Is laterality of congenital diaphragmatic hernia a reliable prognostic factor? French national cohort study.

OBJECTIVES: The objective of this study was to assess whether the laterality of congenital diaphragmatic hernia (CDH) was a prognostic factor for neonatal survival. METHODS: This was a cohort study using the French national database of the Reference Center for Diaphragmatic Hernias. The principal endpoint was survival after hospitalization in intensive care. We made a comparative study between right CDH and left CDH by univariate and multivariate analysis. Terminations and stillbirths were excluded from analyses of neonatal outcomes. RESULTS: A total of 506 CDH were included with 67 (13%) right CDH and 439 left CDH (87%). Rate of survival was 49% for right CDH and 74% for left CDH (P < .01). Multivariate analysis showed two factors significantly associated with mortality: thoracic herniation of liver (OR 2.27; IC 95% [1.07-4.76]; P = .03) and lung-to-head-ratio over under expected (OR 2.99; IC 95% [1.41-6.36]; P < .01). Side of CDH was not significantly associated with mortality (OR 1.87; IC 95% [0.61-5.51], P = .26). CONCLUSION: Rate of right CDH mortality is more important than left CDH. Nevertheless after adjusting for lung-to-head-ratio and thoracic herniation of liver, right CDH does not have a higher risk of mortality than left CDH.

An Automatic Method for the Segmentation and Classification of Imminent Labor Contraction From Electrohysterograms.

OBJECTIVE: Preterm birth is the first cause of perinatal morbidity and mortality. Despite continuous clinical routine improvements, the preterm rate remains steady. Moreover, the specificity of the early diagnosis stays poor as many hospitalized women for preterm delivery threat finally deliver at term. In this context, the use of electrohysterograms may increase the sensitivity and the specificity of early diagnosis of preterm labor. METHODS: This paper proposes a clinical application of electrohysterogram processing for the classification of patients as prone to deliver within a week or later. The approach relies on non-linear correlation analysis for the contraction bursts extraction and uses computation of various features combined with the use of Gaussian mixture models for their classification. The method is tested on a new dataset of 68 records collected on women hospitalized for preterm delivery threat. RESULTS: This paper presents promising results for the automatic segmentation of the contraction and a classification sensitivity, specificity, and accuracy of, respectively, 80.7%, 76.3%, and 76.2%. CONCLUSION: These results are in accordance with the gold standards but have the advantage to be non-invasive and could be performed at home. SIGNIFICANCE: Diagnosis of imminent labor is possible by electrohysterography recording and may help in avoiding over-medication and in providing better cares to at-risk pregnant women.

Impact of establishment of a color code in emergency caesareans in secondary health care maternity.

In 2008, a tertiary health care maternity set up a colour code organization for emergency caesarean to reduce the delay between decision and birth to thirty minutes. The aim of this study is to determine the feasibility of the implementation in secondary health care maternity. MATERIALS AND METHODS: This retrospective study was conducted in secondary health care maternity and it was divided in two phases: phase I corresponding to the period before the implementation of colour code and phase II, to the period after the implementation of colour code. All patients who had an emergency caesarean were included. Then, we compared the decision to birth delay between the two phases and the neonatal state. RESULTS: Two hundred and twenty patients were included (one hundred and thirteen for the first phase and one hundred and seven for the second). The rate of caesarean sections realized within thirty minutes was no different between two groups. Decision to birth delay is variable and tends to decrease between two phases (-7 min for orange code, p = 0.91; and -15 min for red code, p = 0.0769). The medium pH is the same in both groups (7.30, p = 0.22) and the rate of transfer in neonatology is 29% for the first group and 13% in the second (p = 0.004) CONCLUSION: This protocol has resulted in better care for patients who had an emergency caesarean section. Two elements are to be noticed as follows: a reduction of decision to birth delay for extremely emergency caesarean (p = 0.0769) and less transfer in neonatology (p = 0.004).

One-Year Outcome for Congenital Diaphragmatic Hernia: Results From the French National Register.

OBJECTIVE: To evaluate the status of congenital diaphragmatic hernia (CDH) management in France and to assess predictors of adverse outcomes. STUDY DESIGN: We reviewed the first-year outcome of all cases of CDH reported to the French National Register in 2011. RESULTS: A total of 158 cases were included. Of these, 83% (131) were prenatally diagnosed, with a mortality rate of 39% (44 of 112) for live born infants with a known outcome at hospital discharge. Mortality increased to 47% (60 of 128) including those with termination of pregnancy and fetal loss. This contrasts with the 7% (2 of 27) mortality rate of the patients diagnosed postnatally (P = .002). Mortality worsened with 1 prenatal marker of CDH severity (OR 3.38 [1.30-8.83] P = .013) and worsened further with 2 markers (OR 20.64 [5.29-80.62] P < .001). Classic postnatal risk factors of mortality such as side of hernia (nonleft P = .001), prematurity (P < .001), low birth weight (P = .002), and size of the defect (P < .001) were confirmed. Of the 141 live births (114 prenatal and 27 postnatal diagnosis) with known outcomes, 93 (67%) survived to hospital discharge, 68 (60%) with a prenatal diagnosis and 25 (93%) with a postnatal diagnosis. The median time to hospital discharge was 34 days (IQR, 19.25-62). Of these survivors, 71 (76%) were followed up for 1 year. CONCLUSIONS: Despite advances in management of CDH, mortality was high and associated with prenatal risk factors. Postnatally, severe persistent pulmonary hypertension was difficult to predict and presented persistent challenges in management.

Maintenance nifedipine therapy for preterm symptomatic placenta previa: A randomized, multicenter, double-blind, placebo-controlled trial.

OBJECTIVE: To assess the impact of maintenance nifedipine therapy on pregnancy duration in women with preterm placenta previa bleeding. METHODS: PPADAL was a randomized, double-blind, placebo-controlled trial conducted between 05/2008 and 05/2012 in five French hospitals. The trial included 109 women, aged ≥ 18 years, with at least one episode of placenta previa bleeding, intact membranes and no other pregnancy complication, at gestational age 24 to 34 weeks and after 48 hours of complete acute tocolysis. Women were randomly allocated to receive either 20 mg of slow-release nifedipine three times daily (n = 54) or placebo (n = 55) until 36 + 6 weeks of gestation. The primary outcome for the trial was length of pregnancy measured in days after enrolment. Main secondary outcomes were rates of recurrent bleeding, cesarean delivery due to hemorrhage, blood transfusion, maternal side effects, gestational age at delivery and adverse perinatal outcomes (perinatal death, chronic lung disease, neonatal sepsis, intraventricular hemorrhage > grade 2, perventricular leukomalacia > grade 1, or necrotizing enterocolitis). Analysis was by intention to treat. RESULTS: Mean (SD) prolongation of pregnancy was not different between the nifedipine (n = 54) and the placebo (n = 55) group; 42.5 days ± 23.8 versus 44.2 days ± 24.5, p = 0.70. Cesarean due to hemorrhage performed before 37 weeks occurred more frequently in the nifedipine group in comparison with the placebo group (RR, 1.66; 95% confidence interval, 1.05-2.72). Adverse perinatal outcomes were comparable between groups; 3.8% for nifedipine versus 5.5% for placebo (relative risk, 0.52; 95% confidence interval 0.10-2.61). No maternal mortality or perinatal death occurred. CONCLUSION: Maintenance oral nifedipine neither prolongs duration of pregnancy nor improves maternal or perinatal outcomes. TRIAL REGISTRATION: ClinicalTrials.gov NCT00620724.

Better pregnancy monitoring using nonlinear correlation analysis of external uterine electromyography.

The objective of this paper is to evaluate the novel method for analyzing the nonlinear correlation of the uterine electromyography (EMG). The application of this method may improve monitoring in pregnancy, labor detection, and preterm labor detection. Uterine EMG signals recorded from a 4 × 4 matrix of electrodes on the subjects' abdomen are used here. The propagation was analyzed using the nonlinear correlation coefficient h(2). Signals from 49 women (36 during pregnancy and 13 in labor) at different gestational age were used. ROC curves were computed to evaluate the potential of three methods to differentiate between 174 contractions recorded during pregnancy and 115 contractions recorded during labor. The results indicate considerably better performance of the nonlinear correlation analysis (area under curve = 0.85) when compared to classical frequency parameters (area under curve = 0.76 and 0.66) in distinguishing labor contractions from normal pregnancy contractions. We conclude that the analysis of the propagation of the uterine electrical activity using the nonlinear correlation coefficient h(2) is a promising way of improving the usefulness of uterine EMG signals for clinical purposes, such as monitoring in pregnancy, labor detection, and prediction of preterm labor.