[Ketoacidosis complicated by fetal death revealing fulminant diabetes during the third trimester of pregnancy]. / Acidocétose compliquée d'une mort foetale révélant un diabète fulminant au troisième trimestre de grossesse.

We describe an acute onset of diabetes mellitus during third trimester of pregnancy revealed by ketoacidosis, complicated by fetal death, which could evoke fulminant type 1 diabetes, a novel subtype of type 1 diabetes first described in Japan and rarely described in Caucasian people. Diagnosis of diabetic ketoacidosis could be made on simple signs as abdominal pain, vomiting or ketone bodies on urinary multistix. Capillary glycaemic control is necessary to distinguish fast from ketoacidosis. The treatment of this severe imbalance must be initiated in emergency.

[Early neonatal bacterial infections: could superficial bacteriologic samples at birth be limited?]. / Infections bactériennes néonatales précoces en maternité: peut-on limiter les prélèvements bactériologiques périphériques en salle de naissance ?

INTRODUCTION: Without promptly started antibiotic therapy, early neonatal bacterial infections incur a significant mortality. Superficial bacteriologic samples at birth have in France a real place for the diagnosis and the decision to treat a neonate. OBJECTIVES: In order to limit their indication and their choice, the aim of this article was to describe the proportion of neonates with samples and to determine the diagnostic value of the gastric aspirate, the ear swab and the placental sample. METHODS: Neonates born in the CHRU of Lille in 2005 and staying in the maternity ward were prospectively included. Criteria for samples, type of samples and diagnosis taken were noted. Sensibility, specificity, positive and negative predictive values and likelihood ratios for a positive test and a negative test were calculated. RESULTS AND CONCLUSION: This study included 3918 neonates; 1.7% (65 children) were infected according to our criteria; 42.3% received bacteriologic samples. In accordance with the Anaes guidelines (2002), if mothers were Group B Streptococci positive and received intrapartum antibiotics (up to 2 injections) or did not have any screening test without any other indication of samples, the neonate did not have to receive bacteriologic samples. The gastric aspirate was the best exam thanks to the excellent negative predictive value of its direct examination: 99.4% (IC 95%: 98.8-99.7), its high likelihood ratio for a positive test: 10.04 (IC 95%: 8.29-12.15) and its low likelihood ratio for a negative test: 0.16 (IC 95%: 0.09-0.29); this sample could restrict the antibiotics' ratio given to the neonate. Placental sample could be taken only in certain indications.

[Prevention of early-onset group B streptococcus neonatal diseases. The 2005 experience of the Lille University Health Center]. / Prévention des infections bactériennes néonatales précoces à streptocoque B. L'expérience du CHRU de Lille en 2005.

OBJECTIVES: To study the efficiency of the official recommendations on the prevention of group B streptococcus and the impact of this strategy. MATERIALS AND METHODS: A prospective study was realized in 2005. All infants who were live-born at the Jeanne-de-Flandre hospital (Lille, France) and their mothers were included in the study. Data concerned both pregnancy (vaginal screening, intrapartum antibiotic) and newborn (safe, colonization and early-onset neonatal bacterial disease). RESULTS: Our study included 4353 mother-newborn couples. Vaginal screening was performed on 92% of the women included in the study. Prevalence of vaginal group B streptococcus in screened women was 7%. Perpartum antibioprophylaxia of group B streptococcus was achieved in 12% of the women included in the study. Group B streptococcus was associated to 60% of probable and certain early-onset bacterial neonatal diseases, with an incidence of 9/1000 births. Exposition to antenatal antibiotherapy multiplied by two the risk of ampicillin resistant Gram-negative bacilli (RR=2 [1.1-3.8]). CONCLUSION: Recommendations were well followed, but in our health center group, B streptococcus was the main bacteria responsible for early-onset bacterial neonatal diseases. Because of the risk of germ selection, a more targeted antibioprophylaxia has to be preferred.

[Liver hernia. Prognosis and report of 11 cases]. / Les hépatocèles exclusives. Evaluation du pronostic. A propos de 11 observations.

OBJECTIVES: Exclusive hepatocele is defined as a hernia containing in majority the liver with possibly some intestinal loops. This study was undertaken to evaluate neonatal morbidity and mortality in this series of exclusive hepatoceles. MATERIALS AND METHODS: We reviewed 11 cases of exclusive hepatoceles with delivery at the hospital Jeanne-de-Flandre in the CHRU of Lille, in France. RESULTS: The mean gestational age of diagnosis was 14.5+/-3.4 weeks of gestation. Karyotype determination was performed in 100% of cases: it was abnormal in one case of 11. One termination of pregnancy was performed because of trisomy 13. The mean gestational age at delivery was 38+/-1.8 weeks of gestation. Cesarean deliveries were performed in nine cases. Morbidity was important with: one case of fetal growth retardation on total hepatocele, three cases of severe respiratory distress, two cases of severe digestive complications. The mean length of stay was 42.8 days. The mean length of parenteral feeding was 14.4 days. Postnatal mortality concerned one child, which died because of a severe respiratory distress due to pulmonary hypoplasia. CONCLUSION: In this series, morbidity is thus important, making of exclusive hepatoceles a full entity among the omphaloceles. The multidisciplinary take care is more complex but conceivable.

[Twin-to-twin delivery interval: is a time limit justified?]. / Intervalle de naissance entre les jumeaux: une limite de temps est-elle justifiée?

OBJECTIVES: To assess the effect of the twin-to-twin delivery interval on the umbilical cord blood gas status and the neonatal outcome of the second twin following vaginal delivery. PATIENTS AND METHODS: Retrospective study of twin deliveries at or beyond 34 weeks of gestation over a period of five years. The correlation between the twin-to-twin delivery interval, and the umbilical arterial blood gas parameters of the second twin, including pH, PO(2), PCO(2), HCO(3-) and base excess, was studied. A second analysis was performed after exclusion of non-vertex presentation, need for general anesthesia, growth restriction and weight difference between the twin>30%. RESULTS: Two hundred and thirty-nine patients were studied. The mean twin-to-twin delivery interval was 11.3+/-6.4 minutes (between 6 and 14 minutes in 56.1% of cases). The second twin had more Apgar score<7 at 1 minute (P<0.02) and more arterial ombilical pH<7.20 (P<0.01) than the first twin. Over 15 minutes, the mean arterial pH was lower (P<0.01) and the number of arterial pH<7.20 increased (P<0.03). In contrast, the mean Apgar score and the rate of neonatal transfer did not differ significantly. There were significant negative correlations between arterial pH, base excess and bicarbonates and the twin-to-twin delivery interval (P<0.05). Similar results were found in the homogenised population. The reduction in the second twin arterial pH was expressed as pH=7.282-0.003 x time. DISCUSSION AND CONCLUSION: Umbilical cord arterial blood gas parameters deteriorate with increasing twin-to-twin delivery interval. Our results suggest that this interval should be less than 15 minutes, but obstetrician should adapt to every clinic situation.

[Feeding practices in infants: a 6-month prospective cohort study]. / Conduite de la diversification alimentaire: enquête prospective jusqu'à l'âge de 6 mois.

UNLABELLED: The aims of this work were to assess timing of complementary feeding in infants and to precise the underlying factors that may cause inappropriate complementary feeding. PATIENTS AND METHODS: A cohort of 167 newborns, born in the same maternity ward during a 6 week-period, was prospectively analyzed. Only healthy neonates were included in the study. A phone questionnaire was filled at 4 and 6 months of age to evaluate modality of complementary feeding. Multivariate analysis (segmentation tree, analyse by multiple correspondence) was used to study factors associated with inappropriate diversification. RESULTS: Out of the 167 neonates included in the study, 132 mothers could be contacted at 4 months and 116 at 6 months of age. Sixty-seven per cent of mothers started breast feeding at birth. Among these, 33% still breastfed -at least partially- at 4 months and 17% at 6 months. Fifty-two percent of mothers started complementary feeding before 4 months, and 24% of infants received gluten at 4 months of age. Multi-gravida mothers, mothers aged more than 35 years old and mothers who gave infant or follow-up formulae before 4 months, started complementary feeding significantly earlier (P<0.05). Infants who were formula fed received more frequently complementary feeding before the age of 4 months than breast fed infants (57% vs 33%, P<0.05). CONCLUSION: Our study showed that half of infants were introduced solid food too early and allowed to identify a population at risk that could benefit from nutritional intervention programs.

[Diagnosis and treatment of congenital bronchopulmonary malformations. A review of 32 cases]. / Diagnostic et traitement des malformations bronchopulmonaires congénitales : analyse de 32 observations.

OBJECTIVES: Analysis of our experience and propositions on the diagnosis and treatment of congenital bronchopulmonary malformations (BPM). POPULATION AND METHODS: Retrospective study of BPM diagnosed between 1997 and 2001. Analysis of clinical spectrum, diagnosis tools, treatment, and clinical outcome. RESULTS: Thirty-two cases of BPM have been investigated (11 cystic adenomatoid malformations, 7 pulmonary sequestrations, 7 bronchogenic cysts, 4 congenital lobar emphysema, and 3 complex emphysematous malformations). Nineteen patients had a prenatal diagnosis. For 9 others, symptoms occurred before 4 years of age. Evaluation included a CT-scan in all patients (BPM involution in one). Surgical treatment was performed in 30 patients (lobectomy in 18), with a mean age of 7 months for asymptomatic patients. During the follow-up (mean: 3 years), respiratory symptoms were reported in 10 cases, 3 of them were related to the BPM. DISCUSSION: Improvement in prenatal ultrasound diagnosis modified the management strategy. Considering the risk of pulmonary complications, surgical treatment is required during the first months of life. For congenital lobar emphysema, and some pulmonary sequestrations or small cystic adenomatoid malformations (<3 cm), conservative attitude may be preferred. BPM justify a multidisciplinary management.

[Premature discontinuation of breastfeeding]. / Les arrêts prématurés d'allaitement maternel.

UNLABELLED: This study was performed to describe the factors associated with a premature cessation of breastfeeding. BACKGROUND AND METHODS: Three hundred and forty nine women with a plan for prolonged breastfeeding over two months were interviewed during their hospital stay to define sociological and medical variables. One month after discharge, mothers were contacted by a physician for making out evolution of the breastfeeding. RESULTS: Eighty-eight (28%) women were no more breastfeeding their infant and were compared to the other 224 (64%) mothers. The main sociological factors influencing the cessation of breastfeeding were low education level (odds ratio 4.2 [95% CI 2.2-8.3]), and primiparity (odds ratio 2.1 [95% CI 1.1-3.9]). Pacifier use was associated with a lower duration of breastfeeding (odds ratio 2.5 [95% CI 1.4-4.5]). Medical predictive factors were infant weight loss (odds ratio 4.3 [95% CI 1.7-10.6]), respect of intervals between feeding times (odds ratio 2.1 [95% CI 1.1-4.4]), delay before the first feeding (odds ratio 1.9 [95% CI 1.0-3.6]). On the other hand formula supplementation was not related with cessation of breastfeeding. DISCUSSION AND CONCLUSION: As the success of breastfeeding depends on maternal motivation, it seems essential to take into account mothers' plan to study breastfeeding duration. The knowledge of predictive factors of the cessation of breastfeeding should allow to identify mothers who need particularly the attention of healthcare professionals.

N-glycosylation potential of maize: the human lactoferrin used as a model.

In order to determine the N-glycosylation potential of maize, a monocotyledon expression system for the production of recombinant glycoproteins, human lactoferrin was used as a model. The human lactoferrin coding sequence was inserted into the pUC18 plasmid under control of the wheat glutenin promoter. Maize was stably transformed and recombinant lactoferrin was purified from the fourth generation seeds. Glycosylation was analysed by gas chromatography, lectin detection, glycosidase digestions and mass spectrometry. The results indicated that both N-glycosylation sites of recombinant lactoferrin are mainly substituted by typical plant paucimannose-type glycans, with beta1,2-xylose and alpha1,3-linked fucose at the proximal N-acetylglucosamine, and that complex-type glycans with Lewis(a) determinants are not present in maize recombinant lactoferrin.

[Non-medical factors in perinatal health. A study of socioeconomic anc cultural features of women admitted to the maternity hospital in Lens (Pas-de-Calais)]. / Rôle des facteurs non médicaux dans la santé périnatale. Etude des caractéristiques socioéconomiques et culturelles de la population accueillie à la maternité du centre hospitalier de Lens (Pas-de-Calais).

BACKGROUND: The aim of this study was to determine the influence of medical and non-medical factors on perinatal health in an underpriviledged area, the ex-coal mines of Lens (Pas-de-Calais). POPULATION AND METHODS: This prospective study concerned 1,000 women who delivered in the maternity hospital of Lens between January 5, 1993 and May 13, 1993. The relationships between preterm delivery, low birth weight and maternal socioeconomic and cultural characteristics were analyzed. RESULTS: The women included presented adverse pregnancy outcomes. Preterm delivery, low birth weight and neonatal transfer rates were respectively 6.9%, 7.3% and 12.7% higher than the average regional rates. In contrast with these results, antenatal care could be considered correct or even better. The poor socioeconomic status of the population appeared to be a very significant perinatal risk factor. CONCLUSION: At present, in an unfavourable regional conjuncture, socioeconomic and cultural factors have adverse effects on perinatal morbidity and mortality independent of medical factors like prenatal care. The prevention of poor perinatal outcome should be based on these data. Not the access to the health care system but the manner of dispensing health care should require great consideration.

[Fetal arrhythmias: diagnosis, prognosis, treatment; apropos of 33 cases]. / Arythmies foetales: diagnostic, pronostic, traitement; à propos de 33 cas.

From October 1993 to February 1998, 33 cases of fetal cardiac arrhythmia were investigated by doppler-echocardiography at the Lille infantile and congenital cardiology department. Extrasystolic arrhythmias were the most frequently encountered disorder (25 fetuses, i.e., 76% of cases: 24 instances of extrasystolic auricular arrhythmia and one case of extrasystolic ventricular arrhythmia). They were invariably benign, and apart from one case only required standard monitoring. Tachycardia was observed in 15% of cases (three cases of supraventricular tachycardia [SVT] and two cases of auricular flutter [AF]). In no instance was a cardiopathic syndrome noted. A number of efficient treatments have been described, but the prognosis is often poor in the presence of hydrops fetalis. Direct fetal treatments (cordocentesis) are currently under evaluation, and at present can only be used as a last resort. In our series, one fetus died 15 minutes after transplacental Flecaine (flecainide) administration. Two of the three SVT and the two AF cases were successfully treated. Bradycardia, which was unassociated with extrasystolic arrhythmia, was found in 9% of cases. It is concluded that Flecaine is probably the treatment of choice for supraventricular and ventricular fetal tachycardia, as it has no teratogenic effect and crosses the placenta at a fetal concentration that is 80% of the maternal level. However, the administration of this drug is not without risk. It is known to possess certain negative side effects, and its pharmacological profile and maternal and fetal health risks have not yet been fully investigated. At present, no entirely safe and efficient treatment for fetal cardiac arrhythmia has been found.

[Contribution of direct bacteriologic examinations to the diagnosis of early materno-fetal bacterial infection: the Lille experience]. / Apport des examens directs bactériologiques au diagnostic de l'infection bactérienne materno-foetale précoce: expérience lilloise.

A prospective study was conducted in 3056 live-born infants delivered at the Jeanneade-Flandre maternity hospital of the Lille Teaching Hospital between January and August 1997. Clinical, laboratory test, and microbiological test findings were compared. A cohort of 1003 infants who remained in the maternity ward but were considered at increased risk of maternofetal infection (MFI) based on history and/or obstetrical criteria and/or neonatal criteria underwent routine collection of specimens including gastric fluid, auricular and anal swabs, amniotic fluid, and placental fragments. Microscopic examination of gastric fluid smears, the first result available to the clinician, was found to have 27.5% sensitivity (983 samples). Positive predictive value (PPV) was only 17.8% because of a high rate of colonization (16.8%), defined as absence of clinical symptoms and three peripheral specimens positive for the same organism. However, negative predictive value (NPV) was as high as 99.8% as a result of high sensitivity (97.8%) in the infected neonates. The gastric fluid smear was positive in 30% and 35% of neonates born to mothers with hyperpyrexia during early and late labor, respectively, and in 42% of neonates born to mothers with a history of group B streptococcus carriage during the pregnancy. Forty-two per cent of neonates with a history of fetal tachycardia had a positive gastric fluid smear. Diagnostic criteria for infection were three peripheral specimens positive for the same organism, C-reactive protein elevation, and/or one or more clinical signs suggestive of infection, and/or a positive central specimen (blood, CSF). The infection rate in infants who remained in the maternity ward was 1.6%. The most common causative organisms were group B streptococci. These findings illustrate the useful contribution of gastric fluid smears to the early diagnosis of MFI and confirm the predominant role of group B streptococci.

[Fetal cerebral ventriculomegaly. Etiology and outcome, report of 141 cases]. / Ventriculomégalie cérébrale foetale. Etiologie et devenir, à propos de 141 observations.

OBJECTIVE: To present the different etiologies of fetal cerebral ventriculomegaly (VA) and try to evaluate prognosis. MATERIALS AND METHODS: A retrospective analysis was made in 141 cases of fetal cerebral ventriculomegaly diagnosed in our obstetrics department between January 1988 and December 1996. RESULTS: Mean gestational age at diagnosis was 24.8 weeks. Myelomeningoceles were the most frequent etiology (50 cases, 36%), usually diagnosed late in pregnancy (25 weeks gestation). Termination of pregnancy was the most frequent outcome. Agenesis of the corpus callosum (ACC) was observed in 16 cases (11%), 8 of them being diagnosed before birth. This etiology has been an important diagnostic problem until recent years. The advent of improved imaging techniques has facilitated diagnostic procedures. Thus in 1996, the 4 ACC were all diagnosed by prenatal ultrasound. The 8 live infants presented developmental retardation. Termination of pregnancy has been performed more and more frequently in accordance with parent wishes. In 6 cases (4%), the etiology was congenital infection. When a chromosome anomaly was found (7%), ventriculomegaly was always associated with other ultrasonographic anomalies. Ventriculomegaly was associated with other malformations in 23% of the cases but only 17% were discovered prenatally; all the live infants but one had severe neurological impairment. Ventriculomegaly was considered to be the unique anomaly in 37% of the prenatal cases and was truly unique in 24%, an etiology being found in 6%. No explanation was found in 18%. The outcome of live infants is known in 139 cases (2 children lost to follow-up) after a 6 month to 6 year follow-up. Overall prognosis was severe as among the 42 infants (30%), 14 (10%) are well including 12 who had ventriculomegaly alone. CONCLUSION: Prenatal diagnosis of ventriculomegaly implies a severe prognosis. Only children presenting limited ventriculomegaly alone have normal neurological development. In case of ventriculomegaly, clinicians must search carefully for other anomalies, always associated with poor prognosis.

Familial peeling skin syndrome with eosinophilia: clinical, histologic, and ultrastructural study of three cases.

OBJECTIVE: The clinicopathologic features of a rare familial form of congenital blister are analyzed to assess what factors could lead to the cutaneous split. METHODS: Three consanguinous newborn babies had a congenital ichthyosis with eosinophilia and elevated total immunoglobulin E. The type and level of the split were studied on skin biopsies performed on the first day of life. RESULTS: The level of the split was located within the corneocytes. Isolated eosinophilic granules were found at this site. Desmosomes and the dermoepidermal junction were intact. Blisters and eosinophilia resolved in 3 weeks, and there was no recurrence during 4 and 6 years of follow-up in two of the patients. CONCLUSION: Peeling skin syndrome is a rare blistering disorder of the newborn that should be recognized because it has a good prognosis. Eosinophils may play an important role in the cutaneous split of this congenital ichthyosis.

A new application of an old method for respiratory mechanics measurements: the passive inflation method in newborn infants during pressure-controlled ventilation.

We have previously described a passive inflation method during constant inspiratory flow for measuring total respiratory elastance and resistance during mechanical ventilation in newborns. The simple method for measuring respiratory mechanics had been assessed during decelerating inspiratory flow obtained with pressure controlled ventilation (PCV). We report an application of this method to preterm and full-term mechanically ventilated newborn infants and a comparison with the occlusion method. Twenty-one newborn infants (birth weight 1,060 to 3,650 g; gestational age 26 to 41 weeks), between 1 to 55 days of postnatal age, were enrolled in the study. They were ventilated with a "Servo ventilator 900C," first set in the pressure-controlled mode and then in the volume-controlled mode without changing the tidal volume (VT), inspiratory time or ventilator rate. Flow was measured through a pneumotachograph inserted between the endotracheal tube (ETT) and the breathing circuit; VT was obtained by integration of flow and airway pressure measured directly at the airway opening. Flow, volume, and pressure were plotted on analog X/Y tables to obtain pressure-volume (P/V) and flow-volume (V/V) loops, as well as pressure-time curves. Occlusion was performed by using the end-inspiratory and the end-expiratory pause buttons of the ventilator. The passive inflation method during PCV was based on the analysis of P/V and V/V loops and provided compliance (Crs(PC)infl.), resistance Rrs(PC)infl.) of the respiratory system, and intrinsic positive end-expiratory pressure (PEEP(PC)i,infl.). These values were compared with (1) compliance (Crs(PC)occl.) and intrinsic positive end-expiratory pressure (PEEP(PC)i,occl.) measured by the occlusion method during PCV; (2) static (Crs(VC),occl.) and dynamic (Crs(VC),dyn.) compliance, airway (R(aw)(VC),), tissue (Rrs(VC),visc.) and total resistance (Rrs(VC),occl.), and intrinsic positive end-expiratory pressure (PEEP(VC)i,occl.) measured by the occlusion method during volume-controlled ventilation. Crs(PC),infl. correlated well with Crs(PC),occl., Crs(VC),occl., and Crs(VC),dyn.. Furthermore, Crs(PC),infl. and Crs(VC),dyn. did not differ significantly. Rrs(PC),infl. correlated well and did not differ significantly from total inspiratory resistance, i.e., the sum of R(aw)(VC) and Rrs(VC),vis. PEEPPC,i,infl. correlated well and did not differ significantly from PEEP(PC)i.occl. and from PEEP(VC),i,occl. The passive inflation method can be used during PCV with a decelerating flow waveform. It provides dynamic compliance, inspiratory resistance of the respiratory system, and intrinsic PEEP from the analysis of V/V and P/V loops recorded at the airway opening. This technique is simple to use and well tolerated by preterm and full-term ventilated newborn infants. It can be a good alternative to occlusion methods.