Extremely premature infants: How does death in the delivery room influence mortality rates in two level 3 centers in France?

OBJECTIVES

Mortality rates of very preterm infants may vary considerably between healthcare facilities depending on the neonates' place of inclusion in the cohort study. The objective of this study was to compare the mortality rates of live-born extremely preterm neonates observed in two French tertiary referral hospitals, taking into account the occurrence of neonatal death both in the delivery room and in the neonatal intensive care unit (NICU).

METHODS

Retrospective observational study including all pregnancy terminations, stillbirths and live-born infants within a 22- to 26-week ^0/6 gestational age range was registered by two French level 3 university centers between 2009 and 2013. The mortality rates were compared between the two centers according to two places of inclusion: either the delivery room or the NICU.

RESULTS

A total of 344 infants were born at center A and 160 infants were born at center B. Among the live-born neonates, the rates of neonatal death were similar in center A (54/125, 43.2%) and center B (33/69, 47.8%; P=0.54). However, neonatal death occurred significantly more often in the delivery room at center A (31/54, 57.4%) than at center B (6/33, 18.2%; P<0.001). Finally, the neonatal death rate of live-born very preterm neonates admitted to the NICU was significantly lower in center A (25/94, 26.6%) than in center B (27/63, 42.9%; P=0.03).

CONCLUSIONS

This study points out how the inclusion of deaths in the delivery room when comparing neonatal death rates can lead to a substantial bias in benchmarking studies. Center A and center B each endorsed one of the two models of preferential place of neonatal death (delivery room or NICU) detailed in European studies. The reasons behind the two different models and their impact on how parents perceive supporting their neonate need further investigation.

Customized and non-customized live-born birth-weight curves of single and uncomplicated pregnancies from the Burgundy perinatal network. Part I - methodology

OBJECTIVES

To establish non-customized and customized birth-weight curves of single and uncomplicated pregnancies according to gestational age.

MATERIALS AND METHODS

We used data for 64,173 mother-infants pairs from the Burgundy perinatal network database (France) over the period 2005-2013. A validated procedure was used to link mothers with their newborns, and maternal and fetal pathologies likely to affect birth weight were excluded. Multiple regression analysis with covariate selection was used to build a customized growth curve with maternal and fetal parameters.

RESULTS

Using this methodology, three different curves were generated: an unadjusted curve for birth weight, named B0, an curve adjusted for fetal gender, named B1 and a curve adjusted for fetal and maternal parameters (fetal gender, maternal height, weight and parity), named B2.

CONCLUSION

We present curves showing an original distribution of birth weights for the French population in order to improve the diagnosis of small for gestational age. These curves are not based on the Gardosi in utero growth model but on actual birth weights, thus limiting bias. Nevertheless, the minimum gestational age was 25weeks as there was an insufficient number of live-borns in small gestational ages.

[Correlation between the perineal-to-skull measurement by tranperineal ultrasound, failure of vaginal operative delivery and maternal-fetal morbidity]

OBJECTIVES

To assess the influence of the perineal-to-skull measurement by tranperineal ultrasound (TPU) on the outcome of vaginal operative extraction together with maternal and fetal morbidity.

MATERIALS AND METHODS

Retrospective, monocentric and descriptive study was done on 272 patients, from 2009 January 1st to 2009 December 31st. It compares the failure rate of instrumental extraction, total caesarean section rate together with the maternal morbidity (type of perineal tears and post-partum hemorrhage rate) and fetal morbidity (5' Apgar score, arterial pH, transfer in neonatal intensive care unit) to the values obtained with TPU.

RESULTS

There is a correlation between the perineal-to-skull measurements higher or equal to 50mm at TPU and the instrumental failure rate (<50mm 0.8% vs. ≥50mm 11.9%; P<0.0001), caesarean (0.9% vs. 33.3%; P<0.0001), post-partum haemorrhage (3% vs. 11.9%; P=0.02), et paediatric intervention (16.7% vs. 31%; P=0.03).

CONCLUSION

Perineal-to-skull distance measured with TPU higher or equal to 50mm is at risk of instrumental failure and maternal morbidity. Associated with clinical examination and usual obstetrical risk factors, TPU could be useful to the decision between operative vaginal delivery and prophylactic caesarean section.

Molecular characterization of 39 de novo sSMC: contribution to prognosis and genetic counselling, a prospective study

Small supernumerary marker chromosomes (sSMCs) are structurally abnormal chromosomes that cannot be characterized by karyotype. In many prenatal cases of de novo sSMC, the outcome of pregnancy is difficult to predict because the euchromatin content is unclear. This study aimed to determine the presence or absence of euchromatin material of 39 de novo prenatally ascertained sSMC by array-comparative genomic hybridization (array-CGH) or single nucleotide polymorphism (SNP) array. Cases were prospectively ascertained from the study of 65,000 prenatal samples [0.060%; 95% confidence interval (CI), 0.042-0.082]. Array-CGH showed that 22 markers were derived from non-acrocentric markers (56.4%) and 7 from acrocentic markers (18%). The 10 additional cases remained unidentified (25.6%), but 7 of 10 could be further identified using fluorescence in situ hybridization; 69% of de novo sSMC contained euchromatin material, 95.4% of which for non-acrocentric markers. Some sSMC containing euchromatin had a normal phenotype (31% for non-acrocentric and 75% for acrocentric markers). Statistical differences between normal and abnormal phenotypes were shown for the size of the euchromatin material (more or less than 1 Mb, p = 0.0006) and number of genes (more or less than 10, p = 0.0009). This study is the largest to date and shows the utility of array-CGH or SNP array in the detection and characterization of de novo sSMC in a prenatal context.

Arthroscopic repair of large and massive rotator cuff tears using the side-to-side suture technique. Mid-term clinical and anatomic evaluation

PREAMBLE: Arthroscopic repair is our treatment of choice for massive rotator cuff tears. In order to reduce tension, we perform a side-to-side suture technique. The purpose of our work was to study the outcome of such technique by evaluating functional score and rotator cuff integrity using ultrasound at 2-year follow-up.

HYPOTHESIS

The "side-to-side" arthroscopic repair of large and massive rotator cuff tears provides a long-term continuity of rotator cuff mechanism, enhances function and relieves pain with low morbidity.

TYPE OF STUDY

Retrospective monocenter study.

MATERIAL AND METHODS

We included a continuous series of 50 patients of mean age 66.6 years (46-80), operated on between January 2007 and March 2008 for full-thickness retracted tears of the supraspinatus extending or not to the infraspinatus tendon. Management consisted of arthroscopic subacromial bursectomy, acromioplasty and side-to-side repair of the rotator cuff tendons with secure anchor fixation to the tuberosity. The relative Constant score was used for clinical evaluation preoperatively and at a minimum of 24 months after surgery. The continuity of rotator cuff mechanism was evaluated using ultrasound.

RESULTS

The mean relative Constant score improved significantly (p<0.05) from 40% (18-67) preoperatively to 91.7% (40-107) postoperatively. Fifty-six percent of the rotator cuffs from this series demonstrated continuity with a postoperative relative Constant score of 98.4% (74-121) and an increase in the shoulder strength score of 3.6 kg (1-6). Forty-four percent of the rotator cuffs had recurrent tear with an overall relative Constant score of 83.6% (4-126) and we did not observe any improvement in the strength score in this sub-group. Eighty-eight percent of the patients were satisfied or very satisfied with their outcome.

DISCUSSION

At a minimum 24-month follow-up, the side-to-side suturing technique reported excellent functional results with a very high satisfaction rate. For these large and massive rotator cuff tears sometimes considered as irreparable, ultrasound confirmed the continuity of the repair in 56% of the cases. Unhealed patients were not disadvantaged since they experienced pain relief and functional improvement. However, in this sub-group of patients, recovery of shoulder strength was poor.

LEVEL OF EVIDENCE

Level IV.

[Liveborn birth-weight of single and uncomplicated pregnancies between 28 and 42 weeks of gestation from Burgundy perinatal network]

OBJECTIVES

To build a reference chart for birth weight according to gestational age based on a newborn population from single uncomplicated pregnancies.

MATERIALS AND METHODS

We have used data from the Burgundy perinatal network for the years 2000 to 2005. We can exclude, with a validate linkage procedure of all mother-newborn couples, the whole of newborns from pregnancies complicated by mellitus diabetes or pre eclampsia. After statistical validation, the birth weights were modelled and graphically represented.

RESULTS

We have used 105,665 data from the "healthy" sample to construct a birth weight distribution according to gestational age at 28 to 42 weeks'. Results are also represented adjusted for sex.

CONCLUSION

We present an original birth weight distribution according to gestational age from a recent French population sample. Exclusion of maternal conditions which may affect fetal growth modify the data distribution, mainly for low birth weights and premature deliveries. Used in clinical practice, it could lead to better identify newborns with increased risk of postnatal complications.

Syndromic encephalocele in a fetal case with a 1p35-pter deletion and a 14q32-qter duplication inherited from a maternal balanced translocation

Occipital encephalocele belongs to the family of neural tube defects, which occur in one among 2000 to 5000 live births. Syndromic encephaloceles include Meckel-Gruber syndrome and various chromosomal abnormalities. We report on a fetal case (13 WG) with bilateral cleft lip and palate, choanal atresia, occipital encephalocele, bilateral club feet, bilateral multicystic kidneys, enlarged bladder and urethral atresia. The fetal chromosome analysis showed a maternally inherited unbalanced translocation between the short arm of chromosome 1 and the long arm of chromosome 14, resulting in 1p35-pter deletion and 14q32-qter duplication (46,XY,der(1),t(1;14)(p35;q32)). Since the chromosomal breakpoints have not previously been implicated in syndromic encephalocele, this observation is of interest for the identification of other genes responsible for occipital encephalocele.

Microcephaly is not mandatory for the diagnosis of mosaic variegated aneuploidy syndrome

The phenotype of mosaic variegated aneuploidy (MVA) syndrome is characterized by severe microcephaly, growth deficiency, mental retardation, and mild physical anomalies. The MVA syndrome is associated with mosaicism for several different aneuploidies involving many different chromosomes with or without premature centromere division (PCD). To date 28 cases of MVA syndrome have been reported. We report the first case of MVA syndrome without microcephaly. The clinical features in our patient included craniofacial dysmorphic features, growth retardation, and developmental delay. Cytogenetics analyses and FISH studies showed multiple aneuploidy with trisomy 18, 19, and 8, respectively in blood lymphocyte and fibroblasts without PCD. This case is compared with the other of MVA syndrome previously reported in literature. From this case report, we suggest that microcephaly is not mandatory for the diagnosis of MVA syndrome.

Interest of F-18 fluorodeoxyglucose positron emission tomography in the evaluation of vaginal malignant melanoma

BACKGROUND

This is the first report of FDG-PET findings in a case of vaginal melanoma.

CASE

The tumor arose from the anterior wall of the vaginal canal. As the tumor was limited to the vaginal wall and as there was no evidence of distant metastases, the disease was staged as IIC (AJCC 2002). PET-CT images showed two mediastinal foci localized to the left highest mediastinal and subcarinal nodes on fusion PET/CT images. As it was metastatic, the disease was staged IV (AJCC 2002).

CONCLUSION

In comparison to conventional imaging, FDG-PET provides a more accurate assessment of the extent of disease spread in patients with vaginal melanoma as with cutaneous melanoma. Significant alterations in the surgical management and treatment were made based on PET results.

Diagnostic and therapeutic dilemma with large prenatally detected cystic adrenal masses

OBJECTIVES

The prenatal finding of a large cystic adrenal mass raises the dilemma of the differential diagnosis between adrenal hemorrhage and cystic neuroblastoma. The possibility of a neuroblastoma usually leads to surgical excision of such tumors. Nevertheless, an adrenal hemorrhage has to be recognized, so that unnecessary surgery may be avoided.

METHODS

Three cases of large prenatally detected adrenal masses managed nonoperatively are reported. Data studied were: age at the diagnosis, prenatal and postnatal ultrasonographic consistency, and tumor marker levels. Size and sonographic evolution were also studied.

RESULTS

In all 3 cases, a cystic mass, measuring more than 40 mm in size, was detected during the 3rd trimester of pregnancy. The sonographic appearance evolved from a sonolucent tumor to a heterogeneous mass with hyperechoic areas. The tumor marker levels were normal. All infants had a documented decrease in mass size at birth and were managed nonoperatively. All these tumors were considered adrenal hemorrhages.

CONCLUSIONS

Prenatal ultrasonography rarely permits to distinguish an adrenal hemorrhage from a cystic neuroblastoma. The differential diagnosis, even in large masses, is based on close postnatal follow-up with serial sonography. Surgery is not mandatory, unless the size does not decrease. However, without pathologic proof, it is not possible to differentiate an adrenal hemorrhage from a spontaneously resolved neuroblastoma.

Familial orofaciodigital syndrome type I revealed by ultrasound prenatal diagnosis of porencephaly

Porencephaly is a rare central nervous system (CNS) abnormality that can be caused by an intraparenchymal destructive process or a developmental defect. Here we report on a prenatal ultrasound diagnosis of complex CNS abnormalities including agenesis of the corpus callosum, agenesis of the cerebellar vermis, bilateral hydrocephaly, and bilateral porencephaly in fetus at 33 weeks' gestation. The diagnosis of familial orofaciodigital syndrome type I (OFD I) was raised after fetal autopsy, clinical examination of the family, and the X-linked dominant inheritance pattern. This is the fourth report of porencephaly in association with OFD I. We discuss the difficulties in genetic counselling since OFD I shows variable expressivity of the phenotypic features. Furthermore, we emphasize the importance of a detailed ultrasound examination after a prenatal diagnosis of porencephaly.

[Voluntary interruption of pregnancy: comparative study between 1982 and 1996 in the main center of Côte d'Or. Study of women having repeat voluntary interruption of pregnancy]

Since the egal use of induced abortion (1975), all the studies have shown a relative stability of the abortion rate related to delivery. Otherwise since 1985 we have noted an increase of repeat abortions.

OBJECTIVE

We compared in same center two populations of aborters with a fifteen year's interval. Then we analysed the psyco-social conditions of patients who had more than one abortion (R).

METHODS

It was a comparative study between 1982 and 1996 in the main center of Côte d'Or (France). A representative sample of patients coming for abortion was retrospectively compared, (348 for 1982 and 343 for 1996).

RESULTS

There were more not married patients (p = 0.0003), more nulliparous women (p = 0.0017) and more nulligestities' one (p = 0.03) in 1996 than 1982. The interval between the previous pregnancy and in 1996 (p = 0.03). Repeat abortions (R) represented 15.8% in 1982 and 21.6% in 1996. Women who have had two or more abortions had increased significantly between 1982 (1.4%) and 1996 (5.2%) (p = 0.013). The R patients had more living children than patients who accessed for the first time at abortion (noR) in the two periods (p = 0.0003) and there were more women less thirty years old in the R group in 1996 than in 1992 (p < 0.05). The R mean age for the first abortion and for the first pregnancy were lower than the noR group in 1996: respectively 23.7 years versus 27.4% years (p = 0.00009) and 20.8 years versus 23.7 years (p = 0.0001). There were no significant difference between R and noR groups with regards of contraceptive failing, the reasons of abortion and the socio-professional categories.

CONCLUSIONS

There were no difference in the number of abortion between 1982 and 1996. However we noted an increase of repeat abortion. This group was characterised by great socio-economic problems, unstable couples and ambivalence with wish of pregnancy and no wish of children. It seemed exist a real psycho-social precariousness. Actually, this population was perfectly aware of contraceptive methods.

Severe fetal cytomegalic inclusion disease after documented maternal reactivation of cytomegalovirus infection during pregnancy

Recurrent cytomegalovirus infection during pregnancy is considered less dangerous for the fetus than primary infection. We present a case of severe fetal cytomegalic inclusion disease after maternal reactivation of cytomegalovirus during the first trimester of pregnancy. The possibility of such fetal injury is an argument for prenatal diagnosis in seropositive pregnant women when ultrasonographic findings suggest cytomegalovirus infection.

[Carcinoma of Bellini's tubules]

Carcinoma of the papillary ducts of Bellini is a rare form of renal cancer. Patients are usually asymptomatic middle-aged men who frequently have metastatic disease at the time of diagnosis. The diagnosis is based on histological examination of the nephrectomy specimen with a precise immunohistochemical examination. Radical nephrectomy is the first-line treatment and adjuvant chemotherapy, recommended by certain authors, does not appear to improve the usually poor prognosis of these tumours.

[Relationship between some health indicators of physical, mental well-being and handicaps in the aged (author's transl)]

The health status of 1,025 senior urban citizens was determined by a questionnaire based on the subjects' view of physical, mental and global well-being and of dependency (indicators of Belloc and all., Berkman, Grogono and Woodgate, Linn). The significant correlation was observed between different health indicators. However, these correlations are not strong enough to allow the explanation of one indicator by the others. The mental well-being is most independent of all other health measurements under study. The valuable information on the prevalence of some health limitations in the population is given by the constituents of the health indexes used. On the contrary, a more complete view of the health of the population should be obtained by the non correlated methods of measurement. The situation may vary following the epidemiological characteristics of the population studied.