalence of low-risk HPV DNA was similar between groups: 13.2% of cases and 17.2% of controls (ORadj=0.91; 95% CI: 0.35-2.31, p-value=0.834). CONCLUSIONS: AGC-grade cases contained a significantly higher rate of HR-HPV compared to controls, supporting earlier recommendations for HPV testing of AGC-grade cytology specimens. Our findings also suggest that follow-up genotyping of HR-HPV containing AGC cases for HPV-16 and/or -18 specifically would be useful in patient management.

Blood flow distribution and brain metabolism during tolazoline-induced hypotension in newborn dogs.

Tolazoline is used in neonatal intensive care to treat hypoxia secondary to persistent pulmonary hypertension of the newborn. Its use is often complicated by systemic hypotension. We compared the effect of tolazoline-induced hypotension on organ blood flow, regional brain blood flow, and cerebral metabolism in hypoxic newborn dogs whose mean arterial pressure fell by more than 20% with a second group whose blood pressure fell by less than 20%. Blood flows were measured by the radioactive microsphere technique. We found no changes in organ blood flow, regional brain blood flow, and cerebral metabolism in hypoxic animals whose mean arterial blood pressure decreased less than 20% during tolazoline administration. However, in those animals whose mean arterial blood pressure decreased more than 20%, we found a decrease in cerebral blood flow. As a consequence of decreased cerebral blood flow, cerebral oxygen delivery decreased. However, oxygen extraction increased so that cerebral metabolic rate was preserved.

Effects of chronic maternal anemia on systemic and uteroplacental oxygenation in near-term pregnant sheep.

OBJECTIVE: The hypothesis of our study was that both the systemic and uteroplacental circulations would adapt to chronic maternal anemia to ensure that oxygen supply to maternal tissues would be adequate. STUDY DESIGN: We measured cardiac output and uteroplacental blood flow and calculated systemic and uteroplacental oxygen delivery, extraction, and consumption in pregnant sheep that were anemic for 6 days (hematocrit 14%) and in normal sheep (hematocrit 28%). RESULTS: When compared with normal pregnant sheep, anemic pregnant sheep had increases in cardiac output and uteroplacental blood flow, neither of which was sufficient to prevent systemic or uteroplacental oxygen delivery from decreasing. In spite of decreases in oxygen delivery, systemic and uteroplacental oxygen consumptions were maintained at normal levels because of increases in oxygen extraction. CONCLUSION: Maternal systemic and uteroplacental circulations are capable of adapting well to chronic maternal anemia.

Congenital cytomegalovirus infection in offspring of liver transplant recipients.

There has been an increasing number of women undergoing liver transplantation during their childbearing years. As the number of pregnancies among these women increases, complications during pregnancy and risks to the fetus associated with liver transplantation will be better defined. We report three cases of cytomegalovirus (CMV) infection in offspring of liver transplant recipients. Two of these recipients had preterm labor and gave birth at approximately 23 weeks' gestation; both neonates had clinical (hydrops fetalis), laboratory, and placental evidence of CMV infection. The third recipient gave birth at 26 weeks' gestation because of severe preeclampsia, and the neonate died at 12 days of age of CMV sepsis. Placental CMV infection was confirmed in this case by polymerase chain reaction analysis, which is a valuable tool for prospectively or retrospectively diagnosing this infection. Our findings indicate that CMV infection poses a significant risk to offspring of liver transplant recipients.

Pulse dexamethasone does not impair growth and body composition of very low birth weight infants.

OBJECTIVE: Evaluation of repeated pulses of dexamethasone (PDEX), given to improve cardiopulmonary outcome, on growth of very low birth weight (VLBW, < 1500 g) infants. METHODS: In this prospective, double-blind, randomized clinical trial, VLBW infants mechanically ventilated at 1 week of age received intravenous PDEX or saline placebo (P) for 3 days, every 10 days, until no supplemental oxygen or ventilation was required or 36 weeks postmenstrual age (PMA). Weight gain, fluid intake, caloric intake, and serum glucose were monitored throughout the study. Nutritional assessment at 36 weeks PMA consisted of weight, length, head circumference, skinfold thickness measures, body composition by total body electrical conductance, and bone mineral content (BMC) by single beam photon absorptiometry. RESULTS: 37 PDEX and 31 P infants survived at least 36 days and completed the protocol. Average daily weight gain, fluid intake and caloric intake were not different between groups. The pattern of weight gain (g/kg/day, mean +/- SD) was different: PDEX infants showed significant growth delay during (3.0 +/- 11.4) and immediately after (7.8 +/- 8.7) each pulse, with subsequent growth acceleration (18.3 +/- 8.2) until the next steroid pulse. In contrast, growth rate of P infants was constant (12.6 +/- 3.7) (p = 0.04). Hyperglycemia requiring insulin therapy occurred only in the PDEX group (10/37). The catch-up growth noted between pulses in the PDEX group was explained only in part by insulin therapy. At 36 weeks PMA, there were no differences between groups in body size, composition, or BMC. CONCLUSION: PDEX negatively affected glucose metabolism and growth patterns during and immediately after drug exposure. However, assessment near term gestational age showed similar body composition and size in both groups.

Effect of pulse dexamethasone therapy on the incidence and severity of chronic lung disease in the very low birth weight infant.

We conducted a prospective, randomized, double-blind trial to assess the efficacy and safety of pulse doses of dexamethasone on survival without supplemental oxygen in very low birth weight infants at high risk of having chronic lung disease. Seventy-eight infants with birth weights < or = 1500 gm who were ventilator dependent at 7 days of postnatal age were randomly assigned to receive pulse doses of dexamethasone, 0.5 mg/kg per day, divided twice daily (n = 39), or an equivalent volume of saline solution placebo (n = 39), for 3 days at 10-day intervals until they no longer required supplemental oxygen or assisted ventilation, or reached 36 weeks of postmenstrual age. At study entry, the groups did not differ by birth weight, gestational age, or severity of lung disease. At 36 weeks of postmenstrual age, there was both a significant increase in survival rates without oxygen supplementation (p = 0.03) and a significant decrease in the incidence of chronic lung disease (p = 0.047) in the group that received pulse therapy. Supplemental oxygen requirements were less throughout the study period in the group that received repeated pulse doses of dexamethasone (p = 0.013). The total numbers of deaths and the durations of supplemental oxygen, ventilator support, and hospital stay did not differ between groups. Recorded side effects in the pulse therapy group were minimal and included an increase in the use of insulin therapy for hyperglycemia (p < 0.05). We conclude that in this population of very low birth weight infants, treatment with pulse doses of dexamethasone resulted in improvement in pulmonary outcome without clinically significant side effects.

A multicenter randomized, masked comparison trial of natural versus synthetic surfactant for the treatment of respiratory distress syndrome.

OBJECTIVE: To compare the efficacy and safety of two surfactant preparations in the treatment of respiratory distress syndrome (RDS). METHODS: We conducted a randomized, masked comparison trial at 21 centers. Infants with RDS who were undergoing mechanical ventilation were eligible for treatment with two doses of either a synthetic (Exosurf) or natural (Infasurf) surfactant if the ratio of arterial to alveolar partial pressure of oxygen was less than or equal to 0.22. Crossover treatment was allowed within 96 hours of age if severe respiratory failure (defined as two consecutive arterial/alveolar oxygen tension ratios < or = 0.10) persisted after two doses of the randomly assigned surfactant. Four primary outcome measures of efficacy (the incidence of pulmonary air leak (< or = 7 days); the severity of RDS; the incidence of death from RDS; and the incidence of survival without bronchopulmonary dysplasia (BPD) at 28 days after birth) were compared by means of linear regression techniques. RESULTS: The primary analysis of efficacy was performed in 1033 eligible infants and an analysis of safety outcomes in the 1126 infants who received study surfactant. Preentry demographic characteristics and respiratory status were similar for the two treatment groups, except for a small but significant difference in mean gestational age (0.5 week) that favored the infasurf treatment group. Pulmonary air leak (< or = 7 days) occurred in 21% of Exosurf- and 11% of infasurf-treated infants (adjusted relative risk, 0.53; 95% confidence interval, 0.40 to 0.71; p < or = 0.0001). During the 72 hours after the initial surfactant treatment, the average fraction of inspired oxygen (+/-SEM) was 0.47 +/- 0.01 for Exosurf- and 0.39 +/- 0.01 for infasurf-treated infants (difference, 0.08; 95% confidence interval, 0.06 to 0.10; p < 0.0001); the average mean airway pressure (+/-SEM) was 8.6 +/- 0.1 cm H2O; for Exosurf- and 7.2 +/- 0.1 cm H2O for Infasurf-treated infants (difference, 1.4 cm H2O; 95% confidence interval, 1.0 to 1.8 cm H2O; p < 0.0001). The incidences of RDS-related death, total respiratory death, death to discharge, and survival without bronchopulmonary dysplasia at 28 days after birth did not differ. The number of days of more than 30% inspired oxygen and of assisted ventilation, but not the duration of hospitalization, were significantly lower in Infasurf-treated infants. CONCLUSION: Compared with Exosurf, Infasurf provided more effective therapy for RDS as assessed by significant reductions in the severity of respiratory disease and in the incidence of air leak complications.