Épidémiologie de la prématurité : prévalence, évolution, devenir des enfants

Neuroinflammatory markers at school age in preterm born children with neurodevelopmental impairments

Background

Immune system activation in the neonatal period is associated with white matter injury in preterm infants. In animal studies, neonatal priming of the immune system leads to chronic activation of i.e. microglia cells and altered neuroinflammatory responses potentially years after preterm birth. This may contribute further to brain injury and neurodevelopmental impairment. It is unknown to what extend this also occurs in human.

Aim

To identify neuro-inflammatory markers at school age that relate to motor, cognitive and behavioral impairments in preterm born children in a pilot case-control study.

Methods

We included n = 20 preterm born children (GA < 28 weeks) in this study, of which n = 10 with motor, cognitive and behavorial impairments and n = 10 preterm born controls next to n = 30 healthy adult controls. In the preterm children, at 8-9 years, 39 inflammatory markers were assessed by Luminex assay in blood serum samples. Firstly, the preterm concentrations of these markers were compared to n = 30 adult controls. Then a univariate analysis was performed to determine differences in values between preterm children with and without impairment at school age. Finally, a principal component analysis and hierarchical clustering was performed to identify protein profiles in preterm born children that relate to impairment at school age.

Results

Inflammatory proteins in preterm children at school age differed from values of adult controls. Within the group of preterm children, we found significantly higher levels of GM-CSF in preterms with impairment (p < 0.01) and a trend towards significance for Gal1 and TRAIL (p = 0.06 and p = 0.06 respectively) when compared to preterms without impairment. In addition, differences in clustering of proteins between preterm children was observed, however this variance was not explained by presence of neurodevelopmental impairments.

Conclusion

The inflammatory profile at school age in preterm children is different from that of adult controls. The immune modulating cytokines GM-CSF, Gal1 and TRAIL were higher in preterm children with impairment than control preterm children, suggesting that immune responses are altered in these children. No specific cluster of inflammatory markers could be identified. Results indicate that even at school age, neuroinflammatory pathways are activated in preterm born children with neurodevelopmental impairments.

[Being born moderately premature: a risky developmental trajectory]

Babies born prematurely are frequently prone to developmental disorders, which are all the more severe in babies of low gestational age. However, medium prematurity also generates its own set of difficulties, including sensory, motor, cognitive, behavioral, relational and emotional disorders. It is essential to gain a better understanding of the developmental trajectory of these children and its various ups and downs, in order to support their development as early as possible.

[What are the considerations for medium prematurity?]

Despite its high prevalence, moderate prematurity has been little studied in comparison with great or very great prematurity. In order to better understand the causes of this under-representation in the literature and in post-hospital care, this article proposes to analyze the historical and medical issues surrounding prematurity, and to investigate the different representations, by caregivers and parents, of the subject of intermediate prematurity. A necessary step in the evolution of practices.

Hepatocellular carcinoma in pregnancy: A systematic review

INTRODUCTION

Hepatocellular carcinoma (HCC) is the most frequent primary malignant liver tumor and typically develops in the context of chronic liver disease, such as liver cirrhosis or chronic hepatitis B virus infection. Ultrasound evaluation, CT scan, and MRI are used to detect HCC. α-fetoprotein (AFP) is a common marker used to detect HCC in the non-pregnant population, which notoriously increases in pregnant women in relation to gestational age. Treatment is driven by the extent of the disease and the severity of underlying liver disease. Pregnancy may represent an obstacle to diagnosis and appropriate treatment of HCC. The aim of this descriptive systematic review was to describe the clinical features and maternal and neonatal outcomes of HCC in pregnancy.

MATERIAL AND METHODS

We performed a systematic review of the literature about HCC diagnosed in pregnancy and the postpartum period, with signs or symptoms arising in pregnancy. We included case reports and case series describing the clinical features of women diagnosed with HCC, fibrolamellar variant of HCC, and mixed HCC and cholangiocarcinoma during pregnancy or the postpartum period (with onset of symptoms during pregnancy), from inception to March 2023. The study protocol was registered with the PROSPERO database (Registration number: ID CRD42021275584).

RESULTS

We identified 180 records. The articles included in this systematic review were 47 case reports and 5 case series, for a total of 63 pregnancies. The two most frequent predisposing conditions were hepatitis B virus infection (30/63; 47%) and liver cirrhosis (14/63; 22%). Ultrasound evaluation was the most used technique to detect HCC. AFP was higher than normal in 28/46 patients tested (61%). Surgical treatment was the most used therapy, both during pregnancy and after delivery. Twenty-six patients (26/63; 42%) died within 6 months of diagnosis. Survival >24 months was 9% (4/46) in symptomatic and 29% (5/17) in asymptomatic women. No patient with cirrhotic liver survived more than 12 months. Thirty-eight newborns were alive at 28 days of age (38/63; 61%).

CONCLUSIONS

Hepatocellular carcinoma in pregnancy is associated with a high risk of maternal and neonatal mortality. Diagnosis in asymptomatic high-risk women or following abnormal maternal serum AFP screening is associated with better maternal outcomes.

Extreme prematurity: Factors associated with perinatal management and morbi-mortality in western Normandy, France

BACKGROUND

Extreme prematurity (birth before 26 weeks of gestation), presents complex challenges and can lead to various complications. Survival rates of extremely preterm infants are lower in France than in other countries. The choice between active and palliative care is decisive in managing these births.

OBJECTIVE

To conduct an observational study focused on factors associated with perinatal management, mortality, and morbidity outcomes among extremely preterm births in a regional perinatal network.

METHODS

We undertook a retrospective, multicenter study within the western Normandy perinatal network, encompassing live births between 230/6 and 256/6 weeks from 2015 to 2019. Data were extracted from the perinatal network database and medical records.

RESULTS

One hundred and seven infants born from 94 women were included. In the antenatal period, 79 were exposed to corticosteroids, 66 to magnesium sulfate, and 67 to antibiotics. Active care at birth was provided to 84 neonates of whom 42 survived. In total, 65 infants died. Among the 42 surviving neonates, 9 experienced no severe morbidity, 29 displayed one and 4 exhibited two criteria of severe morbidity. Active care was associated with gestational age. Neonatal survival was correlated with antenatal exposure to antibiotics and magnesium sulfate as well as with postnatal corticosteroids. We found no significant association between mortality and gestational age at birth.

CONCLUSION

Prognostic factors must be weighed to discuss active antenatal care which is crucial for survival of extremely preterm neonates. Cooperation between obstetricians and neonatal caregivers is a cornerstone on a regional perinatal network scale.

Physiotherapy Intervention on Premature Infants-A Pilot Study

Background and Objectives: Considering the fact that prematurity echoes in terms of motor development even up to the age of adolescence, through the presence of deficiencies, the importance of starting kinetotherapeutic treatment as soon as possible is highlighted, even in the absence of brain damage or obvious motor delays. Therefore, the objectives of this study are to analyze the factors that influence the level of motor development of premature babies up to 9 months and identify the motor development curve of premature babies according to the three stages of motor development: the position of symmetrical support on the elbows at 3 months, sitting with support at 6 months, and verticalization at 9 months. Materials and Methods: This prospective pilot study was conducted within a rehabilitation facility located in Targu Mureș, Romania, spanning a duration of 2 years from June 2021 to 2023. Results: The study involved a population of 78 children, all premature infants, selected from the patient pool of the rehabilitation facility, specifically chosen based on adherence to the predetermined inclusion and exclusion criteria outlined in the study protocol. Two physiotherapists specialized in child recovery were involved in the study, and one performed the assessments and the other applied the Bobath therapy. Conclusions: Early physiotherapy interventions can have a positive influence in terms of reducing differences in motor development between preterm and full-term infants. This study identified several factors that influence the motor development of premature infants. Among these, the most prominent biological factors were gestational age and birth weight.

Trace elements status in human breast milk of mothers from Île-de-France region

Breastfeeding is the main source of nutrition during first months of life. Its composition varies according to parameters like mother's diet and health, living area, number of pregnancies and lactation duration… Trace-elements concentration in breastmilk is then an important parameter that can affect infant's health, growth or immune system and organ functions. Few data are available on this topic, and results are often very variable. The aim of this work is to determine reference values of Copper (Cu), Zinc (Zn), Selenium (Se), Cobalt (Co), Iron (Fe) and Iodine (I) in human breastmilk according to lactation duration and to study influencing parameters on its elementary composition. Regional Human Milk Bank of Necker Enfants Malades Hospital provided samples that came from breastfeeding woman involved in voluntary milk donation and epidemiologic data. Two hundred thirty-two breastmilk were analysed. After nitric acid mineralization of milk samples, Cu, Zn, Se, Co and I were determined by Inductively Coupled Plasma Mass Spectrometry (ICP-MS) in a standard mode. Fe was measured by Inductively Coupled Plasma Optical Emission Spectroscopy (ICP-OES). Both assays were validated in terms of sensitivity, repeatability and accuracy.Studied breast milks came from mothers with an average age of 32 years and donation time ranged from one day after childbirth to 974 days (> 2.5 years); mean lactation duration is 59 days (> 8 weeks) while median duration is 29 days (around 4 weeks). In all studied samples, mean results and reference values are for Cu: 6.02 (1.71-13.23), Zn: 43.86 (7.3-107.0), Se: 0.12 (0.07-0.24), I: 0.29 (0.07-1.01) and Fe: 4.72 (1.25-11.49) µmol/L and for Co: 12.28 (5.27-25.82) nmol/L. Important number of studied milks allowed their distribution into seven classes of lactation durations. Samples were divided into four successive classes of fifteen days after childbirth, two other classes corresponding to the 3rd and 4th months and a last class for milks sampled after 4 months of lactation. Results were analysed in each class allowing study of evolution during lactation. That was particularly interesting for Zn, that presented an important variability in the total population (4-132 µmol/L) explained by variation along lactation evolution decreasing from 48 to 17 µmol/L in first and last duration classes respectively. In addition, Cu and Fe concentrations were also significantly correlated with lactation duration while Se and I were in a lesser extent (p = 0.002). In this study, we present reference values for studied trace elements at different lactation stages, allowing a fine interpretation of future breast milk samples results according to their sampling time. By continuing this study, we plan to increase number of samples in some of the classes and to study the influence of premature birth or twin pregnancy on breast milk elementary composition.

Anthropological overview of kangaroo care in community settings in Madagascar

The management of preterm births remains a major challenge in Madagascar, given the lack of equipped facilities in rural areas, and the absence of precise data concerning the incidence of such births. The World Health Organization (WHO) recommends the kangaroo method (skin-to-skin contact) for the management of preterm infants. In this article, we examine the conditions for success and the obstacles facing kangaroo care in community settings in Madagascar. We performed a qualitative research, collecting data from the districts of Antananarivo and Mahajanga in 2021. In total, 54 semi-structured interviews and two focus group sessions were conducted with the parents of preterm infants and healthcare professionals.The obstacles identified by the research included incomplete and inaccurate knowledge, leading to heterogeneity in the practice of kangaroo care: arbitrary duration, lack of kangaroo care at night, exclusive breastfeeding, and only partially practiced skin-to-skin contact. We found that the conditions for success depended on: (1) the healthcare system, (2) local interpretations of pregnancy, and (3) the structure of the infant's family. Failings of the medical system, cultural habits going against kangaroo care, and "nuclear" and/or "single parent" family structures undermine the application of this practice, jeopardizing upscaling efforts. We hope that the results of this research will guide community strategies for the management of preterm infants and kangaroo care.

Risk factors associated with necrotizing enterocolitis in preterm infants: A case-control study

BACKGROUND

Necrotizing enterocolitis (NEC) is the most common life-threatening gastrointestinal emergency in prematurity. The pathophysiology is multifactorial and remains incompletely understood. Early diagnosis and treatment could reduce the risk of mortality and morbidity. We aimed to identify factors associated with NEC in preterm newborns.

METHOD

This case-control study included all preterm newborns presenting with NEC and managed between January 1, 2009 and December 31, 2018 in the neonatal intensive care unit of Nancy. For each case, two controls were matched according to three criteria: gestational age (WG), date of birth, and mode of delivery. Antenatal, peripartum, and postnatal risk factors prior to NEC were analyzed.

RESULTS

A total of 292 infants were involved in the study, 113 of whom had NEC. Mean gestational age for newborns with NEC was 29 WG, and mean birth weight, 1340 g. Only early-onset infection was identified as a significant risk factor for NEC (15% vs. 6.6% for infection p<0.04, and 28.3% vs. 16.4% p<0.02 for infection and sepsis, NEC vs. controls, respectively). Late-onset feeding and initial continuous enteral feeding were significantly associated with the occurrence of more severe NEC (p<0.02 and p = 0.03, respectively).

CONCLUSION

The results of this study are consistent with intestinal dysbiosis being a risk factor for NEC. Early-onset infection was found to be a significant risk factor. Enteral feeding practice may also be associated with NEC.

Taking Care of Preterm Infants: Outpatient Considerations

In recent decades, the number of pre-term infants born each year has been on the rise as mortality rates decline with improvements in technology and medical care. As a result, many preterm infants are successfully discharged from the neonatal intensive care unit (NICU). However, with prematurity comes the increased risk of ongoing health and development needs. Special attention must be given to certain chronic conditions by the outpatient provider, including growth and nutrition; gastroesophageal reflux; immunizations; vision and hearing impairments; chronic lung diseases, including bronchopulmonary dysplasia and pulmonary hypertension; and neurodevelopmental outcomes. This article will detail some of these topics to better inform the primary care provider of appropriate strategies to manage these chronic conditions and sequalae on NICU discharge. [Pediatr Ann. 2023;52(6):e200-e205.].

A Comparison of the Clinical Presentation of Preterm Birth and Autism Spectrum Disorder: Commonalities and Distinctions in Children Under 3

Premature infants and infants later diagnosed with autism spectrum disorder (ASD) share many commonalities in clinical presentations. However, prematurity and ASD also have differences in clinical presentation. These overlapping phenotypes can lead to misdiagnoses of ASD or missing a diagnosis of ASD in preterm infants. We document these commonalities and differences in various developmental domains with the hope of aiding in the accurate early detection of ASD and timely intervention implementation in children born premature. Given the degree of similarities in presentation, evidence-based interventions designed specifically for preterm toddlers or toddlers with ASD may ultimately aid both populations.

Preterm birth characteristics and outcomes in Portugal, between 2010 and 2018-A cross-sectional sequential study

Introduction

According to the World Health Organization, 11% of all children are born prematurely, representing 15 million births annually. An extensive analysis on preterm birth, from extreme to late prematurity and associated deaths, has not been published. The authors characterize premature births in Portugal, between 2010 and 2018, according to gestational age, geographic distribution, month, multiple gestations, comorbidities, and outcomes.

Methods

A sequential, cross-sectional, observational epidemiologic study was conducted, and data were collected from the Hospital Morbidity Database, an anonymous administrative database containing information on all hospitalizations in National Health Service hospitals in Portugal, and coded according to the ICD-9-CM (International Classification of Diseases), until 2016, and ICD-10 subsequently. Data from the National Institute of Statistics was utilized to compare the Portuguese population. Data were analyzed using R software.

Results

In this 9-year study, 51.316 births were preterm, representing an overall prematurity rate of 7.7%. Under 29 weeks, birth rates varied between 5.5% and 7.6%, while births between 33 and 36 weeks varied between 76.9% and 81.0%. Urban districts presented the highest preterm rates. Multiple births were 8× more likely preterm and accounted for 37%-42% of all preterm births. Preterm birth rates slightly increased in February, July, August, and October. Overall, respiratory distress syndrome (RDS), sepsis, and intraventricular hemorrhage were the most common morbidities. Preterm mortality rates varied significantly with gestational age.

Conclusion

In Portugal, 1 in 13 babies was born prematurely. Prematurity was more common in predominantly urban districts, a surprise finding that warrants further studies. Seasonal preterm variation rates also require further analysis and modelling to factor in heat waves and low temperatures. A decrease in the case rate of RDS and sepsis was observed. Compared with previously published results, preterm mortality per gestational age decreased; however, further improvements are attainable in comparison with other countries.

DYNAMICS OF MISCARRIAGE AMONG THE FEMALE POPULATION OF FERTILE AGE IN UKRAINE AND IN LVIV REGION IN 2014-2021

Aim. The research aims at rationalizing of the epidemiological component in the process of developing a model for preventing miscarriage among the female population of Ukraine. Materials and Methods. A retrospective analysis of the indicators of miscarriage among the female population of Ukraine and Lviv region for the period from 2014 to 2021 was carried out. Statistical data of the Center for Medical Statistics of the Ministry of Health of Ukraine were used, namely Form No. 21 "Report on medical care for pregnant women, women in labor and women giving birth". The study uses the methods of a systemic approach and structural-logical analysis, medical-statistical analysis, namely the calculation of chain (relative to the previous year) indicators of a dynamic series: absolute growth, growth rate and increment rate. Results and Discussion. A decrease in the female population of fertile age by 13.03% in Ukraine and by 5.81% in Lviv region was noted in the analyzed period of 2014-2021, while the number of spontaneous abortions in Ukraine decreased by an average of 3.45% per year, and grew in Lviv region in 2015, 2018, 2019 and 2020 by 5.72%, 6.87%, 19.29% and 6.59%, respectively. The rates of spontaneous abortions per 1,000 women of fertile age in Lviv region were twice as low as in Ukraine. Over the analyzed 8-year period, the share of premature children among all live births increased from 4.68% to 5.68% in Ukraine, and from 4.18% to 5.65% in Lviv region, respectively; these indicators in Lviv region were smaller compared to the indicators in Ukraine. The share of premature babies among stillbirths averaged 63.07% in Ukraine and 67.69% in Lviv region, had a growing trend, and the indicators in Lviv region were higher every year compared to the indicators in Ukraine. The ratio of the total rate of miscarriage to the total number of pregnancies (cases of miscarriage per 100 pregnancies) increased from 5.50 in 2014 to 6.22 in 2021 in Ukraine and from 3.57 to 4.72 in Lviv region respectively. Conclusions. There was a trend of annual increase in the index of the ratio of the total miscarriage rate to the total number of pregnancies, the share of prematures from the total number of live births and the share of premature births from the number of stillbirths in the analyzed 8-year period, both in Ukraine and in Lviv region. The analyzed indicators of the share of premature newborns from the total number of live births in Lviv region were lower every year, and the share of newborns from the total number of stillbirths was higher compared to the average annual indicators in Ukraine. The dynamics of spontaneous abortions showed a clear trend towards an annual decrease in Ukraine and their increase in 2015, 2018-2020 in Lviv region. The rate of spontaneous abortions among women of fertile age in Lviv region from 2014 to 2021 was annually half as low compared to the average annual levels of this indicator in Ukraine.

Preterm birth and postpartum depression within 6 months after childbirth in a Brazilian cohort

Preterm birth (PTB) and postpartum depression (PPD) are important public health issues, and although literature mainly supports the association between them, some reviews have highlighted methodological limitations in the studies in this field, restricting the interpretation of such finding. This study aimed at assessing the association between PTB and PPD, by comparing groups of preterm and full-term mothers in two Brazilian cities with contrasting sociodemographic indicators. This prospective convenience cohort study assessed 1421 women during pregnancy, at childbirth, and in the postpartum period. The Edinburgh Postnatal Depression Scale (EPDS) was administrated to assess PPD within 6 months after delivery and women were considered probably depressed if scores were EDPS ≥ 12. PTB was defined as the delivery before 37 completed weeks of pregnancy. A multivariate Poisson regression was used to estimate relative risk for PPD in mothers of preterm infants, and the final analysis models were adjusted for psychosocial variables, selected according to the directed acyclic graph (DAG) approach. Frequencies of PPD were not significantly different in mothers of preterm and full-term infants, in neither city. In the final adjusted model, PTB was not associated with PPD. The association between PTB and PPD was not confirmed in two large samples from two Brazilian cities with contrasting socioeconomic profile. However, maternal health during pregnancy plays an important role in predicting PPD. Prenatal care should promote maternal mental health as an effort towards decreasing unfavored outcomes for mothers, infants, and families.

Human Breast Milk: The Key Role in the Maturation of Immune, Gastrointestinal and Central Nervous Systems: A Narrative Review

Premature birth is a major cause of mortality and morbidity in the pediatric population. Because their immune, gastrointestinal and nervous systems are not fully developed, preterm infants (<37 weeks of gestation) and especially very preterm infants (VPIs, <32 weeks of gestation) are more prone to infectious diseases, tissue damage and future neurodevelopmental impairment. The aim of this narrative review is to report the immaturity of VPI systems and examine the role of Human Breast Milk (HBM) in their development and protection against infectious diseases, inflammation and tissue damage. For this purpose, we searched and synthesized the data from the existing literature published in the English language. Studies revealed the significance of HBM and indicate HBM as the best dietary choice for VPIs.

Neurodevelopment at two years and appropriate schooling at five years in children born very preterm

AIM

This single-centre French cohort study evaluated the relationship between standardised assessment at 2 years of corrected age and schooling level at 5 years of age in children born at ≤32 weeks' gestational age.

METHODS

This was a single-centre retrospective study of children born preterm between 2010 and 2014 included in a follow-up network. At 5 years of age, the population was divided into 2 groups: (1) 'appropriate schooling', defined as age-appropriate schooling without support, and (2) 'schooling with support'. At 2 years of corrected age, the developmental quotient (DQ) was calculated using the revised Brunet-Lezine test. Neonatal variables and DQ categories were compared between the 2 groups on univariate and multivariate analyses.

RESULTS

DQ was available for 251 of the 270 children included (93%), with a median score of 93.0 (IQR [87.0-100.0]), and 171 children (68%) were in the schooling without support group. On multivariate analysis, DQ ≥100 (n = 67) was the only variable that significantly associated with schooling without support (OR = 13.9; 95% CI: 5.5-35.4) at 5 years of age.

CONCLUSION

This result may be useful for clinicians in their routine practice and for information given to parents in neonatal follow-up.

Telomeres, oxidative stress, and timing for spontaneous term and preterm labor

Telomeres are nucleoprotein complexes located at the distal ends of chromosomes. In adults, progressive telomere shortening occurs throughout the lifetime and is thought to contribute to progressive aging, physiological senescence, multiorgan dysfunction, and ultimately, death. As discussed in this review, multiple lines of evidence provide support for the biological plausibility that a telomere-based clock mechanism also determines the length of gestation, leading to the onset of labor (parturition). After telomere expansion at the beginning of pregnancy, the telomere lengths in the gestational tissues (ie, the placenta and fetal membranes) progressively shorten throughout the remainder of pregnancy. The rate of telomere shortening can be accelerated by conditions that affect the mother and result in oxidative stress. Preterm births in the United States are associated with multiple risk factors that are linked with increased oxidative stress. Antioxidant vitamins (ie, vitamins E and C) mitigate the effects of oxidative stress and delay or prevent telomere shortening. Clinical trials with vitamins E and C and with multivitamins started during the periconception period have been associated with reduced rates of preterm births. In the United States, African-American women have a 2-3-fold higher rate of preterm birth. African-American women have multiple risk factors for premature birth, all of which are distinct and potentially additive with regard to epigenetic telomere shortening. The "weathering effect" is the hypothesis to explain the increased rates of chronic illness, disabilities, and early death observed in African-Americans. With regard to pregnancy, accelerated weathering with the associated telomere shortening in the gestational tissues would not only explain the preterm birth disparity but could also explain why highly educated, affluent African-American women continue to have an increased rate of preterm birth. These studies suggest that the racial disparities in preterm birth are potentially mediated by telomere shortening produced by lifetime or even generational exposure to the effects of systemic racism and socioeconomic marginalization. In conclusion, this review presents multiple lines of evidence supporting a novel hypothesis regarding the biological clock mechanism that determines the length of pregnancy, and it opens the possibility of new approaches to prevent or reduce the rate of spontaneous preterm birth.

Neurobehavioral Phenotype and Dysexecutive Syndrome of Preterm Children: Comorbidity or Trigger? An Update

Premature birth is a worldwide public health priority. One in ten children is born before 37 weeks of gestational age and, in developed countries, survival rates without major neonatal morbidity are increasing. Although severe sequelae associated with these births have decreased, their neurobehavioral difficulties, often associated in multiple fields, remain stable but still widespread. These neurobehavioral difficulties hamper the normal development of academic achievements and societal integration and intensify the children's needs for rehabilitation during their preschool and academic years. Severe sequelae increase when gestational age decreases. This is even truer if the socio-cultural background is impeded by low income, education and language skills as compared with defined averages. However, moderate and/or minor neurocognitive and/or behavioral difficulties are almost identical for a moderate or a late preterm birth. Obtaining a better clinical description of neurobehavioral characteristics of those pretermly born, once they reach preschool age, is essential to detect behavioral issues as well as early specific cognitive difficulties (working memory, planning, inhibition, language expression and reception, attention and fine motor skills, etc.). Such information would provide a better understanding of the executive functions' role in brain connectivity, neurodevelopment and neuroanatomical correlation with premature encephalopathy.

Toxic epidermal necrolysis induced by ritodrine in pregnancy: A case report

BACKGROUND

Preterm birth accounts for about 12% of all pregnancies worldwide and is the leading cause of neonatal morbidity and mortality. In order to avoid premature birth and prolong gestational age, tocolytics are the first and the best choice. Ritodrine is the most commonly used tocolytic medication. However, side effects such as pulmonary edema, hypokalemia, and hyperglycemia are known. Here we report a rare but serious side effect–toxic epidermal necrolysis (TEN)–caused by ritodrine.

CASE SUMMARY

A woman (31 years, gravida 4, para 2) was hospitalized because of premature contractions at 27 + 6 wk of gestation. A skin rash with pruritus appeared at 32 + 3 wk of gestation after administration of ritodrine, indomethacin, and dexamethasone, and it spread throughout the whole body in 3 d, particularly the four limbs. After 11 d’ treatment, she was diagnosed with TEN. An emergency cesarean section was performed immediately to deliver the baby and intensive symptomatic treatment was promptly commenced after delivery. She recovered from the severe condition without any sequelae except for slight pigmentation after symptomatic treatment.

CONCLUSION

When a skin rash appears during the administration of ritodrine, we are supposed to consider the risk of TEN.

Prenatal exposure to air pollution and the risk of preterm birth in rural population of Henan Province

Due to the poor living and healthcare conditions, preterm birth (PTB) in rural population is a pressing health issue. However, PTB studies in rural population are rare. To explore the effects of air pollutants on PTB in rural population, we collected 697,316 medical records during 2014-2016 based on the National Free Preconception Health Examination Project. Logistic regression models were used to estimate the association between air pollutants and PTB and the modifying effects of demographic characteristics. Relative contribution and principal component analysis-generalized linear model (PCA-GLM) analysis were used to explore the most significant air pollutant and gestational period. Our results demonstrated that PTB risk is positively associated with exposure to air pollutants including PM₁₀, PM_2.5, SO₂, NO₂, and CO, while negatively associated with O₃ exposure (P < 0.05). In addition, we found that NO₂ was the largest contributor to the risk of PTB caused by air pollutants (26.5%). The third trimester of pregnancy was the most sensitive exposure window. PCA-GLM analysis showed that the first component (a combination of PM, SO₂, NO₂, and CO) increased the risk of PTB. Moreover, we found that rural women who are younger, had higher educated, multi-parity, or smoke appeared to be more sensitive to the association between air pollutants exposure and PTB (P_-interaction<0.05). Our findings suggested that increased air pollutants except O₃ were associated with elevated PTB risk, especially among vulnerable mothers. Therefore, the effects of air pollutants exposure on PTB should be mitigated by restricting emission sources of NO₂ and SO₂ in rural population, especially during the third trimester.

Prevention of Preterm Birth with Progesterone

Gestational age at birth is a critical factor for perinatal and adulthood outcomes, and even for transgenerational conditions' effects. Preterm birth (PTB) (prematurity) is still the main determinant for infant mortality and morbidity leading cause of infant morbidity and mortality. Unfortunately, preterm birth (PTB) is a relevant public health issue worldwide and the global PTB rate is around 11%. The premature activation of labor is underlined by complex mechanisms, with a multifactorial origin influenced by numerous known and probably unknown triggers. The possible mechanisms involved in a too early labor activation have been partially explained, and involve chemokines, receptors, and imbalanced inflammatory paths. Strategies for the early detection and prevention of this obstetric condition were proposed in clinical settings with interesting results. Progesterone has been demonstrated to have a key role in PTB prevention, showing several positive effects, such as lower prostaglandin synthesis, the inhibition of cervical stromal degradation, modulating the inflammatory response, reducing gap junction formation, and decreasing myometrial activation. The available scientific knowledge, data and recommendations address multiple current areas of debate regarding the use of progesterone in multifetal gestation, including different formulations, doses and routes of administration and its safety profile in pregnancy.

A randomized EPIREMED protocol study on the long-term visuo spatial effects of very preterm children with a working memory deficit

BACKGROUND

Very preterm children generally perform poorly in executive functions and particularly in working memory. Adaptive training tasks encouraging these children to work continuously on their personal working memory capacity can be very useful. Above all in preschool-age children, several cognitive training programs focused on improving working memory capacity. Cogmed is a computerized visuospatial cognitive training program that improves working memory in children and adolescents with attention-deficit/hyperactivity disorder. The main objective is to assess the long-term effects (18 months) of cognitive training (Cogmed) on visuospatial processing in preschool-age very preterm children with working memory impairment.

METHODS

The EPIREMED study is a prospective, randomized, controlled, multicentric trial nested in a population based epidemiological survey. An intervention group (Cogmed cognitive training) and a control group (standard care management) will compare children aged 5½ to 6 years, born between 24- and 34-weeks' gestational age, with a global intelligence quotient > 70 and a working memory index < 85. The study will include 166 children from national study EPIPAGE-2 (Epidemiological Study on Small Gestational Ages). The intervention consists of 25 sessions administered over a 5- to 8-week period. The primary endpoint will be the visuospatial processing, assessed by the score of the visuospatial index: score of the WPPSI-IV (Wechsler Preschool and Primary Scale of Intelligence). The secondary endpoints will allow to assess the executive functions, language and abilities, infant behavior, quality of life assessment, school performance and parental anxiety.

DISCUSSION

This project's primary goal is to demonstrate the necessity of early visuospatial memory assessment within the vulnerable population of very preterm children, and to prove the feasibility and efficacy of computerized cognitive training using online software programs. A better global neuropsychological development improvement (visuospatial processing and other far transfer) can be expected with an improvement in learning and decreased behavioral problems. In the long term, these improvements might also reduce those global costs linked to the consequences of extreme prematurity.

TRIAL REGISTRATION

NCT02757794 (registered on 2nd May 2016 at ClinicalTrial.gov).

Socioeconomic Risk Factors for Preterm Birth in the state of Qatar: A Population-based Study

Objectives:

To review the demographics and socioeconomic determinants of preterm birth (PTB) compared to term births among the Qatari population.

Methods:

This was a retrospective data analysis of 59,308 births. Data were retrieved from a Population-based Cohort Study. Data were gathered from the PEARL-Peristat maternal newborn registry for 2011, 2012, 2017, and 2018. We compared the preterm births group (delivery < 37 weeks) with the term group (delivery ≥ 37 weeks) regarding socioeconomic factors, including maternal nationality, religion, level of education, mother’s occupation, family income, housing, consanguinity, early childbearing, high-risk pregnancy, smoking, assisted conception, antenatal care, and place of delivery.

Results:

The prevalence of preterm birth was 9%. There were more Saudi nations in the preterm group compared to term (33% vs. 28%, p-value < 0.001). There were more preterm births than term births among working mothers (40% vs. 35%), high-risk pregnancies (24% vs. 18%), those that has used assisted conception (18% vs. 3%), those without antenatal care (11% vs. 5.6%), and those delivered in a tertiary women hospital (88.5% vs. 84.5%) (all p-values < 0.001). There were more women living in villas (41% vs. 38%, p = 0.01) and more smokers (0.8% vs. 0.5%, p = 0.030) in the preterm group than in the term group. There were no differences between the two groups regarding religion, level of maternal education, family income, and early childbearing.

Conclusion:

In our population, we identified several factors associated with preterm births. (www.actabiomedica.it)

Maturation of the auditory system in normal-hearing newborns with a very or extremely premature birth

BACKGROUND

Literature shows that lower gestational age leads to greater delays in the auditory conduction, which suggests atypical maturation of the brainstem in normal-hearing premature newborns. Our aim is to investigate if there is a difference between the extrauterine and intrauterine maturation of the auditory system in normal-hearing newborns with a very premature (28-31 weeks) or extremely premature (<28 weeks) birth.

METHODS

Results of the Automated Auditory Brainstem Response Newborn Hearing Screening Program in Dutch Neonatal Intensive Care Units and diagnostic examinations were centrally registered from 1998 to 2016. Normal-hearing newborns with a gestational age of 25-31 weeks were included. Screening results at 32-45 weeks of postmenstrual age were compared between newborns born with different gestational ages. Multiple imputation was used to predict missing screening results. Small for gestational age was defined as birth weight corrected for gestational age < -1.6 standard deviation. Descriptive and (pooled) logistic regression analyses were performed.

RESULTS

23,964 newborns with 28,754 screening results were eligible. At the same postmenstrual age, pass rates were lower when gestational age was lower in normal-hearing newborns with a very and extremely preterm birth. Pass rates of 80% could be obtained at 34-35, 32-33, and 30-32 weeks' postmenstrual age in newborns with 25, 26-27, 28-31 weeks gestational age, respectively. Small for gestational age had an additional negative effect on pass rates.

CONCLUSION

Analysis of hearing screening data suggests that extrauterine maturation of the auditory system is delayed in normal-hearing newborns with a very or extremely premature birth.

Association between omega-3 fatty acid supplementation and lower risk of preterm delivery: a systematic review and meta-analysis

OBJECTIVE

To explore whether omega-3 fatty acid supplementation is associated with lower risk of preterm delivery.

METHODS

Searching the RCTs which were compared preterm birth between women with omega-3 fatty acid supplementation and without before December 2019 on Medline, EMBASE and Cochrane's Library, then performing a meta-analysis.

RESULTS

26 trials were identified, included 20124 women. There was almost no association between omega-3 fatty acid supplementation and lower risk of preterm delivery (risk ratio 0.92, 95% confidence interval 0.85 to 1.01, I² = 9%), gestational duration (0.30, -0.05 to 0.64, I² = 48%). In subgroup analyses, preterm delivery lower rate occurred in groups with mixed DHA and EPA supplementation not only DHA supplementation groups (P for interaction = 0.02); The dose of equivalent greater than 1 g made a higher reduction in preterm birth significantly.

CONCLUSIONS

Omega-3 fatty acid supplementation was not associated with reduced risk of preterm delivery compared with placebo or no treatment during pregnancy. Relationship between Omega-3 fatty acid supplementation and other pregnant outcomes need more evidence and clinical studies.

Comparison between type A and type B early adiposity rebound in predicting overweight and obesity in children: a longitudinal study

Early adiposity rebound (EAR) predicts paediatric overweight/obesity, but current approaches do not consider both the starting point of EAR and the BMI trajectory. We compared the clinical characteristics at birth, age 3-5 and 6-8 years of children, according to the EAR and to its type (type A/type B-EAR). We assessed the children's odds of being classified as overweight/obese at age 6-8 years, according to the type of EAR as defined at age 3-5 years. As part of this two-wave observational study, 1055 children were recruited and examined at age 3-5 years. Antenatal and postnatal information was collected through interviews with parents, and weight and height from the health records. Type A and type B-EAR were defined in wave 1 according to the BMI nadir and the variation of BMI z-score between the starting point of the adiposity rebound and the last point on the curve. At 6-8 years (wave 2), 867 children were followed up; 426 (40·4 %) children demonstrated EAR. Among them, 172 had type A-EAR, higher rates of parental obesity (P < 0·05) and greater birth weight compared with other children (P < 0·001). Odds for overweight/obesity at 6-8 years, when adjusting for antenatal and postnatal factors, was 21·35 (95 % CI 10·94, 41·66) in type A-EAR children and not significant in type B-EAR children (OR 1·76; 95 % CI 0·84, 3·68) compared with children without EAR. Classification of EAR into two subtypes provides physicians with a reliable approach to identify children at risk for overweight/obesity before the age of 5 years.

Atypical neuromagnetic resting activity associated with thalamic volume and cognitive outcome in very preterm children

Children born very preterm, even in the absence of overt brain injury or major impairment, are at increased risk of cognitive difficulties. This risk is associated with developmental disruptions of the thalamocortical system during critical periods while in the neonatal intensive care unit. The thalamus is an important structure that not only relays sensory information but acts as a hub for integration of cortical activity which regulates cortical power across a range of frequencies. In this study, we investigate the association between atypical power at rest in children born very preterm at school age using magnetoencephalography (MEG), neurocognitive function and structural alterations related to the thalamus using MRI. Our results indicate that children born extremely preterm have higher power at slow frequencies (delta and theta) and lower power at faster frequencies (alpha and beta), compared to controls born full-term. A similar pattern of spectral power was found to be associated with poorer neurocognitive outcomes, as well as with normalized T1 intensity and the volume of the thalamus. Overall, this study provides evidence regarding relations between structural alterations related to very preterm birth, atypical oscillatory power at rest and neurocognitive difficulties at school-age children born very preterm.

[Cell-free DNA fraction: Can it be used to evaluate the risk of obstetrical issues?]

OBJECTIVE

The aim of the study was to evaluate if fetal cell-free DNA (cfDNA) fraction circulating in maternal blood at the beginning of the second trimester is associated with obstetrical complications.

METHODS

This is a retrospective unicentric study conducted at the hospital of Poissy Saint Germain between the 1^st January 2015, and the 31^st. December 2016, Each woman who had a genetic counseling in order to realize a non-invasive prenatal test (NIPT) was included. Only singleton pregnancies with a documented-issue were analysed. The primary criteria was a composite criteria, defined as the occurrence of preeclampsia, in utero fetal growth, or a spontaneous preterm delivery. A descriptive analyse was first conducted, secondly completed by a sub-group one: "high fetal fraction" (>90^th percentile) group, "low fetal-fraction" group (<10^th percentile) and "medium fetal-fraction" (control group) group.

RESULTS

A total of 417 women had a cfDNA test, which was performed at a mean gestational age of 17.1 weeks of gestation. A total of 17% of pregnancies met the primary criteria. Among them, there were 8 (1.9%) pre-eclampsia, 49 (11.8%) intra-uterine growth restriction and 14 (3.4%) preterm births. There was no significant difference for the occurrence of the primary criteria (P>0.99) and of each obstetrical complication between each group.

CONCLUSION

Fetal cf-DNA fraction measured at the beginning of the second trimester is not associated with common obstetrical complications.

Incomplete Gestation has an Impact on Cognitive Abilities in Autism Spectrum Disorder

Extreme prematurity is known as a risk factor for autism spectrum disorder (ASD). However, the association between prematurity and ASD, for children born moderately and late preterm (MLPT) and those born early term (ET), is less established. This retrospective study aimed to characterize the phenotypic characteristics (i.e. behavioral profile and cognitive abilities) of 254 children with ASD, between 3 and 15 years of age, born MLPT (19 children), ET (60 children) and full term (175 children). MLPT and ET births do not modify ASD symptomatology, but modify cognitive development. The results highlight that incomplete gestation, i.e., MLPT or ET, has a negative impact on both verbal and nonverbal cognitive abilities, in children with neurodevelopmental vulnerability.

Cord blood procalcitonin level and early-onset sepsis in extremely preterm infants

Early-onset neonatal sepsis (EOS) is observed in 1.7% of extremely preterm infants, with high morbidity and mortality rate. Cord blood procalcitonin (PCT) is a sensitive marker of EOS in full-term newborns, but it has been rarely studied in premature infants. The diagnostic value of cord blood PCT by immunofluorescence has been assessed as an early marker of EOS in a prospective cohort of extremely preterm infants, with a threshold at 0.5 μg/L. EOS was defined by a positive bacterial culture or by the association of postnatal biological/clinical signs of EOS and antibiotic treatment for more than 72 h. Correlation between PCT serum concentrations and postnatal morbidities was also analyzed. Among a total of 186 infants, 45 (24%) were classified as EOS. Blood PCT concentration was ≤ 0.5 μg/L in 114 infants, including 11 EOS (9.6%) and PCT was > 0.5 μg/L in 72 babies including 34 EOS (47.2%). PCT concentration > 0.5 μg/L was associated with higher risk of EOS (OR 2.18; CI95% 1.58-3.02; p < 0.0001). The receiver operating characteristic curve determined a cutoff of 0.7 μg/L as the best compromise, with an area under the curve of 0.75 (sensitivity 69%, specificity 70%). In multivariate analysis, clinical chorioamnionitis was associated with PCT concentration > 0.5 μg/L (OR 2.58; CI95% 1.35-4.94; p = 0.004). Cord blood PCT is a marker significantly associated with EOS in extremely preterm infants, but its sensitivity remains low. Its added value in combination with other early marker of EOS needs to be further investigated in this high-risk population.

Reference percentiles for paired arterial and venous umbilical cord blood gases: An indirect nonparametric approach

BACKGROUND

Reference intervals for arterial and venous umbilical cord blood gas (UCBG) parameters are scarce, are mainly focused on pH, pO2, pCO2 and base deficit, and are usually assessed using parametric tests, despite a generally skewed data distribution. Here, the purpose is to determine reference percentiles for nine parameters of concomitant arterial and venous UCBG (CAV-UCBG) from neonates at birth, using nonparametric tests.

METHODS

Results of CAV-UCBG, assayed over a 4.5-year period, were extracted from a hospital laboratory database for pH, pCO2, pO2, oxygen saturation, concentration of total oxygen, total carbon dioxide, hydrogen carbonate, total haemoglobin, and acid-base excess. Exclusion criteria were: a venous-arterial pH difference <0.02, an arterial-venous pCO2 <0.7 kPa, and a venous pCO2 <2.9 kPa. Nonparametric bivariate kernel density estimations were used for the selection of plots within the 95% percentile surface of the pCO2-to-pH relationship (NBKDE-95P). Outliers from skewed data were removed using an adjusted-Tukey method, and percentiles were calculated according to the CLSI EP28-A3 nonparametric method.

RESULTS

Overall, 31% (5033/16164) of CAV-UCBG were discarded using the three exclusion criteria. Then, 6% (670/11131) of CAV-UCBG were excluded from the NBKDE-95P, and 0.1 to 3.5% outliers were subsequently removed. Depending on the parameter, the 2.5th and 97.5th percentiles from the whole group were similar or slightly narrower compared to reference intervals from other studies, while those from female and male neonates did not differ substantially.

CONCLUSIONS

Using an indirect nonparametric approach, this study proposes new percentiles for parameters from concomitant arterial and venous umbilical cord blood gases.

Nutrition of Preterm Infants and Raw Breast Milk-Acquired Cytomegalovirus Infection: French National Audit of Clinical Practices and Diagnostic Approach

Raw breast milk is the optimal nutrition for infants, but it is also the primary cause of acquired cytomegalovirus (CMV) infection. Thus, many countries have chosen to contraindicate to feed raw breast milk preterm infants from CMV-positive mothers before a corrected age of 32 weeks or under a weight of 1500 g. French national recommendations have not been updated since 2005. An audit of the French practices regarding the nutrition with raw breast milk in preterm infants was carried out using a questionnaire sent to all neonatal care units. Diagnosed postnatal milk-acquired CMV infections have been analysed using hospitalisation reports. Seventy-five percent of the neonatal units responded: 24% complied with the French recommendations, 20% contraindicated raw breast milk to all infants before 32 weeks regardless of the mothers' CMV-status, whereas 25% fed all preterm infants unconditionally with raw breast milk. Thirty-five cases of infants with milk-acquired CMV infections have been reported. The diagnosis was undeniable for five patients. In France, a high heterogeneity marks medical practices concerning the use of raw breast milk and the diagnostic approach for breast milk-acquired CMV infection is often incomplete. In this context, updated national recommendations and monitored CMV infections are urgently needed.

Folic acid level and preterm birth among Sudanese women

BACKGROUND

Preterm birth (PTB) is the major health problem world-wide; there are few published studies on PTB and folic acid.

METHODS

The study was conducted to assess the serum level of folic acid in PTB. A case-control study was conducted at Saad Abualila maternity hospital (Khartoum, Sudan) during the period of March through December 2015. Women who delivered live singleton babies were dived in two groups; the cases were women who had PTB "delivery before completed 37weeks but after 24 weeks of pregnancy" and the controls were women who delivered at term (37-42 weeks). Medical and obstetrics history was gathered using questionnaire. Serum folic acid was measured.

RESULTS

One hundred and twelve (56 in arm of the study) women were enrolled to the study. There was no significant difference between the cases and the controls in their age, parity, hemoglobin, body mass index, education and occupation. The median (interquartile) level of folic acid was significantly lower in the cases (PTB) than the level in the controls, 4.8(2.8-8.2) vs. 9.5(8.6-12.0) ng/ml. In binary regression, folic acid level was associated with lower risk of PTB (OR=0.64; 95%=0.53-0.77, P < 0.001). There was a significant positive correlation between gestational age and folic acid level (r = 0.447, P<0.001).

CONCLUSION

Thus serum folic acid level was significantly lower in women with PTB. Folic acid level was associated with lower risk of PTB.

New model for predicting preterm delivery during the second trimester of pregnancy

In this study, a new model for predicting preterm delivery (PD) was proposed. The primary model was constructed using ten selected variables, as previously defined in seventeen different studies. The ability of the model to predict PD was evaluated using the combined measurement from these variables. Therefore, a prospective investigation was performed by enrolling 130 pregnant patients whose gestational ages varied from 17⁺⁰ to 28⁺⁶ weeks. The patients underwent epidemiological surveys and ultrasonographic measurements of their cervixes, and cervicovaginal fluid and serum were collected during a routine speculum examination performed by the managing gynecologist. The results showed eight significant variables were included in the present analysis, and combination of the positive variables indicated an increased probability of PD in pregnant patients. The accuracy for predicting PD were as follows: one positive – 42.9%; two positives – 75.0%; three positives – 81.8% and four positives – 100.0%. In particular, the combination of ≥2× positives had the best predictive value, with a relatively high sensitivity (82.6%), specificity (88.1%) and accuracy rate (79.2%), and was considered the cut-off point for predicting PD. In conclusion, the new model provides a useful reference for evaluating the risk of PD in clinical cases.

[Does post operative sonographic position of preventive cervical cerclage affect gestational age at birth?]

OBJECTIVE

To evaluate whether the position of preventive cerclage determined by immediate postoperative transvaginal cervical ultrasound is predictive of preterm birth.

METHODS

A single-center retrospective study conducted between 1 August 2007 and 31 December 2015 in a maternity type III who included women carrying out for a single pregnancy and who receive a McDonald preventive cerclage. Measurements of internal os-stitch, stitch-external os and the total length of the cervix were performed during immediate postoperative transvaginal cervical ultrasound. The position of the cerclage has been defined by the internal os-stitch/cervical length and stitch-external os/cervical length ratios. Measures were compared according to gestational age at delivery (before and after 32weeks and before and after 37weeks).

RESULTS

During the study period, 379 single pregnancies that received a McDonald preventive cerclage were included. The mean gestational age at delivery was 37.6±3.6 SA. The rate of preterm birth before 32weeks was 6.5% (n=25) and before 37weeks was 16.6% (n=63). There was no significant difference in the internal ost-stitch/cervical length ratios and the stitch-external ost/cervical length ratio between women who delivered before and after 32weeks or for those who delivered before and after 37weeks. The areas under the ROC curves for the various parameters studied were all less than or equal to 0.6.

CONCLUSIONS

The position of cerclage determined by transvaginal cervical ultrasound in immediate post operative does not seem predictive of the risk of premature birth.

[Epidemiology and risk factors of preterm birth]

OBJECTIVE

To synthesize the available evidence regarding the incidence and several risk factors of preterm birth. To describe neonatal outcomes according to gestational age and to the context of delivery.

MATERIALS AND METHODS

Consultation of the Medline database.

RESULTS

In 2010, 11% of live births (15 million babies) occurred before 37 completed weeks of gestation worldwide. About 85% of these births were moderate to late preterm babies (32-36 weeks), 10% were very preterm babies (28-31 weeks) and 5% were extremely preterm babies (<28 weeks). In France, premature birth concerns 60,000 neonates every year, 12,000 of whom are born before 32 completed weeks of gestation. Half of them are delivered after spontaneous onset of labor or preterm premature rupture of the membranes, and the other half are provider-initiated preterm births. Several maternal factors are associated with preterm birth, including sociodemographic, obstetrical, psychological, and genetic factors; paternal and environmental factors are also involved. Gestational age is highly associated with neonatal mortality and with short- and long-term morbidities. Pregnancy complications and the context of delivery also have an impact on neonatal outcomes.

CONCLUSION

Preterm birth is one of the leading cause of the under-five mortality and of neurodevelopmental impairment worldwide; it remains a major public health issue.