Neonatal herpes: case series in two obstetric centres over a 10-year period (2013-2023), France.

Neonatal herpes simplex virus (HSV) infection (HSV infection in infants less than 6 weeks of age) is rare but mortality and morbidity rates are high after disseminated disease and encephalitis. In France, the epidemiology is poorly described, and two decades ago, incidence was estimated to be 3 per 100,000 live births a year. We describe determinants, epidemiologic and clinical characteristics of neonatal HSV infection in a managed-care population attending in two major obstetric and paediatric centres, Paris, France, over a 10-year period. This retrospective case series study was conducted from 2013 to 2023, in infants less than 42 days of age who had virologically confirmed HSV infection. We report an overall rate of neonatal herpes of 5.5 per 100,000 live births a year and an incidence of symptomatic cases of 1.2 per 100,000 live births a year. HSV-1 was the major serotype involved (84.2%) and post-natal acquisition through the orolabial route reached 63.2%. All neonates who had neonatal HSV PCR screening (owing to clinical signs in parents) and who received prompt acyclovir treatment remained asymptomatic. Symptomatic forms accounted for 21.1% cases of the total and mortality was high (62.5% of symptomatic forms).   Conclusion: This case series confirms that neonates at risk for HSV disease and poor outcome are those born to HSV-seronegative mothers, preterm infants, and those who received acyclovir after onset of symptoms (mainly because mothers did not present evidence of acute HSV infection). Our study confirms the major role of HSV-1 and the frequency of its early post-natal acquisition. What is known: • Neonatal herpes simplex virus infection is rare but motality and morbidity rates are high after disseminted disease and encephalitis. National recommendations exist worldwide but mangement of this disease is not always easy. What is new: • As in France epidemiology of neonatal herpes is poorly described, our report is potentially an important addition to the existing literature. Moreover, we describe local practice that may be useful to physicians.

Serum calcium normal range in 1000 term newborns.

INTRODUCTION: Serum calcium rapidly declines at birth because of the sudden interruption of the maternal-fetal calcium influx. Several factors are known to influence serum calcium in the first days of life, including circulating concentrations of maternal vitamin D. Objective was to establish the normal range variations of neonatal serum calcium according to the French current vitamin D supplementation during pregnancy, i.e. 100,000 IU of cholecalciferol during the third trimester. METHODS: We included in our prospective cohort study 1002 mother-newborn dyads from, with recruitments from April 2012 to July 2014 in France, in two recruiting centers located in Paris neighborhoods. RESULTS: Total serum calcium at 3 days of life in neonates varied from 2.06 to 2.73 mmol/L [2.5 and 97.5 percentiles], with a mean of 2.45 mmol/L. Serum calcium was similar between babies born from vitamin D supplemented mothers and those born from the non-supplemented ones. Univariate and multivariable analyses demonstrated the importance of maternal and cord blood 25(OH)D concentrations for newborn serum calcium maintenance. CONCLUSION: We established that the expected serum calcium in neonates ranges between 2.06 and 2.73 mmol/L which is significantly wider than the adult range. This finding should help physicians in the diagnosis of hypo- or hypercalcemia. In addition, our study supports the importance of vitamin D supplementation and 25(OH)D status for neonatal serum calcium maintenance.

Performance of Targeted Congenital Cytomegalovirus Screening in Newborns Failing Universal Hearing Screening: A Multicenter Study.

BACKGROUND: Cytomegalovirus (CMV) is the most frequent cause of congenital infection and ≈20% of all infected neonates present or will develop sensorineural hearing loss. Targeted congenital CMV (cCMV) screening in newborns who failed universal newborn hearing screening has been proposed as a strategy to identify neonates with both hearing loss and cCMV infection who could benefit from antiviral treatment implemented within the first month of life. OBJECTIVES: To evaluate the feasibility and performance of cCMV targeted screening in a French setting. METHODS: Neonates were recruited in 5 maternity centers in greater Paris. A saliva sample for CMV polymerase chain reaction (PCR) testing was collected in neonates who failed newborn hearing screening. Outcomes including CMV PCR result and confirmation of hearing loss by an otorhinolaryngologist specialist were documented. RESULTS: Two-hundred thirty-six newborns were included and a saliva sample was collected in 98% (231/236) of them. The result of CMV PCR was available at a median of 9 days (7-10 days) of life and in 96% of cases within the first month of life. Two neonates were infected with CMV. The result of the otorhinolaryngologist assessment was available in 75% (178/236) of cases at a median of 16 days (9-26 days). Hearing loss was confirmed in 2.8% (5/178). The 2 infected neonates had hearing loss confirmed at 5 and 8 days of life and were treated with valganciclovir at days 9 and 16, respectively. CONCLUSIONS: The result of this study confirms that targeted cCMV screening is feasible in these French settings.

Allowing more time to ILCOR Step A of neonatal resuscitation leads to better residents' task completion in simulated scenarios. A problem of time pressure?

BACKGROUND: Roughly 10% of newborns need help to complete the transition of birth. For these infants, international guidelines recommend supporting them using a 4-step procedure (A to D). Step A is an assessment time, which includes eight tasks and finishes by starting the positive pressure ventilation (PPV), if necessary (step B). The guidelines changed in 2015 and the allotted time was raised from 30 to 60 seconds for step A completion. This study aimed to assess if the reduced time constraint in step A could have an impact on 1st-year pediatric residents' performance to complete step A and if could lead to later initiation of step A. METHODS: Using video recordings of standardized neonatal scenarios over 6 years (3 before the change and 3 after), we assessed the ability of 1st-year pediatric residents of the Paris region to complete step A and initiate PPV in the allotted time in each period. Among the sessions, including at least five scenarios we evaluated all the PPV required scenarios executed for the first time by a dyad of 1st-year pediatric residents. RESULTS: Among 52 sessions, we included 104 scenarios (25 sessions and 50 scenarios before the change and 27 sessions and 54 scenarios after). PPV started roughly at 1-minute resuscitation in both periods, but completion of the tasks before PPV-start was significant. Only 12% of the dyad of residents executed the eight tasks before PPV initiation in the first period versus 54% in the second period (p < 0.0001). Additionally, the completion of the eight tasks of step A was significantly better during the second period (6 [6-7] vs. 8 [7-8] p < 0.001). CONCLUSIONS: These results could suggest that a reduced time constraint for step A imposed by the new Guidelines was associated with better performance.

Staffing needs for unscheduled activity in obstetrics and gynecology.

INTRODUCTION: To determine a minimum threshold of medical staffing needs (obstetricians-gynecologists, anesthesiologists-resuscitation specialists, nurse-anesthetists, pediatricians, and midwives) to ensure the safety and quality of care for unscheduled obstetrics-gynecology activity. MATERIALS AND METHODS: Face to face meetings of French healthcare professionals involved in perinatal care in different types of practices (academic hospital, community hospital or private practice) who belong to French perinatal societies: French National College of Gynecologists-Obstetricians (CNGOF), the French Society of Anesthesia and Resuscitation Specialists (SFAR), the French Society of Neonatology (SFN), the French Society of Perinatal Medicine (SFMP), the National College of French Midwives (CNSF), and the French Federation of Perinatal Care Networks (FFRSP). RESULTS: Different minimum thresholds for each category of care provider were proposed according to the number of births/year in the facility. These minimum thresholds can be modulated upwards as a function of the level of care (Level 1, 2 or 3 for perinatal centers), existence of an emergency department, and responsibilities as a referral center for maternal-fetal and/or surgical care. For example, an obstetrics-gynecology department handling 3000-4500 births per year without serving as a referral center must have an obstetrician-gynecologist, an anesthesiologist-resuscitation specialist, a nurse-anesthetist, and a pediatrician onsite specifically to provide care for unscheduled obstetrics-gynecology needs and a second obstetrician-gynecologist available within a time compatible with security requirements 24/7; the number of midwives always present (24/7) onsite and dedicated to unscheduled care is 5.1 for 3000 births and 7.2 for 4500 births. A maternity unit's occupancy rate must not exceed 85 %. CONCLUSION: The minimum thresholds proposed here are intended to improve the safety and quality of care of women who require unscheduled care in obstetrics-gynecology or during the perinatal period.

Management and Outcomes of Neonatal Arteriovenous Brain Malformations with Cardiac Failure: A 17 Years' Experience in a Tertiary Referral Center.

OBJECTIVES: To assess the management and outcomes of neonatal arteriovenous brain malformations (mostly vein of Galen malformations) complicated by cardiac failure in the era of prenatal diagnosis and endovascular treatment in a tertiary referral center. STUDY DESIGN: This observational study included 77 living newborn infants with arteriovenous brain malformations with cardiac failure, admitted to our referral center from 2001 to 2017. All infants underwent cardiovascular evaluation including echocardiogram and brain magnetic resonance imaging. Long-term survivors had standard neurocognitive assessments. RESULTS: Infants were admitted to the neonatal intensive care unit at a median of 5 days of age (including 18 inborn patients since 2009). Sixty transarterial shunt embolizations were performed in 46 patients during their first month (at a median age of 7.5 days) or postponed beyond the first month in another 10 long-term survivors. Embolization was not performed in 21 infants, including 19 nonsurvivors with severe brain injury, uncontrolled cardiac failure, or multiple organ failure. Cardiac failure requiring vasopressor infusion occurred in 48 patients (64%) during the hospitalization. Infants who survived the first month underwent a median of 3 embolization sessions. Among the 51 survivors, 21 had a good outcome and 19 had a poor outcome at follow-up (median age, 5.3 years); 11 children were lost to follow-up. CONCLUSIONS: In the era of multidisciplinary prenatal diagnosis, using a standardized care protocol, 47% of liveborn infants with an arteriovenous shunt malformation with cardiac failure experienced a favorable outcome.

Study of the Factors Leading to Fetal and Neonatal Dysthyroidism in Children of Patients With Graves Disease.

CONTEXT: Neonatal hyperthyroidism was first described in 1912 and in 1964 was shown to be linked to transplacental passage of maternal antibodies. Few multicenter studies have described the perinatal factors leading to fetal and neonatal dysthyroidism. OBJECTIVE: To show how fetal dysthyroidism (FD) and neonatal dysthyroidism (ND) can be predicted from perinatal variables, in particular, the levels of anti-thyrotropin receptor antibodies (TRAbs) circulating in the mother and child. DESIGN AND PATIENTS: This was a retrospective multicenter study of data from the medical records of all patients monitored for pregnancy from 2007 to 2014. SETTING: Among 280,000 births, the medical records of 2288 women with thyroid dysfunction were selected and screened, and 417 women with Graves disease and positive for TRAbs during pregnancy were included. RESULTS: Using the maternal TRAb levels, the cutoff value of 2.5 IU/L best predicted for FD, with a sensitivity of 100% and specificity of 64%. Using the newborn TRAb levels, the cutoff value of 6.8 IU/L best predicted for ND, with a sensitivity of 100% and a specificity of 94%. In our study, 65% of women with a history of Graves disease did not receive antithyroid drugs during pregnancy but still had infants at risk of ND. CONCLUSIONS: In pregnant women with TRAb levels ≥2.5 IU/L, fetal ultrasound monitoring is essential until delivery. All newborns with TRAb levels ≥6.8 IU/L should be examined by a pediatrician with special attention for thyroid dysfunction and treated, if necessary.

Outcomes of Preterm Neonates Transferred Between Tertiary Perinatal Centers.

OBJECTIVE: To verify if preterm neonates transferred between tertiary referral centers have worse outcomes than matched untransferred infants. DESIGN: Cohort study with a historically matched control group. SETTING: Two tertiary-level neonatal ICUs. PATIENTS: Seventy-five neonates per group. INTERVENTIONS: Transfer between tertiary-level neonatal ICUs carried out by a fully equipped transportation team. MEASUREMENTS AND MAIN RESULTS: We measured in-hospital mortality, frequency of intraventricular hemorrhage greater than 2nd grade, periventricular leukomalacia, necrotizing enterocolitis greater than or equal to grade 2, bronchopulmonary dysplasia, composite outcomes (in-hospital mortality/bronchopulmonary dysplasia, in-hospital mortality/intraventricular hemorrhage > 2nd grade, and bronchopulmonary dysplasia/periventricular leukomalacia/intraventricular hemorrhage > 2nd grade), length of neonatal ICU stay, weight at discharge, and time spent on ventilatory support. Seventy-five similar (except for antenatal steroids administration) neonates were enrolled in each cohort. Cohorts did not differ in mortality, bronchopulmonary dysplasia, intraventricular hemorrhage greater than 2nd grade, periventricular leukomalacia, necrotizing enterocolitis greater than or equal to grade 2, any composite outcomes, neonatal ICU stay, weight at discharge, and duration of respiratory support. Results were unchanged adjusting for antenatal steroids. CONCLUSIONS: Neonatal transfer between tertiary-level centers does not impact on clinical outcomes, if performed under optimal conditions.

Caesarean before labour between 34 and 37 weeks: what are the risk factors of severe neonatal respiratory distress?

OBJECTIVE: To assess the frequency of severe neonatal respiratory distress and identify its risk factors in caesarean deliveries before labour between 34 and 37 weeks' gestation. STUDY DESIGN: Retrospective study of children born by caesarean delivery before labour between 34 and 37 weeks, between 1999 and 2003 in a level 3 maternity unit. The frequencies of severe and mild neonatal respiratory distress were calculated. Univariate and multivariate analyses studied the factors potentially associated with severe respiratory distress: gestational age, type of pregnancy (singleton or multiple), condition of membranes, maternal diabetes, indication for caesarean, antenatal corticosteroid therapy, intrauterine growth retardation, infant's sex and birth weight. RESULTS: The 189 study subjects included 107 singletons and 82 twins: 28% required intensive care for severe respiratory distress and 30.2% developed mild respiratory distress. Gestational age was a significant risk factor (p = 0.01), especially before 36 weeks (adjusted OR = 2.1; 95% CI: 1.0-4.4). The multivariate analysis indicated that singleton pregnancies (adjusted OR = 3.2; 95% CI: 1.5-6.7) and caesareans for fetal indications (adjusted OR = 2.7; 95% CI: 1.2-5.7) are also risk factors and that premature rupture of the membranes is a "protective" factor against respiratory complications (adjusted OR = 0.2; 95% CI: 0.1-0.8). CONCLUSION: More than a quarter of the infants delivered by caesarean before labour between 34 and 37 weeks' gestation in our level 3 maternity unit had severe respiratory distress. Although our population may not be typical of the general population, this finding and the risk factors associated with it should be taken into account in determining the best time and place for delivery of each patient.

Embryo reduction and birth weight discordance in dichorionic twins.

BACKGROUND: Twin birth weight discordance is associated with a poor perinatal outcome. The aim of this study was to analyse the risk factors of growth discordance among dichorionic twin pregnancies. METHODS: A cohort of 346 dichorionic twin pregnancies delivered at one perinatal centre between January 1996 and December 1999 was analysed. Two groups were created, according to the presence or absence of intra-pair birth weight discordance (n = 75 and 271 respectively). Birth weight discordance was defined as a difference of >/=20% of the weight of the heavier twin. The two groups were compared by uni- and multivariate analysis, with regard to the woman's characteristics, risk factors for growth restriction or discordance, and outcome of pregnancy. RESULTS: Pregnancies with birth weight discordance had a poor outcome compared with pregnancies without discordance, with a 4-fold increase in neonatal mortality. The rate of iatrogenic embryo reduction was significantly higher in discordant pregnancies (14.7 versus 6.6%, P = 0.03). The risk of birth weight discordance was increased with a larger starting number of embryos before reduction [20.2% (64/317), 28.6% (6/21), 57.1% (4/7) and 100% (1/1) respectively, for an initial number of two (no reduction), three, four, and five embryos, P = 0.02]. In multivariate analysis, embryo reduction was the only significant risk factor for the occurrence of birth weight discordance [adjusted odds ratio (OR) = 2.3 (1.0-5.2)]. CONCLUSIONS: Birth weight discordance carries a poor perinatal outcome. Embryo reduction is an independent risk factor for birth weight discordance in dichorionic twins. This finding emphasises the need for better control of assisted reproductive technology in order to avoid high-order multiple pregnancies.