Frequency of dosage prescribing medication errors associated with manual prescriptions for very preterm infants.

WHAT IS KNOWN AND OBJECTIVE: The risk of dosage Prescription Medication Error (PME) among manually written prescriptions within 'mixed' prescribing system (computerized physician order entry (CPOE) + manual prescriptions) has not been previously assessed in neonatology. This study aimed to evaluate the rate of dosage PME related to manual prescriptions in the high-risk population of very preterm infants (GA < 33 weeks) in a mixed prescription system. METHODS: The study was based on a retrospective review of a random sample of manual daily prescriptions in two neonatal intensive care units (NICU) A and B, located in different French University hospitals (Dijon and La Reunion island). Daily prescription was defined as the set of all drugs manually prescribed on a single day for one patient. Dosage error was defined as a deviation of at least ±10% from the weight-appropriate recommended dose. RESULTS AND DISCUSSION: The analyses were based on the assessment of 676 manually prescribed drugs from NICU A (58 different drugs from 93 newborns and 240 daily prescriptions) and 354 manually prescribed drugs from NICU B (73 different drugs from 131 newborns and 241 daily prescriptions). The dosage error rate per 100 manually prescribed drugs was similar in both NICU: 3·8% (95% CI: 2·5-5·6%) in NICU A and 3·1% (95% CI: 1·6-5·5%) in NICU B (P = 0·54). Among all the 37 identified dosage errors, the over-dosing was almost as frequent as the under-dosing (17 and 20 errors, respectively). Potentially severe dosage errors occurred in a total of seven drug prescriptions. None of the dosage PME was recorded in the corresponding medical files and information on clinical outcome was not sufficient to identify clinical conditions related to dosage PME. Overall, 46·8% of manually prescribed drugs were off label or unlicensed, with no significant differences between prescriptions with or without dosage error. The risk of a dosage PME increased significantly if the drug was included in the CPOE system but was manually prescribed (OR = 3·3; 95% CI: 1·6-7·0, P < 0·001). WHAT IS NEW AND CONCLUSION: The presence of dosage PME in the manual prescriptions written within mixed prescription systems suggests that manual prescriptions should be totally avoided in neonatal units.

[Current debates on immunology of preeclampsia. Report of the sixth international workshop of Reunion Island (Indian Ocean, December 2008)]. / Débats actuels sur l'immunologie de la prééclampsie. Comptes rendus du sixième colloque international de La Réunion (décembre 2008).

Hypertensive disorders of pregnancy (HDP) represent globally 10% of human births and their major complication, preeclampsia, 3 to 5%. The etiology of these HDP remains still uncertain, however major advances have been made these last 25 years. The Sixth International Workshop on Reproductive Immunology, Immunological Tolerance and Immunology of Preeclampsia 2008 celebrated its 10th Anniversary in Reunion-island (French overseas Department in the Indian Ocean). Over this decade, these six workshops have contributed extensively to immunological, epidemiological, anthropological and even vascular debates. The defect of trophoblastic invasion encountered in preeclampsia, intra-uterine growth retardation and to some extend also preterm labour has been understood only at the end of the 1970's. On the other hand, clinical and epidemiological findings at the end of the 20th century permitted to apprehend that "preeclampsia disease of primiparae" may in fact well be the disease of first pregnancies at the level of human couples. Among the important advances, immunology of reproduction is certainly the topic where knowledge has literally exploded in the last decade. This paper relates some major steps in comprehension of this disease and focuses on the interest to follow these immunological works and their new concepts. It seems, at the beginning of the 21st century, that we are possibly closer than ever to understand the etiology of this obstetrical enigma. In this quest, the immunology of reproduction will certainly come out as one of the main players.

[Early onset neonatal infections in the South of the Reunion Island: Incidence and use of 2002 ANAES risk criteria]. / Infection bactérienne néonatale précoce dans le sud de la Réunion: incidence et application des critères de risque Anaes 2002.

OBJECTIVES: The aim of this study was to describe the incidence of early onset neonatal infections (EONI) in the southern part of the Reunion Island, and to study the application of ANAES criteria. PATIENTS AND METHODS: A cross-sectional study was made of data collected for all live births having occurred between 1st January 2001 and 31st December 2004. RESULTS: Four hundred and thirty-seven in 16,071 neonates (out of 21,231 live births) presented with a certain or probable EONI, accounting for a regional rate of 20 per thousand (CI95 % 18-23 per thousand). Among 437 EONIs, group B streptococcus (GBS) was reported in 70.5% of the cases (n=308), Gram negative bacteria in 19.9% (n=87), of which nearly two thirds of Escherichia coli (n=56). Applying ANAES criteria led to identify 380 EONIs among 437 proven infections (sensitivity: 87%, specificity: 26%). A logistic regression analysis identified eight EONI predictors for the 7015 neonates for whom the mother GBS screening was documented: GBS positive vaginal culture (OR 4.2; CI95% 3.3-5.4), unexplained preterm birth less than 35 weeks (OR 5.7; CI95% 3.7-8.7), prolonged rupture of membranes greater than or equal to 18 hours (OR 2.1; CI95% 1.4-3.0), maternal fever greater than or equal to 37.8 degrees C (OR 3.2; CI95% 2.3-4.5), fetal tachycardia greater than or equal to 160 ppm (OR 2.7; CI95% 1.8-4.0), and thin (OR 1.6; CI95% 1.2-2.1) or thick meconium-stained amniotic fluid (OR 3.0; CI95% 2.1-4.5) or fetid fluid (OR 14.8; CI95% 4.2-51.8). CONCLUSION: The incidence of EONIS far exceeded that observed in metropolitan France, and the ANAES criteria lack sensitivity and specificity.

[Obstetrical and neonatal outcomes of gestational diabetes mellitus at Reunion Island (France)]. / Conséquences obstétricales et néonatales du diabète gestationnel dans la population du sud de l'île de la Réunion.

OBJECTIVE: To assess maternal and fetal outcomes in patients with gestational diabetes mellitus. PATIENTS AND METHODS: A retrospective study was conducted at the Sud-Reunion Hospital's maternity (French overseas department located in the Indian Ocean), during the period from January 1, 2001, through December 31, 2004. During this period, 1172 pregnant women presenting gestational diabetes mellitus were compared with 1172 non-diabetic controls matched on the basis of age, parity. Student t test, Pearson chi-square test and logistic regression model were used for statistical analysis. RESULTS: Gestational diabetes mellitus complicates about 7.5% of pregnancies in Reunion Island. Its occurrence was associated with a significantly increased prevalence of pre-pregnancy obesity (27 versus 9.4%) and chronic hypertension (5.3 versus 3.3%). The prevalence of preeclampsia and obstetrical vascular disorders were not different between the two groups, respectively 2.2 versus 2.7% (P=0.43) and 6.2 versus 4.4% (P=0.06). The rate of caesarean sections and inductions of labour was increased in the study group. The term of delivery was inferior in the study group, consecutive to increased rate of labour induction at 38 week-gestation. Macrosomia and large for gestational age (LGA) newborns rate were significantly higher in the study group, respectively 8.9 versus 4.2% and 22.5 versus 10.1% (P<0.001) but the rate of admission into neonatal unit was not significantly different. DISCUSSION AND CONCLUSION: Active management of gestational diabetes mellitus is associated with low maternal and perinatal morbidity. While age and parity are controlled by the study design, the prevalence of preeclampsia and gestational hypertension are not increased in women presenting gestational diabetes mellitus.

Obstetrical and neonatal outcomes in obese women.

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.

[Pseudomonas aeruginosa infections in a neonatal care unit at Reunion Island]. / Infections nosocomiales à Pseudomonas aeruginosa en néonatalogie à l'île de la Réunion.

OBJECTIVE: To investigate an outbreak of Pseudomonas aeruginosa (PA) hospital-acquired infections in neonates. METHODS: Incidences were assessed retrospectively in the neonatal care units of the Groupe Hospitalier Sud-Réunion, from January 2003 to September 2005. Environmental survey, audit of health care workers and case-control study were performed to reinforce staff training and to determine risk factors. RESULTS: Of 1432 neonates, 40 were infected (median gestational age: 29 weeks, median birth weight: 1195 g), accounting for an attack rate of 2.8%. Between January 2003 and January 2004, incidence rates were less than 2 infections per 1000 hospitalisation days. In the last trimester of year 2004, the incidence rose to 5.6 infections per 1000 hospitalisation days and PA was found in all ocular swabs, leading to diagnose an epidemic. However, it was only 3 months later, after 3 new deaths of very preterm neonates, that the implementation of control measures and an audit of health care practices focused on water utilisation ruled out the outbreak. The overall fatality rate was 25%, and of 71% in severe diseases (septicemia or pneumonia). The epidemic pattern argued for a common unique source. Two risk factors were identified by logistic regression: exposure to mechanical ventilation beyond 4 days (OR 3.3; CI 95%: 1.3-8.4) and very preterm birth (OR 2.7; CI 95%: 1.0-7.7). CONCLUSION: Our findings highlight the need for a close collaboration between neonatologists and hygienists to improve health care practices and surveillance.

[Study of 178 ante partum deaths in 2001-2004 in the southern part of Reunion Island]. / Etude des 178 morts foetales in utero dans le sud de l'île de la Réunion en 2001-2004.

INTRODUCTION: The perinatal mortality rate is 18.5 in the southern part of the Reunion Island (Indian Ocean), of which 2/3 are due to antepartum fetal deaths (APFD). METHODS: During a 4-year period (2001-2004) all APFD from 22 weeks gestation were recorded and analyzed with placental histology, bacteriological samples and autopsies in 27% of cases. The Australasian and New-Zealand classification PSANZ-PDC (2000) was used. Risk factors of fetal death with monofetal pregnancies are determined in comparison with live births. RESULTS: Out of 21.495 total births, 178 APFD were recorded. The main obstetrical risk factors were primiparity (OR 1.6, p = 0.002), maternal age over 34 years (OR 1.6, p = 0.01), hypertensive disorders of pregnancy (OR 3.0, p < .001) and multiple births (OR 2.5, p < 0.001). The great majority of APFD (76%) involved preterm fetuses, of which 61% of very preterm (<33 weeks), and 25% of fetuses were growth retarded (OR 3.9, p < 0.001). Only 8% of cases were considered unexplained. The main etiologies were infectious causes in 26% of cases, vascular fetal growth restriction (18%), specific perinatal conditions (14%) of which one-third were due to cord anomalies, preeclampsia (10%), maternal conditions (8%), congenital anomalies (8%) and ante-partum hemorrhage (7%). We discuss the interests and the limitations of using the Australian and New-Zealand classification PSANZ 2000. Intra-uterine growth retardation is one of the principal risk factors of fetal death. CONCLUSION: Besides well-known obstetrical risk factors such as diabetes, hypertension, multiple pregnancies, all screening of intra-uterine growth retardation in the second trimester of pregnancy should include a special survey in order to minimize the incidence of APFDs.

[Twin pregnancies in southern Reunion Island: a three-year cross-sectional study of risk factors and complications]. / Grossesses gémellaires dans le sud de l'île de la Réunion: étude transversale sur 3 ans des facteurs de risque et des complications.

OBJECTIVES: To describe characteristics of multiples pregnancies in southern Reunion Island. MATERIAL AND METHODS: A three-year [corrected] cross-sectional observational study aimed at describing risk factors, events and [corrcected] complications and associated with twin pregnancies from 22 weeks gestation onward, within a tertiary care hospital centre, the Groupe Hospitalier Sud-Réunion. RESULTS: The study included 241 multiple pregnancies out of 15 837 pregnant women. The regional incidence of multiple pregnancies was 1.5%. Indicators of eligible twin pregnancies (n=234) were mother age up or equal to 35 years (63% of women, OR 8.4; CI95% 6.3-11.1), infertility treatments (15%): ovarian stimulations (OR: 50.2; CI95% 24.7-102) and in vitro-fertilisations (OR: 44.3; CI95% 22.6-86.3). A low maternal corpulence before pregnancy (BMI<20) and celibacy were negatively associated with twin pregnancies. Prenatal cares for twin pregnancies were globally adequate. The need for hospitalisation was 50% (30% of whom for preterm delivery threats). Twin pregnancies increased risks for pre eclampsia (OR: 3.0; CI95% 1.6-5.7) and gestational diabetes (OR: 1.9; CI95% 1.2-2.8). Caesareans and instrumental delivery rates were 50% and 12% (vs 16% and 7%), respectively. Twin infants were preterm for 62% and very preterm for 18%. Last, they were more likely to die than singletons (perinatal mortality: 78 per thousand for monochorionic twins, 57 per thousand for bichorionic twins vs 17 per thousand, p<0.0001, respectively). CONCLUSION: In Reunion Island, the incidence of multiple pregnancies is similar to that seen in Europe, but seems less due to assisted reproduction techniques. In return, they are associated with higher morbidity and mortality rates.

[Chikungunya infection in pregnancy: Evidence for intrauterine infection in pregnant women and vertical transmission in the parturient. Survey of the Reunion Island outbreak]. / Infection à Chikungunya chez la femme enceinte et risque de transmission materno-foetale.

PURPOSE: Since February 2005, an outbreak of Chikungunya virus (CHIKV) infections occurred in Reunion Island. It is transmitted by the Aedes albopictus mosquito. Neonatal cases observations suggest possible fetal transmission during pregnancy. MATERIAL [corrected] AND METHODS. Observations made in 160 pregnant mothers infected by CHIKV between June 1, 2005 and February 28, 2006, in the south of Reunion island were recorded. RESULTS: Three of nine miscarriages before 22 weeks of gestation could be attributed to the virus. 3,829 births took place during this time. Among the 151 infected women, 118 were viremia negative at delivery, and none of the newborns showed any damage. Among the 33 with positive viremia at delivery, 16 newborns (48.5%) presented neonatal Chikungunya. DISCUSSION: Though fetal contamination risks appear to be rare before 22 weeks of gestation, they are potentially dangerous. After 22 weeks gestation, newborns infection occurs if the mother is viremia positive at delivery. Transplacental transmission is suspected, but the pathogenic mechanism remains unknown.

Preeclampsia: a couple's disease with maternal and fetal manifestations.

Preeclampsia still ranks as one of obstetrics major problems. Clinicians typically encounter preeclampsia as maternal disease with variable degrees of fetal involvement. More and more the unique immunogenetic maternal-paternal relationship is appreciated, and as such also the specific 'genetic conflict' that is characteristic of haemochorial placentation. From that perspective preeclampsia can also been seen as a disease of an individual couple with primarily maternal and fetal manifestations. Factors that are unique to a specific couple would include the length and type of sexual relationship, the maternal (decidual natural killer cells) acceptation of the invading cytotrophoblast (paternal HLA-C), and seminal levels of transforming growth factor-beta and probably other cytokines. The magnitude of the maternal response would be determined by factors including a maternal set of genes determining her characteristic inflammatory responsiveness, age, quality of her endothelium, obesity/insulin resistance and probably a whole series of susceptibility genes amongst which the thrombophilias received a lot of attention in recent years.

[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.

[Obstetrical risk factors of 365 primiparous adolescent pregnancies in Reunion Island]. / Etude des facteurs de risques obstétricaux dans le suivi de 365 grossesses primipares adolescentes à l'île de la Réunion.

OBJECTIVES: Analysis of obstetrical risk factors in teenage primiparous pregnancies in Reunion Island (4% of total births). MATERIALS AND METHODS: Retrospective study, between 2001 and 2002, comparing primiparous adolescents (13-17 years, n = 365), with primiparous controls (18-29 years, n = 2050). The analysis included demographical factors, maternal medical histories, prenatal follow-up, obstetrical risk factors, delivery modes and neonatal characteristics. RESULTS: Adolescents attended on average 8 prenatal consultations, however 4% had poor prenatal care (less than 3 visits, OR 4.2, P < 0.001 vs controls). They presented less gestational diabetes, but there were no differences concerning pre-existing hypertension, hypertensive disorders of pregnancy, medical reasons of hospitalisation between the two groups. Mode of delivery was more favorable in adolescents (half rate of caesarean sections, shorter duration of membrane ruptures). Nevertheless, adolescents presented a higher risk of severe prematurity (<32 Weeks gestation, incidence 3.6% vs 1.6%, OR 2.3, p = 0.008). CONCLUSION: With optimal prenatal care (more than 90% of our cohort), primiparous adolescents present globally a favorable course of their pregnancies and have better deliveries than their young (18-29 years) counterparts. However, there is a significant risk of severe prematurity requiring special care for these pregnancies.

Paternity patterns and risk of preeclampsia in the last pregnancy in multiparae.

Few authors have published investigations regarding a possible association between preeclampsia and changing paternity. This study employs an epidemiological approach to explore the relationship between severe preeclampsia and changes in paternity patterns among multigravidae in a Caribbean community (Guadeloupe, French West Indies). Multiparae who were diagnosed with preeclampsia or eclampsia with fetal complications (transfer of their infants in the Neonatal Department) and controls were examined (134 mothers' interviews). Information concerning paternity for the index and previous pregnancies was collected from three groups: women with pregnancy-induced hypertension (PIH); women with chronic hypertension (CH); and a control group consisting of women without hypertension during pregnancy. In 21/34 (61.7%) of PIH mothers, the father of the current pregnancy was different than that of the former, compared to 4/40 (10%) among CH and 10/60 (16.6%) in the controls (P < 0.0001). Moreover, considering three and four consecutive pregnancies, there was a significant trend (P < 0.005 and P < 0.02) for an increase in PIH with having a different father in each successive pregnancy. Patterns of changing paternity were significantly correlated with pregnancy-induced hypertension in multiparae but not with chronic hypertension and controls.

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.

Immune maladaptation in the etiology of preeclampsia: a review of corroborative epidemiologic studies.

Genuine preeclampsia is a disease of first pregnancies. The protective effect of multiparity, however, is lost with change of partner. Also, exposure to semen provides protection against developing preeclampsia. Analogous to altered paternity, artificial donor insemination and oocyte donation are reported to result in a substantial increase of preeclampsia. Thus, epidemiologic studies strongly suggest that immune maladaptation is involved in the etiology of preeclampsia. Although the exact etiology of preeclampsia remains unknown, the conclusions derived from epidemiologic studies may have consequences for practicing physicians: 1) according to the primipaternity concept, a multiparous women with a new partner should be approached as being a primigravid women; 2) artificial donor insemination and oocyte donation are associated with an increased risk of developing pregnancy-induced hypertensive disorders; 3) a more or less prolonged period of sperm exposure provides a partial protection against pregnancy-induced hypertensive disorders. In the 1990s, all women with changing partners are strongly advised to use condoms to prevent sexually transmitted diseases. However, a certain period of sperm exposure within a stable relation, when pregnancy is aimed for, is associated with a partial protection against preeclampsia.

Validity of postnatal assessments of gestational age in low birthweight infants from a Caribbean community.

The Dubowitz assessment of gestational maturity was compared with the best obstetric estimate of gestational age based on date of last menstrual period (LMP) or ultrasonography performed early in the pregnancy or both. This study involved 384 low birthweight infants admitted to the neonatal tertiary center in Guadeloupe, French West Indies, during the period 1986 through 1988. The Dubowitz assessment exceeded the best obstetric estimation by an average of nearly 5 days. This overestimation by the Dubowitz method was observed at every gestational age and was greatest at gestational ages of less than 35 weeks. The physical characteristics of the postnatal assessment were in closer agreement with the best obstetric estimate than the neurological characteristics. These findings concur with other investigations that indicate that the Dubowitz postnatal assessment of gestational age overestimates the gestational age interval from date of LMP in low birthweight and preterm infants.

PIP: Physicians used data on 384 low birth weight neonates born between January 1986 and December 1988, who were in the neonatal intensive care unit at Pointe-a-Pitre Hospital in Guadeloupe, to compare the Dubowitz assessment of gestational age with the best obstetric estimate of gestational age. They needed a valid estimate of gestational age to quickly differentiate premature newborns from small-for-dates newborns. The hospital had limited technical and human resources, so it needed to determine which infants were at greater risk. The Dubowitz assessment resulted in a mean gestational age about 5 days longer than the obstetric estimate. There was almost a 2 week difference in mean gestational age between the neurological component and the physical component of the Dubowitz assessment (35 weeks, 4 days vs. 33 weeks, 5 days). The 2 estimates agreed completely in just 25% of cases. They disagreed by at least 2 weeks in 18% of the cases and by at least 3 weeks in 8% of cases. The analysis indicated that the Dubowitz assessment consistently overestimated gestational age in both low birth weight and premature infants and that the mean difference increased as gestational ages fell. The Dubowitz assessment even had this effect when the researchers separated the newborns into those whose gestational age was based just on last menstrual period (LMP) and those whose gestational age was based just on last (LMP) confirmed by ultrasound at a gestational age 20 weeks. The neurological component significantly overestimated both the combined Dubowitz and obstetric values for premature infants, while the physical component tended to agree.

Determinants of meconium-stained amniotic fluid in term pregnancies.

This study examines ethnic variations in meconium-stained amniotic fluid in term pregnancies, taking into account the role of gestational age, maternal sociodemographic characteristics, and medical risk factors. The study population included black and white singleton live births (N = 14,419) between 37 and 42 weeks' gestation, delivered vaginally at the Medical University of South Carolina from 1982 through 1990. Chi-square and logistic regression analysis were used to examine the association between the independent variables and meconium-stained amniotic fluid (MSAF). An increased risk of MSAF was found for advancing gestational age, indicators of fetal stress, fewer than five prenatal care visits, and > 15 hours labor. After controlling for demographic and clinical characteristics, the risk of MSAF in black patients was approximately 1.5 times that of white patients. The higher proportion of MSAF in blacks could not be explained with obvious risk factors.

Revisiting the epidemiological standard of preeclampsia: primigravidity or primipaternity?

Pregnancy-induced hypertensive disorders, and especially preeclampsia, are documented to occur primarily in first pregnancies and rarely in subsequent pregnancies. Therefore, the concept of primigravidity is the epidemiological cornerstone of this disease. The authors propose a concept in which preeclampsia is a disease of new couples, especially after a short period of sexual cohabitation, and explore if this alternative primipaternity model, as compared with the primigravidity concept, provides a better fit with well-known epidemiologic descriptions. First, the primipaternity model provides a mathematical modelling which may explain the prevalence of approximately 10% in long-term monogamic populations. Further, it proposes explanations for many epidemiological descriptions which were previously difficult to understand and assemble in a single concept.

Hyaline membrane disease in black newborns: does fetal lung maturation occur earlier?

Debate has developed among several authors about possible accelerated maturation of black fetuses in comparison with whites. In Guadeloupe, French West Indies, where 85% of the population is of black African-American origin, it has been noted that the incidence of hyaline membrane disease (HMD) represents a significant drop beginning after the 32nd week of gestation. Over a 3-year period, 419 black low-birthweight singleton newborns were admitted in the University Hospital's Neonatal Department covering 70% of all births of the island. The incidence of HMD was 50% among very low birthweight (< 1500 g) and 8.3% among moderate low birthweight (> or = 1500 g; P < 0.001). The incidence of HMD was 48.8% among the very preterm (< 32 weeks) and 7.8% (26/331) among the moderate preterm (> or = 32 weeks; P < 0.001). These differences were similar for appropriate for gestational age and small for gestational age infants. Significant differences remained after controlling for several maternal risk factors. These results suggest that the 32nd week of gestation represents a significant drop in the risk for respiratory distress syndrome in black premature compared with that reported in literature on European infants (34th week) and therefore may implicate different obstetrical decisions in the management of critical pregnancies in this population.

[Hypernatremic dehydration and breastfeeding]. / Déshydratation hypernatrémique et allaitement maternel.

UNLABELLED: Neonatal hypernatremic dehydration due to breast feeding was rarely reported in the French-language literature. CASE REPORT: The authors report hypernatremic dehydration in a 10-day-old exclusively breast-fed infant. The course was favorable. Insufficient breast milk production has been reported for 30 years. CONCLUSION: Early discharge from maternity units is frequent nowadays. Breast-fed newborns without a positive weight gain at discharge should be checked for their weight within the first ten days of life.