Obstetric interventions for babies born before 28 weeks of gestation in Europe: results of the MOSAIC study.

OBJECTIVE: To describe obstetric intervention for extremely preterm births in ten European regions and assess its impact on mortality and short term morbidity. DESIGN: Prospective observational cohort study. SETTING: Ten regions from nine countries participating in the 'Models of Organising Access to Intensive Care for Very Preterm Babies in Europe' (MOSAIC) project. POPULATION: All births from 22 to 29 weeks of gestation (n = 4146) in 2003, excluding terminations of pregnancy. METHODS: Comparison of three obstetric interventions (antenatal corticosteroids, antenatal transfer and caesarean section for fetal indication) rates at 22-23, 24-25 and 26-27 weeks to that at 28-29 weeks and the association of the level of intervention with pregnancy outcome. MAIN OUTCOME MEASURES: Use of antenatal corticosteroids, antenatal transfer and caesarean section by two-week gestational age groups as well as a composite score of these three interventions. Outcomes included stillbirth, in-hospital mortality and intraventricular haemorrhage (IVH) grades III and IV and/or periventricular leucomalacia (PVL) and bronchopulmonary dysplasia (BPD). RESULTS: There were large differences between regions in interventions for births at 22-23 and 24-25 weeks. Differences were most pronounced at 24-25 weeks; in some regions these babies received the same care as babies of 28-29 weeks, whereas elsewhere levels of intervention were distinctly lower. Before 26 weeks and especially at 24-25 weeks, there was an association between the composite intervention score and mortality. No association was observed at 26-27 weeks. For survivors at 24-25 weeks, the intervention score was associated with higher rates of BPD, but not with IVH or PVL. CONCLUSIONS: There are large differences between European regions in obstetric practices at the lower limit of viability and these are related to outcome, especially at 24-25 weeks.

Organisation of obstetric services for very preterm births in Europe: results from the MOSAIC project.

OBJECTIVE: To study the impact of the organisation of obstetric services on the regionalisation of care for very preterm births. DESIGN: Cohort study. SETTING: Ten European regions covering 490 000 live births. POPULATION: All children born in 2003 between 24 and 31 weeks of gestation. METHOD: The rate of specialised maternity units per 10 000 total births, the proportion of total births in specialised units and the proportion of very preterm births by referral status in specialised units were compared. MAIN OUTCOME MEASURE: Birth in a specialised maternity unit (level III unit or unit with a large neonatal unit (at least 50 annual very preterm admissions). RESULTS: The organisation of obstetric care varied in these regions with respect to the supply of level III units (from 2.3 per 10 000 births in the Portuguese region to 0.2 in the Polish region), their characteristics (annual number of deliveries, 24 hour presence of a trained obstetrician) and the proportion of all births (term and preterm) that occur in these units. The proportion of very preterm births in level III units ranged from 93 to 63% in the regions. Different approaches were used to obtain a high level of regionalisation: high proportions of total deliveries in specialised units, high proportions of in utero transfers or high proportions of high-risk women who were referred to a specialised unit during pregnancy. CONCLUSION: Consensus does not exist on the optimal characteristics of specialised units but regionalisation may be achieved in different models of organisation of obstetric services.

Rates of very preterm birth in Europe and neonatal mortality rates.

OBJECTIVE: To estimate the influence of variation in the rate of very preterm delivery on the reported rate of neonatal death in 10 European regions. DESIGN: Comparison of 10 separate geographically defined European populations, from nine European countries, over a 1-year period (7 months in one region). PARTICIPANTS: All births that occurred between 22(+0) and 31(+6) weeks of gestation in 2003. MAIN OUTCOME MEASURE: Neonatal death rate adjusted for rate of delivery at this gestation. RESULTS: Rate of delivery of all births at 22(+0)-31(+6) weeks of gestation and live births only were calculated for each region. Two regions had significantly higher rates of very preterm delivery per 1000 births: Trent UK (16.8, 95% CI 15.7 to 17.9) and Northern UK (17.1, 95% CI 15.6 to 18.6); group mean 13.2 (95% CI 12.9 to 13.5). Four regions had rates significantly below the group average: Portugal North (10.7, 95% CI 9.6 to 11.8), Eastern and Central Netherlands (10.6, 95% CI 9.7 to 11.6), Eastern Denmark (11.2, 95% CI 10.1 to 12.4) and Lazio in Italy (11.0, 95% CI 10.1 to 11.9). Similar trends were seen in live birth data. Published rates of neonatal death for each region were then adjusted by applying (a) a standardised rate of very preterm delivery and (b) the existing death rate for babies born at this gestation in the individual region. This produced much greater homogeneity in terms of neonatal mortality. CONCLUSIONS: Variation in the rate of very preterm delivery has a major influence on reported neonatal death rates.

[Cranial osteopathy as a complementary treatment of postural plagiocephaly]. / Place de l'ostéopathie dans la correction des déformations crâniennes du nouveau-né et du jeune enfant.

For the majority of neonates and young infants, appropriate postures and standard physiotherapy succeed in preventing or correcting acquired cranial deformations (fetal due to restricted mobility in utero or postnatal secondary to exclusive dorsal decubitus). However in some cases, when postural management is not efficient, pediatricians will be asked by the parents about the potential benefits of osteopathy. What is osteopathic treatment? At first, diagnostic palpation will identify which suture is normally mobile with the respiratory cycle, and which has limited or absent mobility secondary to abnormal postures. Later on, the goal of the therapeutic phase is to mobilise impaired sutures, by various gentle maneuvers depending on the topography of the impairment. The treatment is not restricted to the skull but extended to the spine, pelvis and lower extremities which contribute to the deformative sequence. Osteopathic treatment belongs to complementary medicine, therefore demonstration of its scientific value and favorable results have to be provided. Based on randomized studies, the answer is yes, it significantly decreases the degree of asymmetry. Do postural deformations matter to the development of an healthy infant? It seems that the prejudice is not only esthetic but also functional, however more research is necessary. In conclusion, pediatricians should be more aware of the method and expectations: major deformative sequence since birth and increasing deformations despite preventive postures and standard physiotherapy are reasonable indications for such complementary treatment. "Preventive" osteopathy in maternity is not justified. Moreover osteopathy has no place in the treatment of craniosynostosis ; the latter belong to malformations, completely distinct from postural deformations.

Termination of pregnancy among very preterm births and its impact on very preterm mortality: results from ten European population-based cohorts in the MOSAIC study.

OBJECTIVE: To study the impact of terminations of pregnancy (TOP) on very preterm mortality in Europe. DESIGN: European prospective population-based cohort study. SETTING: Ten regions from nine European countries participating in the MOSAIC (Models of OrganiSing Access to Intensive Care for very preterm babies) study. These regions had different policies on screening for congenital anomalies (CAs) and on pregnancy termination. POPULATION OR SAMPLE: Births 22-31 weeks gestational age. METHODS: The analysis compares the proportion of TOP among very preterm births and assesses differences in mortality between the regions. MAIN OUTCOME MEASURES: Pregnancy outcomes (termination, antepartum death, intrapartum death and live birth) and reasons for termination, presence of CAs and causes of death for stillbirths and live births in 2003. RESULTS: Pregnancy terminations constituted between 1 and 21.5% of all very preterm births and between 4 and 53% of stillbirths. Most terminations were for CAs, although some were for obstetric indications (severe pre-eclampsia, growth restriction, premature rupture of membranes). TOP contributed substantially to overall fetal mortality rates in the two regions with late second-trimester screening. There was no clear association between policies governing screening and pregnancy termination and the proportion of CAs among stillbirths and live births, except in Poland, where neonatal deaths associated with CAs were more frequent, reflecting restrictive pregnancy termination policies. CONCLUSION: Proportions of TOP among very preterm births varied widely between European regions. Information on terminations should be reported when very preterm live births and stillbirths are compared internationally since national policies related to screening for CAs and the legality and timing of medical terminations differ.

The association between developmental handicaps and traumatic brain injury during pregnancy: an issue that deserves more systematic evaluation.

AIMS: Trauma during pregnancy is commonly viewed as benign for the foetus when the delivery occurs normally. This study revisits that point of view. METHOD: We included eighteen patients having a neurological handicap with an anamnesis of an accident during pregnancy and a follow-up sufficient to determine a definite outcome. RESULTS: Pregnancy outcome and observed management. Foetal abnormalities were detected in six cases between the first and the thirteenth day after the trauma. Emergency delivery or rapid birth after signs of foetal distress occurred in five cases. One baby died soon after birth. One-third of cases were not submitted to any investigation. VARIOUS NEUROLOGICAL HANDICAPS WERE RECORDED: Congenital microcephaly (three patients), congenital hydrocephalus (three), Infantile cerebral hemiplegy (six), quadriplegy with severe encephalopathy (four), diplegy (one), clumsiness with cerebellar atrophy (one), Moebius syndrome (one), mental retardation with autistic features (two), learning disability (one) auditory agnosia (one). Cerebral imaging showed macroscopic abnormalities in fourteen patients, evoking various pathogenetic hypotheses. CONCLUSION: The association between maternal trauma and foetal brain lesions lacks sufficient investigation in many cases. Prospective studies are needed to clarify both medical and legal issues. Guidelines are proposed for obstetrical and paediatric management after significant maternal trauma.

[Obstetrical outcome in 454 women exposed to diethylstilbesterol during their fetal life: a case-control analysis]. / Résultats obstétricaux de 454 femmes exposées au diéthylstilboestrol pendant leur vie foetale: analyse cas-témoins.

OBJECTIVE: To analyze the predictive effect on obstetrical outcome in women with prenatal exposure to diethylstilbestrol (DES) of previous obstetrical history or the specific risk of DES exposure. PATIENTS AND METHODS: We included all in utero DES-exposed women (454 women) followed and delivered at one maternity unit in Paris and compared them with two control women matched for age, parity, number of late fetal losses, number of previous preterm births, number of singleton or twin fetuses, and follow-up, who were managed by the same team or referred for pregnancy complication. RESULTS: DES women had a higher rate of preterm birth (19.2%) than matched controls (10.5%), even when considering women with a previous preterm birth or twin pregnancy. The rate of fetal or neonatal deaths were lower in DES-exposed women than in controls. DES women showed a higher rate of severe post partum bleeding (2.8%) than matched controls (1.5%) or the global population of women delivered in this maternity unit. CONCLUSION: A history of prenatal exposure to DES is a major predictor of preterm birth for primiparous women and for those with an adverse obstetrical history.

Preterm birth and maternal country of birth in a French district with a multiethnic population.

OBJECTIVES: This analysis explores the association between preterm birth and maternal country of birth in a French district with a multiethnic population. DESIGN: Prospective observational study. SETTING: District of Seine-Saint-Denis in France POPULATION: 48,746 singleton live births from a population-based birth register between October 1998 and December 2000. METHODS: We compare preterm birth rates by mother's country of birth controlling for demographic and obstetric factors as well as insurance coverage and timing of initiation of antenatal care. MAIN OUTCOME MEASURES: Overall preterm birth rates and preterm birth rates by timing of delivery (<33 weeks versus 33-36 weeks of gestation), mode of onset (spontaneous or indicated preterm birth) and the presence of hypertension in pregnancy. RESULTS: Women born in Northern Africa, Southern Europe and South/East Asia did not have higher preterm birth rates than women born in continental France. Rates were significantly higher for women born in the overseas French districts in the Caribbean and Indian Ocean and Sub-Saharan Africa. Excess risk was greatest for early preterm births, medically indicated births and preterm births associated with hypertension. CONCLUSIONS: Patterns of preterm birth with relation to timing, mode of onset and medical complications among of Afro-Caribbean origin should be confirmed in future research.

Maternal predictors of subcutaneous fat in the term newborn.

AIM: To determine the relative influences of some maternal factors on skinfold thickness. The effects of age, parity, height, body mass index (BMI) and pregnancy weight gain (PWG) of the mother on the subscapular skinfold thickness (SST) of the newborn were estimated, and compared with their effects on birthweight (BW), crown-heel length (CHL) and head circumference (HC). METHODS: A sample of 13, 972 healthy, term singletons was selected at the Clamart Maternity Hospital (France). Stepwise regressions were used to determine the most predictive maternal factors for each parameter in the newborn. The respective effects of the mother's age and parity on each newborn dimension were tested by analysis of variance. RESULTS: The SST is a singular parameter, influenced by the mother's BMI and PWG, but not by her height. In contrast, the main predictor of BW, CHL and HC is the height of the mother, and to a lesser extent her PWG and BMI. Parity and maternal age have a smaller effect, except on SST, and essentially between the first and second pregnancies. CONCLUSION: These results clearly separate SST from other newborn dimensions. The skinfold thickness depends only on the nutritional status of the mother, while other dimensions are markedly influenced by the genetic background. This study is the first to demonstrate the singularity of skinfold thickness in newborn infants as a marker of the mother's nutritional status.

Employment, working conditions, and preterm birth: results from the Europop case-control survey.

STUDY OBJECTIVE: To analyse the relation between preterm birth and working conditions in Europe using common measures of exposure and to test whether employment related risks varied by country of residence. DESIGN: A case-control study in which cases included all consecutive singleton preterm births and controls included one of every ten singleton term births in each participating maternity unit. Data about working conditions were obtained by interview from women after delivery. SETTING: Sixteen European countries. PARTICIPANTS: The analysis included 5145 preterm and 7911 term births of which 2369 preterm and 4098 term births were to women employed during pregnancy. Analyses of working conditions were carried out for women working through at least the third month of pregnancy. MAIN RESULTS: Employed women did not have an excess risk of preterm birth. Among working women, a moderate excess risk was observed for women working more than 42 hours a week (OR = 1.33, CI = 1.1 to 1.6), standing more than six hours a day (OR = 1.26, CI = 1.1 to 1.5), and for women with low job satisfaction (OR = 1.27, CI = 1.1 to 1.5). There were stronger links in countries with a lower overall level of perinatal health and a common practice of long prenatal leaves. CONCLUSION: These findings show that specific working conditions affect the risk of preterm birth. They also suggest employment related risks could be mediated by the social and legislative context.

Effect of positioning on the incidence of abnormalities of muscle tone in low-risk, preterm infants.

UNLABELLED: BACKGROUND. The preterm infant is subject to the force of gravity: when its body lies pressed against the mattress on which it is placed. AIMS: The purpose of this study was to investigate short-term effects of varied post-natal lying positions in order to prevent neuromuscular and postural abnormalities. METHODS: 60 low risk preterm infants of 31-36 weeks gestational age were enrolled for this randomised clinical trial. Initially each child underwent neurological and psychomotor assessments which included tonus and reflex protocols as well as behavioral, sensory motor and postural examinations. The lying positions of the treated group were varied (back, prone, and side) using a specially designed moldable mattress that maintained the functional position of the infant's body. The control group was placed on their stomachs, (the standard lying position used in 1994) with a standard orthopaedic bolster support under their hips. All infants underwent a second round of examinations upon discharge to assess any changes in neurological and psychomotor outcomes. RESULTS: The sensory-motor skills examinations showed significant abnormalities in the control group: (1) dominance of the extensor muscles due to muscle shortening, (2) hyper abduction and flexion of the arms, and (3) global neuromuscular rigidity. Psychomotor and neurological exams of the control and treatment groups showed delayed developmental muscular acquisitions for infants in the control group. CONCLUSION: Regular changes in posture, while retaining correct functional positions, allowed maintenance of normal neuromuscular and osteo-articular function and permitted the development of spontaneous and functional motor activity in low-risk perterm infants.

[When the pregnant woman risks iodine deficiency]. / Quand la femme enceinte risque d'être en manque d'iode.

There may be situations in France were women do not have sufficient iodine intake during pregnancy. The nutritional needs for iodine are increased during pregnancy, mostly during the first trimester, for the use of the mother and the embryo and fetus. In France, a deficiency in available iodine has been demonstrated in the general population and in a population of pregnant women. Iodine deficiency may affect the mother (goiter, high TSH, low thyroxin levels) and new information points to a risk of retarded development in children born to women with low thyroxin levels during the first and second trimesters of pregnancy. Iodine deficiency can also induce transient high TSH levels in the newborn. The question raised by these new established facts is whether iodine supplementation should be proposed for all pregnant women, and this before the second trimester of pregnancy. Systematic screening for thyroid deficiency might also be useful at the end of the first trimester of pregnancy.

Bacterial vaginosis: prevalence and predictive value for premature delivery and neonatal infection in women with preterm labour and intact membranes.

OBJECTIVES: Assess the predictive values of bacterial vaginosis (BV) for preterm delivery (PD) and neonatal infection and compare them with standard markers of infection among women with preterm labour (PL). STUDY DESIGN: Prospective blinded study in a tertiary referral centre in Paris. Women hospitalised for PL with intact membranes at a term between 24 and 34 weeks were included. Vaginal fluid, collected at inclusion was Gram-stained, scored, and interpreted according to Nugent's criteria. RESULTS: Out of 354 women tested, 254 had normal flora (72.3%), 76 intermediate (21.7%) and 24 BV (6.8%). A history of spontaneous miscarriage after 14 weeks was the only risk factor significantly associated with BV. BV was not significantly associated with PD<35 weeks or neonatal infection. Very preterm delivery (before 33 weeks) was significantly associated with the flora grade (P=0.02): women with normal, intermediate and abnormal flora, respectively had 27 (10.6%), 14 (18.4%) and 6 (25.0%) births before 33 weeks. Of the markers tested, the highest risk of very preterm delivery was associated with BV (odds ratio 2.95, 95% CI (1.1-0.8.1)) and CRP>20mg/dl (4.23 95% CI (1.8-9.7)). Predictive value of BV for preterm birth before 33 weeks were: sensitivity 12.8%, specificity 95.0%, positive predictive value 35.3%, and negative predictive value 84.3%. CONCLUSIONS: The frequency of BV and its association with PD are probably very variable and must be interpreted differently from one population to another. While we found an association between BV results and delivery before 33 weeks, the predictive value of BV was disappointing. Although these findings reinforce the importance of a useful marker of subclinical infection, the usefulness of testing for BV in women with PL has not been demonstrated.

Preterm birth in a French population: the importance of births by medical decision.

This analysis describes the prevalence of preterm birth by medical decision among 50,307 live births from the district of Seine-Saint-Denis in France, using a classification that distinguishes between medically decided preterm births associated with premature rupture of membranes and those for other reasons. Thirty-seven percent of singleton and 28% of twin preterm births result from labour induction or a caesarean section in the absence of labour. One-quarter of singleton indicated preterm births are associated with premature rupture of membranes. Between 28 and 31 weeks of gestation, 40% of all singleton preterm births result from a medical decision not associated with premature rupture of membranes. The high levels of indicated preterm birth must be taken into account in evaluations of preterm birth rates and trends in developed countries.

[Regionalization of very preterm birth care sites in Ile-de France in 1998]. / Action de régionalisation des sites de naissance des grands prématurés en Ile-de-France en 1998.

The objective of this article is to describe the conditions under which very premature babies were born in the Paris region between June 1 and December 31, 1998, that is to say those born prior to reaching 33 weeks of term (SA) and/or having a birth weight less than 1500 grams. The study looked at all pre-term births, including medical terminations of pregnancy (TOP), occurring in one of the 135 maternity units in the Paris region. Between June 1 and December 31, 1998, 1337 mothers gave birth to babies prior to reaching 33 weeks of term (SA) and/or having a birth weight less than 1500 grams in 84 maternity units in the Paris region, 263 of which had a medical termination of pregnancy (20%). These mothers were older than average for the region (25% were 35 years old or older); 4.3% of them do not have social insurance coverage. The remaining 1074 mothers (excluding TOP) gave birth to 1290 children, of which 202 were stillbirths, 46 died in the labor ward and 1042 were admitted to a neo-natal unit. Of the same group of 1074 mothers, 195 (18%) had a multiple pregnancy--175 twins, 19 triplets, and 1 quadruplet 60% of them (599 women) who had very premature or low birth weight babies (excluding TOPs) delivered them in a tertiary perinatal centre (TPC). This proportion varies according to two variables: 1) the community in which the family lives (40% in the Seine-et-Marne department, the eastern region of Paris and a district without TPCs, to 70% in the Hauts-de-Seine, a northern district), and 2) whether the pregnancy is single (58.8%), twin (72.6%) or triple (84.2%). In utero transfer accounts for 62.7% of the mothers who delivered in TPC, who were transferred prior to delivery. This type of study is useful for measuring the implementation of the regionalisation high-risk perinatal care and access to adequate services. It clearly demonstrates that inequities in access to care exist for women by district of residence.