Factors associated with successful balloon catheter labor induction in women with a previous caesarean section: A retrospective single-center evaluation

BACKGROUND

Labor induction of women with a history of uterine scarring is an increasingly frequent situation and one for which there are currently no clear professional recommendations favoring one method over another. The objectives of this study were to determine the success rate of balloon catheter induction in women with a history of caesarean section and to evaluate the main factors associated with vaginal delivery.

MATERIALS AND METHODS

This single-center retrospective study was conducted between January 1, 2014, and December 31, 2018, in Lille, France, and included all women with one previous caesarean section who were induced by first-line balloon catheter induction. Multivariate analysis was performed to identify the factors associated with the primary outcome (vaginal delivery).

RESULTS

Of the 310 women in the sample, 192 delivered vaginally (62 %). After adjustment, factors associated with successful induction (vaginal delivery) were the number of previous vaginal deliveries (odds ratio [OR] 1.37; 95 % confidence interval [CI] 1.04-1.81), evolution of the Bishop score after balloon removal (OR 1.24; 95 % CI 1.10-1.41), and the initial Bishop score (OR 1.17; 95 % CI 1.00-1.37). Uterine rupture was observed in three women (1 %).

CONCLUSION

The vaginal delivery rate after balloon catheter induction in women with a previous caesarean section was 62 %. Prognostic factors for vaginal delivery include previous vaginal delivery, the initial Bishop score, and evolution of the Bishop score after balloon catheter induction.

Effect of delayed cord clamping on red blood cell alloimmunization: a retrospective cohort study

BACKGROUND

Although delayed cord clamping has well-known benefits for preterm and term neonates, it has been inadequately assessed in alloimmunized neonates.

OBJECTIVE

This study aimed to evaluate the benefits and risks of delayed cord clamping in alloimmunized neonates.

STUDY DESIGN

This was a retrospective comparative pre-post cohort study conducted from 2003 to 2018 in a tertiary care center in France. All living singleton neonates whose mothers were followed up for red blood cell alloimmunization during gestation and confirmed at birth (N=224) were included. Neonates were either exposed to immediate (n=125) or delayed cord clamping (n=99). Our main outcome was the time from birth to first exchange transfusions and/or transfusions. Secondary outcomes were hemoglobin level at birth, rate of exchange transfusion, number of postnatal transfusions, maximum bilirubin level, and number of phototherapy hours.

RESULTS

Hemoglobin at birth was significantly higher in case of delayed cord clamping (mean difference, 1.7 g/dL; 95% confidence interval, 0.7-2.8). Among infants treated with exchange transfusion or transfusion, the time to initial treatment was higher in case of delayed cord clamping (median difference, 8 days; rate ratio, 1.51; 95% confidence interval, 1.09-2.10). There were no significant differences in the need for exchange transfusion, the number of transfusions, the maximum total bilirubin level, nor the number of phototherapy hours. In the subgroup analysis of neonates needing intrauterine transfusion during pregnancy (ie, severe alloimmunization), neonates had a lower rate of exchange transfusion in case of delayed cord clamping (odds ratio, 0.36; 95% confidence interval, 0.15-0.82).

CONCLUSION

Our results indicate a benefit of delayed cord clamping in alloimmunization, regardless of pathology severity, without increased risk of jaundice.

Anti-RH1 alloimmunization: At what maternal antibody threshold is there a risk of severe fetal anemia?

BACKGROUND

To define a threshold of maternal antibodies at risk of severe fetal anemia in patients followed for anti-RH1 alloimmunization (AI).

STUDY, DESIGN, AND METHODS

We conducted a retrospective study of patients followed for anti-RH1 AI at the Lille University Hospital. The first group, severe anemia, included patients who received one or more in utero transfusions (IUT) or who were induced before 37 weeks of pregnancy for suspected severe fetal anemia. The second group, absence of severe anemia, corresponded to patients without intervention during pregnancy related to AI. Sensitivities, specificities, and positive and negative predictive values for screening for severe fetal anemia were calculated for the antibody thresholds of 3.5 and 5 IU/ml for the quantification.

RESULTS

Between 2000 and 2018, 207 patients were included 135 in the severe anemia group and 72 in the no severe anemia group. No severe anemia was observed for an antibody titer below 16. For an antibody threshold of 3.5 IU/ml, the sensitivity was 98.2%, with 30.2% false positives. All severe anemias were detected in the second trimester; two cases of severe anemia were not detected in the third trimester. For an antibody threshold of 5 IU/ml, the sensitivity was lower at 95.6%, with five cases of severe anemia not detected.

CONCLUSION

The antibody threshold of 3.5 IU/ml for the quantification and 16 for the titration allow targeting patients requiring close monitoring by an experienced team in case of anti-RH1 AI.

Associations between fetal heart rate variability and umbilical cord occlusions-induced neural injury: An experimental study in a fetal sheep model

INTRODUCTION

This study evaluated the association between fetal heart rate variability (HRV) and the occurrence of hypoxic-ischemic encephalopathy in a fetal sheep model.

MATERIAL AND METHODS

The experimental protocol created a hypoxic condition with repeated cord occlusions in three phases (A, B, C) to achieve acidosis to pH <7.00. Hemodynamic, gasometric and HRV parameters were analyzed during the protocol, and the fetal brain, brainstem and spinal cord were assessed histopathologically 48 h later. Associations between the various parameters and neural injury were compared between phases A, B and C using Spearman's rho test.

RESULTS

Acute anoxic-ischemic brain lesions in all regions was present in 7/9 fetuses, and specific neural injury was observed in 3/9 fetuses. The number of brainstem lesions correlated significantly and inversely with the HRV fetal stress index (r = -0.784; p = 0.021) in phase C and with HRV long-term variability (r = -0.677; p = 0.045) and short-term variability (r = -0.837; p = 0.005) in phase B. The number of neurological lesions did not correlate significantly with other markers of HRV.

CONCLUSIONS

Neural injury caused by severe hypoxia was associated with HRV changes; in particular, brainstem damage was associated with changes in fetal-specific HRV markers.

Heart rate markers for prediction of fetal acidosis in an experimental study on fetal sheep

To overcome the difficulties in interpreting fetal heart rate (FHR), several tools based on the autonomic nervous system and heart rate variability (HRV) have been developed. The objective of this study was to use FHR and HRV parameters for the prediction of fetal hypoxia. It was an experimental study in the instrumented fetal sheep. Repeated umbilical cord occlusions were performed to achieve severe acidosis. Hemodynamic parameters, ECG, and blood gases were analyzed. The variables used were heart rate baseline, HRV analysis (RMSSD, SDNN, LF, HF, HFnu, Fetal Stress Index (FSI), …), and morphological analysis of decelerations. The gold standard used to classify hypoxia was the fetal arterial pH (pH < 7.10). Different multivariable statistical methods (logistic regression and decision trees) were applied for the detection of acidosis. 21 lambs were instrumented. A total of 130 pairs of FHR/fetal pH analysis were obtained of which 29 in the acidosis group and 101 in the non-acidosis group. After logistic regression model with bootstrap resampling and stepwise backward selection, only one variable was selected, FSI. The AUC of FSI alone in this model was 0.81 with a sensitivity of 0.66, specificity of 0.88, PPV of 0.61, and NPV of 0.90 considering a threshold of 68. Decision trees with CHAID and CART algorithms showed a sensitivity of 0.48 and 0.59, respectively, and a specificity of 0.94 for both. All employed methods identified HRV variables as the most predictive of acidosis. The primary variables selected automatically were those from the HRV. Supporting the use of FHRV measures for the screening of fetal acidosis during labour is interesting.

Long-Lasting Analgesia With Transdermal Fentanyl: A New Approach in Rat Neonatal Research

Background: With advances in neonatal care, management of prolonged pain in newborns is a daily concern. In addition to ethical considerations, pain in early life would have long-term effects and consequences. However, its treatment remains inadequate. It was therefore important to develop an experimental model of long-lasting analgesia for neonatal research.

Materials and Methods: Experiments were performed in six groups of rats with transdermal fentanyl 0, 3, 12, 50, 100, or 200 μg/kg/h from second postnatal day (P2) until weaning. Assessment of analgesia was carried out at P21, with behavioral scores (ranging from 0 to 3) using a 4% formalin test. Plasma levels of fentanyl were determined by UPLC/TQD at P22. Growth rate was investigated.

Results: Fentanyl 100 and 200 μg/kg/h reduced scores of formalin-evoked behavioral pain. They increased time spent in pain score 0 (8 min 55 s and 6 min 34 s versus 23 s in controls) as in low pain scores 1 and 2, and decreased time in the most severe pain score 3 (19 min 56 s and 17 min 39 s versus 44 min 15 s). Fentanylemia increased in a dose-dependent manner from 50 μg/kg/h (2.36 ± 0.64 ng/ml) to 200 μg/kg/h (8.66 ± 1.80 ng/ml). Concerning growth, no difference was observed except weaker growth from P17 to P22 with 200 μg/kg/h. Clinically, we noticed no visible side effect from 3 to 100 μg/kg/h. Concomitantly, 200 μg/kg/h was responsible for ophthalmological side effects with appearance of corneal bilateral clouding in 90% pups. No difference was observed between male and female rats.

Conclusion: Altogether, results indicate that transdermal fentanyl 100 μg/kg/h is an efficient therapeutic for long-lasting analgesia in lactating pups. This new model provides a useful tool for protection and welfare, and future opportunity for studying long-term health consequences of sustainable neonatal analgesia.

Should prenatal chromosomal microarray analysis be offered for isolated fetal growth restriction? A French multicenter study

BACKGROUND

Compared with standard karyotype, chromosomal microarray analysis improves the detection of genetic anomalies and is thus recommended in many prenatal indications. However, evidence is still lacking on the clinical utility of chromosomal microarray analysis in cases of isolated fetal growth restriction.

OBJECTIVE

This study aimed to estimate the proportion of copy number variants detected by chromosomal microarray analysis and the incremental yield of chromosomal microarray analysis compared with karyotype in the detection of genetic abnormalities in fetuses with isolated fetal growth restriction.

STUDY DESIGN

This retrospective study included all singleton fetuses diagnosed with fetal growth restriction and no structural ultrasound anomalies and referred to 13 French fetal medicine centers over 1 year in 2016. Fetal growth restriction was defined as an estimated fetal weight of <tenth percentile for gestational age identified in ultrasound reports. For this analysis, we selected fetuses who underwent invasive genetic testing with karyotype and chromosomal microarray analysis results. Data were obtained from medical records and ultrasound databases and postmortem and placental examination reports in case of spontaneous stillbirths and terminations of pregnancy. Following the American College of Medical Genetics and Genomics guidelines, copy number variants were classified into 5 groups as following: pathogenic, likely pathogenic, variant of unknown significance, likely benign, and benign.

RESULTS

Of 682 referred fetuses diagnosed with isolated fetal growth restriction, both karyotype and chromosomal microarray analysis were performed in 146 fetuses. Overall, the detection rate of genetic anomalies found by chromosomal microarray analysis was estimated to be 7.5% (11 of 146 [95% confidence interval, 3.3-11.8]), including 10 copy number variants classified as pathogenic and 1 copy number variant classified as likely pathogenic. Among the 139 fetuses with normal karyotype, 5 were detected with pathogenic and likely pathogenic copy number variants, resulting in an incremental yield of 3.6% (95% confidence interval, 0.5-6.6) in chromosomal microarray analysis compared with karyotype. All fetuses detected with pathogenic or likely pathogenic copy number variants resulted in terminations of pregnancy. In addition, 3 fetuses with normal karyotype were detected with a variant of unknown significance (2.1%). Among the 7 fetuses with abnormal karyotype, chromosomal microarray analysis did not detect trisomy 18 mosaicism in all fetuses.

CONCLUSION

Our study found that compared with karyotype, chromosomal microarray analysis improves the detection of genetic anomalies in fetuses diagnosed with isolated fetal growth restriction. These results support the use of chromosomal microarray analysis in addition to karyotype for isolated fetal growth restriction.

Risk factors associated with shortened latency before delivery in outpatients managed for preterm prelabor rupture of membranes

INTRODUCTION

Preterm prelabor rupture of membranes (PPROM) occurs in 3% of pregnancies and is the main cause (~30%) of premature delivery. Home care seems to be a safe alternative for the management of patients with PPROM, who have a longer latency than those with PPROM managed with conventional hospitalization. We aimed to identify the risk factors associated with a shortened latency before delivery in women with PPROM managed as outpatients.

MATERIAL AND METHODS

The design was a retrospective cohort study and the setting was a Monocentric Tertiary centre (Lille University Hospital, France) from 2009 to 2018. All consecutive patients in home care after PPROM at 24-36 weeks were included. For the main outcome measure we calculated the latency ratio for each patient as the ratio of the real latency period to the expected latency period, expressed as a percentage. The risk factors influencing this latency ratio were evaluated.

RESULTS

A total of 234 patients were managed at home after PPROM. Mean latency was 35.5 ± 20.7 days, corresponding to an 80% latency ratio. In 196 (83.8%) patients the length of home care was more than 7 days. A lower latency ratio was significantly associated with oligohydramnios (p < 0.001), gestational age at PPROM (p = 0.006), leukocyte count at PPROM more than 12 × 10⁹ /L (p = 0.025), and C-reactive protein concentration more than 5 mg/L at 7 days after PPROM (p = 0.046). Cervical length was not associated with a lower latency ratio.

CONCLUSIONS

Women with PPROM managed with home care are stable. The main risk factor associated with a reduced latency is oligohydramnios. Outpatients with oligohydramnios should be informed of the probability of a shortened latency period.

Changes in S100B and troponin levels in a fetal sheep model of worsening acidosis

BACKGROUND

S100B and cardiac troponin T (c-TnT) are relevant biomarkers at birth of hypoxic-ischemic encephalopathy (HIE) and myocardial ischemia secondary to metabolic acidosis during labor, respectively. The purpose was to assess in-utero changes in S100B and c-TnT levels in an experimental model of labor-like acidosis.

METHODS

Repeated umbilical cord occlusions (UCOs) in ten experiments were performed in mild (phase A, 1 UCO/5 mn), moderate (phase B, 1 UCO/3 mn), and severe (phase C, 1 UCO/2 mn) period. The experiments were stopped if arterial pH reached 6.90.

RESULTS

UCOs resulted in fetal acidosis with pH dropping to 6.99 ±0.13. When compared to the baseline period fetal S100B increased between phases A and B (7% ± 4 vs 17% ± 13, p = 0.030) and between phases A and C (7% ± 4 vs 24% ± 8, p < 0.001). Fetal c-TnT serum levels increased during occlusions: 102 ng/L (58-119) in phase A, vs 119 ng/L (103-198) in phase B vs 169 ng / L (128-268) in phase C (p < 0.05, for all). When compared to the baseline control period, fetal ΔcTnT was significantly modified throughout UCO series: 5.0% (-3; 45) in phase A, 51% (4; 263) in phase B, and 77% (56.5; 269) in phase C (p < 0.05 for all).

CONCLUSIONS

S100B and c-TnT increased when fetal acidosis occurred, which reflects the potential neurological damage and fetal cardiovascular adaptation.

Evaluation and impact of fetal physiology training on fetal heart rate analysis

INTRODUCTION

Evaluation of fetal well-being during labor is based on fetal heart rate (FHR) analysis, which requires physiology expertise. The aim of the present study was to assess medical residents' fetal physiology training in terms of theoretical knowledge, FHR interpretation, and use of second-line examinations.

METHODS

This single-center, prospective study of obstetrics and gynecology residents (N = 34) at CHU de Lille Hospital (Lille, France) was conducted from November 2017 to November 2018. Evaluation and training were conducted in three stages. First, residents' pre-training knowledge of FHR interpretation and use of fetal scalp blood sampling (FBS) was assessed using clinical cases. Second, a didactic training session on fetal physiology was delivered. Finally, post-training knowledge was evaluated using the same cases presented during pre-training. I: Pre-training, 3%, 11.8%, and 14.7% of residents considered their training on fetal physiology, FHR analysis, and second-line examinations, respectively, to be sufficient. Training significantly improved their theoretical knowledge, which was assessed using multiple-choice questions (median [interquartile range]: 1.5 [1.0-2.0] vs. 4.0 [3.0-4.5], p<0.001), and reduced the number of FBS requested (36.3% vs. 29.5%, p = 0.002). Krippendorff's alpha coefficient for the reproducibility of residents' responses improved significantly, reflecting greater homogenization of clinical practice decisions (alpha [95% confidence interval]: 0.60 [0.55-0.65] vs. 0.72 [0.67-0.76]).

CONCLUSION

Improved fetal physiology knowledge promotes more accurate FHR interpretation, better indications for second-line examinations, and greater homogenization of clinical practice decisions. Future studies should evaluate the impact of fetal physiology training on clinical practice.

Fetal sheep cerebral electrical activity: A new technique to record EEG

BACKGROUND

Sheep models are commonly used to study fetal cortical activity, including response to hypoxia. The standard technique consists of recording electrocorticogram (ECOG) in utero using electrodes placed on the dura mater.

NEW METHOD

We propose a new method for recording the electroencephalogram (EEG) of fetal sheep, using electrodes placed above the skull bone and fixed to the cranial periosteum.

RESULTS

Twelve animals were instrumented with this new technique. The EEG signal recorded in utero was of sufficient quality for visual and quantitative analysis of the fetal cortical activity.

COMPARISON WITH EXISTING METHOD

This new method is less invasive than the standard method commonly used to record cerebral activity in fetal sheep, because it avoids drilling the skull by hand. The EEG signal recorded in utero had visual and quantitative characteristics comparable to ECOG.

CONCLUSIONS

We present a new method of EEG recording that appears to be an acceptable alternative to the standard ECOG recording method. Fetal sheep EEG can be used to better understand the physiological mechanisms involved in the cerebral response to hypoxia.

Umbilical cord arterial and venous gases, ionogram, and glucose level for predicting neonatal morbidity at term

OBJECTIVE

To determine which parameter of umbilical arterial cord gas analysis, pH, base deficit, lactate concentration, ionogram values, or glucose level index is the best predictor of neonatal morbidity at term.

DESIGN

We conducted a 15-month retrospective cohort study that included all nonanomalous, singleton, term births at a single center. The predictive ability of lactate concentration, base deficit, pH, ionogram values, and glucose level were compared using receiver-operating characteristic curves for global and neurological composite morbidity. Optimal cutoff values for lactate concentration, base deficit, and pH were estimated based on their maximum area under the curve.

RESULTS

We included 5161 newborns: 52 (1.01 %) had global composite morbidity, and 17 had (0.33 %) neurological composite morbidity. Blood levels of potassium, calcium, natremia, glucose level, and HCO₃^- did not differ significantly between groups. pH, partial pressure of CO₂, partial pressure of O₂, base deficit, and lactate levels differed significantly between neonates in the groups with and without global composite morbidity. Nearly similar results were found for neurological composite morbidity. The predictive ability did not differ between arterial pH and arterial lactate concentration (P = .25) and base deficit (P = .79). Optimal cutoff values to predict global composite morbidity were arterial pH 7.144, venous pH 7.236, and arterial lactate concentration 6.5 mmol/L.

CONCLUSIONS

Acid-base status analysis remains the best objective indicator for predicting neonatal morbidity and can be estimated using pH, lactate, or base deficit. Ionogram cord blood composition and glucose level do not appear to be useful for this purpose.

Can we induce labor by mechanical methods following preterm premature rupture of membranes?

OBJECTIVE

To evaluate the use of the intracervical balloon compared with locally applied prostaglandins for cervical ripening for induction in patients with preterm premature rupture of membranes.

METHODS

Monocentric, retrospective (from 2002 to 2017) observational cohort study of singleton pregnancies complicated by preterm premature rupture of membranes and induced between 34 and 37 weeks. The primary outcome measure was balloon catheter efficiency evaluated by Cesarean section rate. Secondary outcomes were : interval from induction to delivery, labor duration, oxytocin use, intrauterine infection rate, maternal complications (i.e., postpartum hemorrhage and endometritis), and neonatal complications.

RESULTS

60 patients had cervical ripening with prostaglandins alone and 58 had balloon catheter. Demographic characteristics were similar between the groups, except for induction term and neonatal weight. There was not a significant difference in occurrence of Cesarean section rate (p = 0.14). Nor were there significant differences in time from induction to birth (p = 0.32) or in intrauterine infection rate (p = 0.95). Labor duration was shorter (p = 0.006) and total oxytocin dose lower (p = 0.005) in patients induced by prostaglandins alone. Concerning neonatal outcomes, there were more transfers to intensive care (p = 0.008) and more respiratory distress (p = 0.005) among newborns induced by prostaglandins.

CONCLUSION

Compared with locally applied prostaglandins, balloon catheter induction is not associated with an increase of Cesarean section rate in patients with preterm premature rupture of membranes.

[Comparison of antepartum management of breech versus cephalic presentation]

OBJECTIVES

Delivery mode of term breech presentation is still being discussed. The aim of this study was to compare the labor management of a breech presentation to a vertex presentation during a vaginal delivery attempt.

METHODS

It was a single-center, comparative, descriptive retrospective study from 2014 to 2017. We studied fetal heart rate (FHR) during labor and expulsion, duration of the different stage of labor, mode of delivery and neonatal outcomes for breech and vertex presentations.

RESULTS

Two hundred and thirty-nine patients were included whom 106 (44%) breech presentation. The use of oxytocin was more common in breech group (63,2% versus 48,1%, P=0.020). Average dilatation rate was slower for breech presentation than for vertex presentation (1.9cm/h vs. 2.8cm/h; P=0.005). There was more FHR with high risk of acidosis in the breech presentations (37.2% vs 19.1%, P=0.001) and Melchior's FHR classification were comparable in both groups.

CONCLUSIONS

The per-partum management of a fetus in breech presentation differs from a fetus in cephalic presentation. It must be known and anticipated for an optimal management in the delivery room.

Prenatal prediction of postnatal survival in fetuses with congenital diaphragmatic hernia using MRI: lung volume measurement, signal intensity ratio, and effect of experience

Objective: To evaluate various signal intensity ratios in isolated congenital diaphragmatic hernia (CDH) and to compare their potential in predicting survival with that of the observed-to-expected (O/E) ratio of total fetal lung volume (TFLV) using magnetic resonance imaging (MRI) measurements. Our second objective was to evaluate the impact of operator's experience in comparing the prediction of postnatal survival by O/E-TFLV.Methods: In 75 conservatively managed CDH fetuses and in 50 who underwent fetoscopic endoluminal tracheal occlusion (FETO), the fetal lung-to-amniotic fluid, lung-to-liver, lung-to-muscle, lung-to-spinal fluid signal intensity ratios, respectively LAFSIR, LLSIR, LMSIR, and LSFSIR, were measured, as was O/E-TFLV. Receiver operating characteristic (ROC) curves were constructed and used to compare the various signal intensity ratios with O/E-TFLV in the prediction of postnatal survival. In 72 MRI lung volumes assessed by the referring radiologists in Paris and Lille and secondarily by our expert radiologist in Brussels (M.M.C.) using the same MRI examinations, ROC curves were constructed and used to compare the value of O/E-TFLV determined by the two centers in the prediction of postnatal survival.Results: In the total cohort of CDH fetuses, O/E-TFLV and LLSIR were predictive of postnatal survival whereas in the conservatively managed group O/E-TFLV, LLSIR, and LMSIR predicted postnatal survival. O/E-TFLV predicted postnatal survival far better than the signal intensity ratios: area under the ROC curve for prediction by O/E-TFLV in the total cohort was 0.866 (p < .001; standard error = 0.031). The area under the ROC curve for prediction of postnatal survival using O/E-TFLV by MRI evaluated at the referral centers was 0.640 (p = 102; standard error = 0.085), and with O/E-TFLV reevaluated by M.M.C., it was 0.872 (p < .001; standard error = 0.061). Pairwise comparison showed a significant difference between the areas under the ROC curves (difference = 0.187, p = .012; standard error = 0.075).Conclusion: In fetuses with CDH with/without FETO, LLSIR was significantly correlated with the prediction of postnatal survival. However, measurement of O/E-TFLV was far better in predicting postnatal outcome. Operator experience in measurement of lung volumes using MRI seem to play a role in the predictive value of the technique.

Is homecare management associated with longer latency in preterm premature rupture of membranes?

PURPOSE

According to national guidelines, conventional management of preterm premature rupture of membranes (PPROM) is hospitalization until induction. Outpatient management could be another option. Our objective was to compare latency period between patients managed in hospital versus outpatients.

METHODS

A retrospective before/after monocentric study that occured from 2002 to 2015. Were included all patients with PPROM prior to 35 weeks with homecare inclusion criteria. The primary outcome measure was to study length of latency period (delay between PPROM and delivery). Second outcome measures were maternal and perinatal morbidities and mortalities.

RESULTS

Among the 395 women included after PPROM, 191 were managed as outpatients and 204 in hospital. In the outpatient group, the length of latency period was longer than in the inpatient group [39 (IQR 20 to 66) versus 21 (IQR 13 to 42) days; p < 0.001]. Clinical chorioamnionitis was observed in 30 (15.7%) in outpatient group versus 49 (24.0%) in inpatient group (p = 0.039). Concerning neonatal outcome, there were less neonatal transfer (49.2% versus 77.2%, p < 0.001), less respiratory distress syndrome (29.4% versus 47.5%; p < 0.001), less neonatal sepsis (13.9% versus 22.1%; p = 0.037), less bronchodysplasia (2.7% versus 9.8%; p = 0.004), and less pulmonary arterial hypertension (4.8% versus 10.3%; p = 0.040) in the outpatient group than in the inpatient group.

CONCLUSION

Home management seems to be a safe option to hospitalization in selected patients with PPROM. However, a randomized study would be required to approve those results.

Comparison of multiple cardiac signal acquisition technologies for heart rate variability analysis

Heart rate variability analysis is a recognized non-invasive tool that is used to assess autonomic nervous system regulation in various clinical settings and medical conditions. A wide variety of HRV analysis methods have been proposed, but they all require a certain number of cardiac beats intervals. There are many ways to record cardiac activity: electrocardiography, phonocardiography, plethysmocardiography, seismocardiography. However, the feasibility of performing HRV analysis with these technologies and particularly their ability to detect autonomic nervous system changes still has to be studied. In this study, we developed a technology allowing the simultaneous monitoring of electrocardiography, phonocardiography, seismocardiography, photoplethysmocardiography and piezoplethysmocardiography and investigated whether these sensors could be used for HRV analysis. We therefore tested the evolution of several HRV parameters computed from several sensors before, during and after a postural change. The main findings of our study is that even if most sensors were suitable for mean HR computation, some of them demonstrated limited agreement for several HRV analyses methods. We also demonstrated that piezoplethysmocardiography showed better agreement with ECG than other sensors for most HRV indexes.

Discordant immune complete heart block and growth restriction in dichorionic twin pregnancy with permanent pacemaker implantation of an 1140 g neonate

Fetal atrioventricular block is a rare pathology, mostly due to placental transmission of maternal SSA/Ro and SSB/La antibodies, and can lead to severe fetal or neonatal outcomes. We report a case of dichorionic, diamniotic twin pregnancy, with maternal SSA/Ro antibodies. Isolated complete atrioventricular block was diagnosed at 23 weeks in one fetus (Twin A), while the second fetus (Twin B) remained in normal sinus rhythm. Severe asymmetric intrauterine growth restriction occurred in Twin A. Delivery was by caesarean section at 32 + 2 weeks. Neonatal permanent pacemaker was inserted on the first day after birth in 1140 g neonate. Discordant heart block in twin pregnancy has already been reported in a few dichorionic pregnancies, but the pathway of discordant disease expression remains unclear. Extraction decision is a dilemma between cardiac failure prevention and prematurity associated twin morbidity. This case shows a successful pacing in a very low birth weight neonate.

Parasympathetic nervous system response to acidosis: Evaluation in an experimental fetal sheep model

INTRODUCTION

Heart rate variability and fetal heart rate decelerations are impacted by parasympathetic function and reflect acid-base status. Our team developed a new heart rate variability index, the fetal stress index (FSI), which has lower interindividual variability and higher sensitivity for detecting fluctuations in parasympathetic nervous system activity. The aim of this study was to explore the ability of the FSI to predict fetal acidosis in a fetal sheep model.

MATERIAL AND METHODS

Repeated 1-minute total umbilical cord occlusions (UCOs) were performed every 2.5 minutes over 3 hours to generate fetal acidosis mimicking that which occurs during labor and contractions. Fetal hemodynamic parameters, blood gas, the FSI and the magnitude (from the beginning to the nadir) of the fetal heart rate deceleration were recorded at regular intervals. The data were analyzed over three time intervals because of variation in the duration of the experiments: period A (first 12 UCOs), period B (middle 12 UCOs) and period C (last 12 UCOs).

RESULTS

Nine experiments were performed. Acidosis was progressive with a significant difference between the pH, lactate levels and base deficit values for the three periods of occlusion (P < 0.05). Both FSI and the magnitude of fetal heart rate decelerations gradually increased during the UCOs and both differed significantly between periods A and C (P = 0.0008 for FSI and P = 0.003 for deceleration).

CONCLUSION

This experimental protocol allowed the development of progressive acidosis in a good model of the physiology of labor. Parasympathetic nervous system activity increased during acidosis and could be measured using our index, the FSI, and the magnitude of fetal heart rate decelerations.

[Per-partum risk factors of neonatal acidemia in planned vaginal delivery for fetuses in breech presentation]

OBJECTIVES

Delivery mode of term breech presentation is debated because of higher rate of neonatal acidosis (pH<7.15) in planned vaginal delivery than in planned caesarean section. The objective was to evaluate per-partum risk factors of neonatal acidosis in vaginal delivery for podalic fetuses.

METHODS

It was a single-centre, case-control retrospective study that included planned vaginal delivery in singleton term breech presentation between 2012 and 2016. The "case" group defined by neonatal pH≤7.10 and the "control" group defined by neonatal pH≥7.20 were matched. The maternal, labor, and neonatal characteristics were noted.

RESULTS

One hundred and thirty-two patients were included: each of 44 patients in "case" group, has been matched according to breech type (legs position) to 2 patients in the "control" group, so 88. In multivariate analysis, significant risk factors identified were oxytocin use [ORa=5.663 (95% CI=1.844-17.397)], "high risk" fetal heart rate (FHR) abnormalities according to FIGO classification [ORa=10.997 (95% CI=1.864-64.866)] and FHR abnormalities during expulsion, Melchior 2 [ORa=8.088 (95% CI=1.192-54.875)] and Melchior 4 [ORa=12.705 (95% CI=1.157-139.541)].

CONCLUSIONS

These risk factors of neonatal acidemia have to be known to improve the labor management in case of breech planned vaginal delivery.

Prenatal diagnosis of esophageal atresia: A case of triple negative screening

Esophageal atresia (EA) is prenatally diagnosed in less than one third of the cases and is usually only suspected. Recently, magnetic resonance imaging (MRI) with dynamic sequence and biochemistry of the amniotic fluid have been proposed to enhance prenatal diagnosis of EA. We report the case of a triple negative screening (ultrasound, MRI with dynamic sequence and biochemistry of the amniotic fluid) with a postnatal diagnosis of EA type III with a small defect. Even using second line tests, prenatal diagnosis of EA remains a challenge.

Does an intrauterine exchange transfusion improve the fetal prognosis in parvovirus infection cases?

BACKGROUND

Almost 20% of parvovirus B19 foetal infections require intrauterine transfusions. In addition, myocardial dysfunction has been observed in severe parvovirus B19 infections. One objective of an intrauterine exchange transfusion (IUET) is to avoid an overload during the transfusion. Our aim was to study the obstetrical and neonatal outcomes in cases of IUETs performed for foetal parvovirus infections and to compare our survival rate to those studies in which simple in utero transfusions were chosen.

STUDY DESIGN AND METHODS

This was a retrospective monocentre study of all patients followed up for parvovirus B19 infections in which IUETs were performed. An IUET was indicated when foetal hydrops was observed and/or when severe foetal anaemia was diagnosed though an elevation in the middle cerebral artery peak systolic velocity. The characteristics of each pregnancy and the neonatal outcomes were studied until hospital discharge.

RESULTS

Thirty-five IUETs were performed in 26 foetuses. The median gestational age of the first IUET was 22.6 weeks. Only one foetal bradycardia incidence was recorded during the procedure. Three medical pregnancy terminations were observed in our series, secondary to severe cerebral anomalies confirmed in the magnetic resonance imaging. Five in utero deaths occurred, in which 2 of the foetuses underwent multiple IUETs. All the neonates had normal haemoglobin levels at birth, and none were transferred to the neonatal intensive care unit. The overall survival rate was 70%.

CONCLUSION

IUETs exhibit a survival rate similar to that of simple intrauterine transfusions in foetal parvovirus infection cases.

Effect of Cell-Free DNA Screening vs Direct Invasive Diagnosis on Miscarriage Rates in Women With Pregnancies at High Risk of Trisomy 21: A Randomized Clinical Trial

IMPORTANCE

Cell-free DNA (cfDNA) tests are increasingly being offered to women in the first trimester of pregnancies at a high risk of trisomy 21 to decrease the number of required invasive fetal karyotyping procedures and their associated miscarriages. The effect of this strategy has not been evaluated.

OBJECTIVE

To compare the rates of miscarriage following invasive procedures only in the case of positive cfDNA test results vs immediate invasive testing procedures (amniocentesis or chorionic villus sampling) in women with pregnancies at high risk of trisomy 21 as identified by first-trimester combined screening.

DESIGN, SETTING, AND PARTICIPANTS

Randomized clinical trial conducted from April 8, 2014, to April 7, 2016, in 57 centers in France among 2111 women with pregnancies with a risk of trisomy 21 between 1 in 5 and 1 in 250 following combined first-trimester screening.

INTERVENTIONS

Patients were randomized to receive either cfDNA testing followed by invasive testing procedures only when cfDNA tests results were positive (n = 1034) or to receive immediate invasive testing procedures (n = 1017). The cfDNA testing was performed using an in-house validated method based on next-generation sequencing.

MAIN OUTCOMES AND MEASURES

The primary outcome was number of miscarriages before 24 weeks' gestation. Secondary outcomes included cfDNA testing detection rate for trisomy 21. The primary outcome underwent 1-sided testing; secondary outcomes underwent 2-sided testing.

RESULTS

Among 2051 women who were randomized and analyzed (mean age, 36.3 [SD, 5.0] years), 1997 (97.4%) completed the trial. The miscarriage rate was not significantly different between groups at 8 (0.8%) vs 8 (0.8%), for a risk difference of -0.03% (1-sided 95% CI, -0.68% to ∞; P = .47). The cfDNA detection rate for trisomy 21 was 100% (95% CI, 87.2%-100%).

CONCLUSIONS AND RELEVANCE

Among women with pregnancies at high risk of trisomy 21, offering cfDNA screening, followed by invasive testing if cfDNA test results were positive, compared with invasive testing procedures alone, did not result in a significant reduction in miscarriage before 24 weeks. The study may have been underpowered to detect clinically important differences in miscarriage rates.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02127515.

Vasodilator effects of dehydroepiandrosterone (DHEA) on fetal pulmonary circulation: An experimental study in pregnant sheep

Persistent pulmonary hypertension (PPHN) remains a severe complication of the transition to extra-uterine life with significant morbidity and mortality in the newborns. Dehydroepiandrosterone (DHEA) represents a new pharmacological agent with vascular effects, including improvement of PPHN in several animal models. We hypothesized that DHEA could decrease pulmonary vascular resistance (PVR) in the pulmonary circulation of fetal sheep. We studied the effect of intravenous infusion of DHEA in fetal lambs using chronically instrumented sheep at 128 days of gestation. PVR was computed before and after intravenous infusion of increasing doses of DHEA. We assessed pre-treatment by L-nitroarginine, an inhibitor of NO production. Blood gases and doses of DHEA were measured in both sheep and fetus before/after DHEA infusion. Intravenous infusion of DHEA had a vasodilator effect with a significant decrease in PVR (respectively -11%, -14% and -36% after infusion of 6, 12 and 24 mg DHEA, p<0.01) without damaging effects on systemic circulation or on blood gases. The inhibitory effect of pre-treatment with L-nitroarginine resulted in a significant increase in PVR. We demonstrated a potent vasodilator effect of DHEA on fetal pulmonary circulation without deleterious effects. DHEA might represent a new treatment for PPHN.

Contribution of fetal brain MRI in management of severe fetal anemia

INTRODUCTION

Intrauterine transfusion (IUT) has changed fetal anemia prognosis. However, long-term neurodevelopmental outcome is altered in 5% of children. Our objective was to study the contribution of fetal MRI to diagnosis brain lesions in case of fetal anemia.

MATERIAL AND METHODS

Retrospective monocentric descriptive study from 2005 to 2016, including all patients followed for fetal anemia requiring IUT. The indications for MRI were: hydrops fetalis and / or hemoglobin <5 g / dL and / or more than 3 IUTs and / or acute severe anemia and / or ultrasound abnormality. Fetal and neonatal outcome and pediatric neurological monitoring were studied.

RESULTS

89 patients were followed for fetal anemia with IUT and 28 (29.1%) had fetal MRI, 12 of which were abnormal. Two out of twelve had abnormal ultrasound. Seven out of twelve had poor neurological prognosis: 2 medical terminations of pregnancy were performed; 2 children had severe developmental delay and 3 children had schooling difficulties. Five out of twelve children had favorable neurological prognosis.

CONCLUSION

MRI of the fetal brain makes it possible to better detect brain lesions than ultrasound does in the management of severe fetal anemia and seems particularly appropriate in cases of acute anemia.

When should foetal pH measurements be performed after a prolonged deceleration? An experimental study in a fetal sheep model

OBJECTIVE

The aim of fetal heart rate monitoring during labour is to identify and prevent foetal distress, but its evaluation is not perfect. Fetal scalp blood sampling for pH measurement is one of the second-line methods of monitoring when fetal heart rate is classified as suspicious. This study aims to determine when pH testing should be performed after a prolonged deceleration.

STUDY DESIGN

This was an experimental study in a fetal sheep model. A partial umbilical cord occlusion was performed for seven minutes followed by a recuperation period of 30 min. Hemodynamic parameters (heart rate, mean blood pressure and intra-amniotic pressure) and blood gases were recorded before occlusion (T0), during occlusion (T4), just after the end of occlusion (T7), and then 10, 20 and 30 min after occlusion (T17, T27 and T37 respectively).

RESULTS

Ten experiments were carried out. During partial cord occlusion, the fetal pH decreased significantly to acidosis. After a prolonged deceleration with fetal acidosis, the pH recovered to a normal value, defined by a pH greater than or equal to 7.25, after 20 min of recuperation.

CONCLUSION

After a prolonged deceleration, fetal pH normalizes between 20 and 30 min thereafter. Thus, if a foetal blood sample is indicated, this delay must be respected in order to avoid inducing an unnecessary intervention decision.

Exploring fetal response to acidosis in ewes: Choosing an adequate experimental model

INTRODUCTION

Knowledge of fetal physiology during labor has been largely generated from animal models. Our team recently developed a new index to assess parasympathetic activity using different experimental protocols to obtain acidosis. The objective of the present study was to discuss the different protocols and to review other models proposed in the literature.

MATERIAL AND METHODS

Pregnant ewes underwent a surgical procedure at the 123±2 days gestational age (term=145 days). Three experimental protocols were used: protocol A consisted of 25%, 50% and 75% umbilical cord occlusion (UCO) for 20min. Protocol B consisted of partial 75% UCO until reaching a pH<7.10. Protocol C consisted of brief, repetitive complete occlusion until severe acidosis occurred. Hemodynamic and blood gas parameters were compared to those of the stability period before UCO.

RESULTS

Protocol A led to a progressive response depending on the degree of occlusion (decrease in fetal heart rate, arterial hypertension and pH). Protocol B led to severe acidosis, although the duration of UCO varied per animal. Protocol C also progressively led to acidosis. We observed high inter individual variability in the acidosis response.

CONCLUSION

Pregnant ewes are a relevant model for exploring fetal response to acidosis. The frequency of UCO and partial or complete occlusion should be adapted to the expected effects. Knowledge of these protocols is important to respect ethical guidelines and to reduce the required number of animals. Moreover, it is important to consider the high individual variability of the acidosis response in the interpretation of the results.

Correlation of a new index reflecting the fluctuation of parasympathetic tone and fetal acidosis in an experimental study in a sheep model

The autonomic nervous system plays a leading role in the control of fetal homeostasis. Fetal heart rate variability (HRV) analysis is a reflection of its activity. We developed a new index (the Fetal Stress Index, FSI) reflecting parasympathetic tone. The objective of this study was to evaluate this index as a predictor of fetal acid-base status. This was an experimental study on chronically instrumented fetal lambs (n = 11, surgery at 128 +/- 2 days gestational age, term = 145 days). The model was based on 75% occlusion of the umbilical cord for a maximum of 120 minutes or until an arterial pH ≤ 7.20 was reached. Hemodynamic, gasometric and FSI parameters were recorded throughout the experimentation. We studied the FSI during the 10 minutes prior to pH samplings and compared values for pH>7.20 and pH≤ 7.20. In order to analyze the FSI evolution during the 10 minutes periods, we analyzed the minimum, maximum and mean values of the FSI (respectively FSImin, FSImax and FSImean) over the periods. 11 experimentations were performed. During occlusion, the heart rate dropped with an increase in blood pressure (respectively 160(155-182) vs 106(101-120) bpm and 42(41-45) vs 58(55-62) mmHg after occlusion). The FSImin was 38.6 (35.2-43.3) in the group pH>7.20 and was higher in the group pH less than 7.20 (46.5 (43.3-52.0), p = 0.012). The correlation of FSImin was significant for arterial pH (coefficient of -0.671; p = 0.004) and for base excess (coefficient of -0.632; p = 0.009). The correlations were not significant for the other parameters. In conclusion, our new index seems well correlated with the fetal acid-base status. Other studies must be carried out in a situation close to the physiology of labor by sequential occlusion of the cord.

Impact of a shift in nuchal translucency measurements on the detection rate of first-trimester Down syndrome screening: A population-based study

OBJECTIVE

To assess the distribution of nuchal translucency (NT) measurements following a national policy without credentialing and its impact on first-trimester Down syndrome screening (DSS) detection rate.

METHOD

All first-trimester DSS data recorded in France (2010-2014) were collected by the laboratories in charge via an Internet database (https://www.bionuqual.org/echo.php). There was no minimal requirement for image quality to allow sonographers to enter the screening process. A subgroup of DSS with complete DS follow-up corresponded to 1614 sonographers. Based on the distribution of maternal age, DS detection rate was calculated and split as a function of the distribution of NT multiple of the median (MoM).

RESULTS

Four thousand nine hundred forty-three sonographers performed 2,337,372 NT measurements. Median NT expressed in MoM was 0.83. Screenings with complete follow-up consisted of 197,417 screenings, in which DSS detection rates were respectively 70.4%, 70.9%, 79.4%, 87.7%, and 79.5% for the following median NT MoM ranges: <0.7, 0.70 to 0.79, 0.80 to 0.89, 0.90 to 0.99, and >0.99 (trend χ = 12.21; P = .0158).

CONCLUSION

In France, following a policy of quality assessment without standardized credentialing, the distribution of NT measurements did not fit the expected distribution. Down syndrome detection rate was 10% lower in screenings by sonographers with a median NT < 0.80 MoM.

A new analysis of heart rate variability in the assessment of fetal parasympathetic activity: An experimental study in a fetal sheep model

Analysis of heart rate variability (HRV) is a recognized tool in the assessment of autonomic nervous system (ANS) activity. Indeed, both time and spectral analysis techniques enable us to obtain indexes that are related to the way the ANS regulates the heart rate. However, these techniques are limited in terms of the lack of thresholds of the numerical indexes, which is primarily due to high inter-subject variability. We proposed a new fetal HRV analysis method related to the parasympathetic activity of the ANS. The aim of this study was to evaluate the performance of our method compared to commonly used HRV analysis, with regard to i) the ability to detect changes in ANS activity and ii) inter-subject variability. This study was performed in seven sheep fetuses. In order to evaluate the sensitivity and specificity of our index in evaluating parasympathetic activity, we directly administered 2.5 mg intravenous atropine, to inhibit parasympathetic tone, and 5 mg propranolol to block sympathetic activity. Our index, as well as time analysis (root mean square of the successive differences; RMSSD) and spectral analysis (high frequency (HF) and low frequency (LF) spectral components obtained via fast Fourier transform), were measured before and after injection. Inter-subject variability was estimated by the coefficient of variance (%CV). In order to evaluate the ability of HRV parameters to detect fetal parasympathetic decrease, we also estimated the effect size for each HRV parameter before and after injections. As expected, our index, the HF spectral component, and the RMSSD were reduced after the atropine injection. Moreover, our index presented a higher effect size. The %CV was far lower for our index than for RMSSD, HF, and LF. Although LF decreased after propranolol administration, fetal stress index, RMSSD, and HF were not significantly different, confirming the fact that those indexes are specific to the parasympathetic nervous system. In conclusion, our method appeared to be effective in detecting parasympathetic inhibition. Moreover, inter-subject variability was much lower, and effect size higher, with our method compared to other HRV analysis methods.

Impact of customized growth curves on screening for small for gestational age twins

OBJECTIVE

The choice of a growth curve determines the screening for small-for-gestational-age (SGA) fetuses and little data is available on SGA twins. Our aim was to evaluate small-for-gestational-age (SGA) detection rate in twin pregnancies and assess whether the use of a customized curve allowed better identification of SGA fetuses.

STUDY DESIGN

Retrospective study including all twins between 2010 and 2013. Two groups were formed: the SGA and the non-SGA group. Four curves were compared: Hadlock's curve, a customized curve, EPOPé M0 and EPOPé M1. We defined a composite neonatal complication criterion (transfer to intensive care unit, respiratory distress and death).

RESULT

472 fetuses were included with a 34.3% prevalence of SGA. Hadlock's curve showed better sensitivity for the detection of SGA <10th percentile (67.3% vs. 63%, 59.9% and 57.4% respectively). Diagnostic Odd Ratio were comparable for the detection of SGA. For the composite variable, there was a significant difference between the 2 groups using a customized curve adjusted for fetal sex (EPOPé M1).

CONCLUSION

The EPOPé (M0 and M1) and customized curves do not improve screening for SGA infants below the 10th percentile. The reduced effectiveness of customized curves can be related to the greater impact of placentation or cord insertion on the potential for fetal growth.

Impact on spina bifida screening of shifting prenatal Down syndrome maternal serum screening from the second trimester to the first

OBJECTIVES

Shifting screening for trisomy 21 to the first trimester has resulted in the loss of maternal serum alpha-fetoprotein screening for spina bifida. The aim of this study was to study the impact on open spina bifida prenatal screening.

STUDY DESIGN

We reviewed prenatally diagnosed cases of spina bifida over three years: 2009 (only second-trimester screening, MSM2T), 2010 (transient period) and 2011 (majority first-trimester screening, MSM1T). Cases were assigned to three groups based on maternal serum markers (MSM2T, MSM1T and 'not performed'). Gestational age at diagnosis of spina bifida was compared between these three groups and between the years 2009 and 2011.

RESULTS

Median gestational ages at diagnosis of the 742 spina bifida cases between the three groups were 22 weeks [18⁺⁶ -23], 22⁺¹  weeks [21⁺³ -23] and 21⁺⁴  weeks [14⁺¹ -23], respectively (P < 0.005). The diagnosis was made at 14-20 weeks in 34.7% for MSM2T group versus 8.5% for MSM1T (P < 0.001). Spina bifida diagnosis at 14-20 weeks declined from 38.8% in 2009 to 13.3% in 2011 (P < 0.001).

CONCLUSION

Loss of maternal serum alpha-fetoprotein had a tangible effect on the gestational age at diagnosis of spina bifida and resulted in a decrease of 25% of cases of spina bifida detected before 20 weeks. © 2017 John Wiley & Sons, Ltd.

Understanding fetal physiology and second line monitoring during labor

Cardiotocography (CTG) is a technique used to monitor intrapartum fetal condition and is one of the most common obstetric procedures. Second line methods of fetal monitoring have been developed in an attempt to reduce unnecessary interventions due to continuous cardiotocography and to better identify fetuses at risk of intrapartum asphyxia. The acid-base balance of the fetus is evaluated by fetal blood scalp samples, the modification of the myocardial oxygenation by the fetal ECG ST-segment analysis (STAN) and the autonomic nervous system by the power spectral analysis of the fetal heart variability. To correctly interpret the features observed on CTG traces or second line methods, it seems important to understand normal physiology during labor and the compensatory mechanisms of the fetus in case of hypoxemia. Therefore, the aim of this review is first to describe fetal physiology during labor and then to explain the modification of the second line monitoring during labor.

In utero treatment of severe fetal anemia resulting from fetomaternal red blood cell incompatibility: a comparison of simple transfusion and exchange transfusion

OBJECTIVE

To compare in utero exchange transfusions (IUET) and in utero simple transfusions (IUST) for the treatment of fetal anemia resulting from red blood cell fetomaternal incompatibility.

STUDY DESIGN

Retrospective comparative study from January 2006 through December 2011. The two techniques were compared for effectiveness, complications, and neonatal outcomes.

RESULTS

36 patients had 87 IUETs and 85 patients 241 IUSTs. Gestational age at the first transfusion was similar in both groups (IUET: 27±3.8 weeks; IUST: 27±4.7 weeks; NS) as was the initial fetal hemoglobin level (IUET: 6.4±2.8g/dL; IUST: 6.0±2.5g/dL; NS). No significant differences were noted for postprocedure complications or efficacy. The daily drop in hemoglobin level was similar in both groups (IUET: 0.41±0.23g/dL/day; IUST: 0.44±0.17g/dL/day; NS) as were the time intervals between two procedures. Gestational age at birth was earlier in the IUET group (34.4±1.3 weeks vs 35.5±1.8 weeks; p<0.001), but the postnatal transfusions or exchange transfusions rates and the duration of intensive phototherapy did not differ. No significant differences were noted for the overall survival rates (IUET: 100%; IUST: 96.4%; p>0.99).

CONCLUSION

IUET does not appear to provide any benefits compared with IUST, neither to be associated with a higher complication rate. The choice of the technique depends on availability of packed blood cells with high hematocrit (70-80%).

Benefits of Delayed Cord Clamping in Red Blood Cell Alloimmunization

BACKGROUND AND OBJECTIVE

Several studies have shown the benefits of delayed cord clamping (DCC) in preterm and in healthy newborns at short and long term. Our objective was to evaluate the potentials benefits and risks of DCC in red cell alloimmunization.

METHODS

This was a comparative before/after study of all living born neonates followed after fetal anemia requiring in utero transfusion. DCC was defined as cord clamping 30 seconds after birth.

RESULTS

We included a continuous series of 72 neonates: 36 without DDC (group 1) and 36 with DDC (group 2). Hemoglobin at birth was lower in group 1 (10.2 vs 13.4 g/dL, P = .0003); 7 (25%) neonates in group 1 vs 24 (70.6%) in group 2 had no anemia at birth (P = .004). The rate of transfusion was similar between the 2 groups. Postnatal exchange transfusions were more likely performed in the group without DCC than in the group with DCC (47.2% vs 19.4%, P = .0124). Delay between birth and first transfusion was higher in group 2 (0 [0-13] vs 1 [0-21], P = .0274). The maximum level of bilirubin, the rate of intensive phototherapy, and the total duration of phototherapy were similar in the 2 groups.

CONCLUSIONS

This study highlights a significant benefit of DCC in anemia secondary to red blood cell alloimmunization with a resulting decreased postnatal exchange transfusion needs, an improvement in the hemoglobin level at birth and longer delay between birth and first transfusion with no severe hyperbilirubinemia.

Neonatal outcome after fetal anemia managed by intrauterine transfusion

In-utero transfusion is now well under control and improves the survival of foetuses monitored for fetal anemia with a survival rate of more than 80 %. The aim was to evaluate short-term neonatal outcome after fetal severe anemia managed by intrauterine transfusions. We did a retrospective study of all neonates born after management of severe fetal anemia (n = 93) between January 1999 and January 2013 in our regional center. The two main causes of anemia were maternal red blood cell alloimmunization (N = 81, 87 %) and Parvovirus B19 infection (N = 10, 10.8 %). In the alloimmunization group, phototherapy was implemented in 85.2 % of cases with a maximum level of bilirubin of 114.4 ± 60.7 (mg/dl). Transfusion and exchange transfusion were, respectively, required in 51.9 % and in 34.6 % of cases. One neonate presented a convulsive episode, and we observed three neonatal deaths. In the parvovirus group, none of the child had anemia at birth and no management was necessary.

CONCLUSION

Contemporary management of Rhesus disease is associated with encouraging neonatal outcomes. In case of Parvovirus infection, no specific management is necessary at. But, in all cases of fetal anemia, children should be followed up with particular attention to neurologic development.

WHAT IS KNOWN

• In-utero transfusion is now well under control and improves the survival of fetuses monitored for fetal anemia. • Limited studies are available on the effect of IUT on postnatal outcome in infants with a history of fetal anemia. What is New: • Contemporary management of severe Rhesus disease is associated with encouraging neonatal outcomes. • The majority of infants can be managed with phototherapy and a limited number of top-up transfusions and exchange transfusions. In case of Parvovirus infection, the short-term neonatal outcome is excellent.