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Évaluer chez l’enfant né prématuré les bénéfices neuroprotecteurs et les risques de l’administration anténatale de sulfate de magnésium (MgSO4) aux femmes à risque imminent d’accouchement prématuré.

Déterminer les mesures permettant de prévenir la prématurité spontanée et ses conséquences (hors rupture des membranes).

Déterminer les mesures permettant de prévenir la prématurité spontanée et ses conséquences (hors rupture des membranes).

To determine the impact of clinical and/or histological chorioamnionitis on neurodevelopmental outcomes in premature infants.

Déterminer les mesures permettant de prévenir la prématurité spontanée et ses conséquences (hors rupture des membranes).

Faire la synthèse des connaissances sur l’incidence et sur certains facteurs de risque de la prématurité. Décrire la morbi-mortalité néonatale et le devenir des enfants nés prématurément selon l’âge gestationnel et le contexte de naissance.

Évaluer chez l’enfant né prématuré les bénéfices neuroprotecteurs et les risques de l’administration anténatale de sulfate de magnésium (MgSO4) aux femmes à risque imminent d’accouchement prématuré.

La prématurité (naissance avant 37 semaines d’aménorrhée révolues) concerne dans le monde environ 15 millions d’enfants par an – soit 11 % des naissances vivantes –, dont 60 000 en France. Quatre-vingt-cinq pour cent d’entre eux relèvent de la prématurité modérée (32–33 SA) ou tardive (34–36 SA), 10 % de la grande prématurité (28–31 SA) et 5 % de la très grande prématurité (< 28 SA). Bien qu’en diminution, la mortalité néonatale reste élevée et dépend fortement de l’âge gestationnel à la naissance (mortalité supérieure à 10 % à < 28 SA, 5–10 % à 28–31 SA, 1–2 % à 32–34 SA). La morbidité néonatale sévère et les handicaps dans l’enfance sont également fréquents et concernent, à des degrés divers, tous les âges gestationnels. Même tardive, la prématurité ne doit pas être banalisée. Ainsi, les risques de handicap moteur ou de déficience intellectuelle sont 2 à 3 fois plus élevés chez les enfants nés à 34–36 SA que chez les enfants nés à terme. Les cohortes récentes ont mis l’accent sur le suivi des très grands prématurés ; pour autant l’évaluation du devenir reste essentielle à tous les âges gestationnels. Les modalités de prise en charge et le pronostic sont très variables, que ce soit entre les pays industrialisés et ceux en développement, mais également au sein des pays à haut niveau de soins.

Epithelial-to-mesenchymal transition (EMT) of tubular epithelial cells (TECs) may participate in the pathogenesis of renal fibrosis. We performed a prospective study of EMT markers in protocol biopsies obtained 3 months after engraftment from 56 patients who received deceased donor kidneys and who had stable renal function. The presence of EMT was examined, and quantified by immunohistochemical staining for vimentin and translocation of β-catenin to the cytoplasm. EMT status was defined as the presence of EMT markers in ≥10% of TECs. EMT features were virtually absent in implantation biopsies, whereas 41% of the grafts were EMT-positive in the absence of advanced chronic allograft nephropathy. Thirteen patients (23%) had borderline changes or acute rejection. EMT features were more frequent in these patients than in those with normal kidney grafts (vimentin expression, p = 0.003; β-catenin translocation, p = 0.002). EMT in grafts corresponded with elevated serum creatinine of the donor before the recovery of kidney (p = 0.02) and longer cold ischemia time (p = 0.02). In contrast, the donor age had no influence on the expression of EMT markers. These results suggest that EMT is an early and frequent phenomenon in kidney transplants that could be triggered by immunological and/or ischemic tubular injury.

Data from a case-control survey in Europe, carried out between 1994 and 1997, were used to investigate the risk factors for spontaneous abortions at 14-21 weeks (late abortions), according to the vital status of the fetus before the onset of labour. Late abortions included 62 involving a fetus alive before the onset of labour, 216 late abortions of a fetus already dead, together with 4592 control pregnancies at term (>/=37 weeks) from seven countries. Histories of induced abortion, spontaneous abortion and preterm birth were more closely associated with late abortion of a live fetus than with late abortion of a dead fetus. Women aged >/=35 years and women living alone had a much higher risk of late abortions than women aged 20-24 years and married women, regardless of the vital status of the fetus before labour. These results provide evidence that obstetric history and socio-demographic factors are risk factors for late abortions but differences are observed according to the vital status of the fetus before labour.

The objective of this study was to identify the prognostic factors for conception after myomectomy carried out in cases of infertility. A total of 91 infertile patients presenting at least one subserous or intramural myoma measuring >2 cm underwent myomectomy. The characteristics of the patients, myomata and associated infertility factors were collected in a uniform and systematic way. A postal questionnaire was sent to patients. For each of the various factors studied, the specific cumulative probability of spontaneous intrauterine conception was estimated using the Kaplan-Meier method. Multiple regression analysis was then carried out using Cox's proportional hazards model. The cumulative probability of spontaneous intrauterine conception at 2 years follow-up was 44% (95% confidence interval: 32-56%). The cumulative probability of conception was less after removal of a posterior or intramural myoma, after a sutured hysterotomy, and when accompanied by a male factor, associated tubal or ovulation pathology. The cumulative probability of conception was greater after ablation of myomata responsible for menometrorrhagia. The size, deforming effect on the cavity and age played no role in our sample. Our results indirectly suggest that post myomectomy adhesions could have an adverse effect on fertility. Myomata responsible for menometrorrhagia are also the cause of infertility. In the presence of an associated male, tubal or ovulatory factor, the results were poor and it was not possible to determine if a myomectomy should be performed in these cases in order to enhance fertility.

Objective To test whether being small for gestational age, defined as having a birthweight less than the 10th centile of intrauterine growth references, is a risk factor for preterm delivery for singleton live births.

Study objectiveTo analyse the relation between unemployment and the psychological distress of mothers one year after childbirth.DesignMulticentric survey concerning births occurring between September 1993 and July 1994.SettingIn France: two maternity units in the Parisian area and one in Champagne-Ardennes, in the east of France, comprising both urban and rural areas.ParticipantsPrimipara and secondipara women were interviewed three times: at birth by a face to face interview, five months and 12 months after the birth, by postal questionnaires, with a 83% response rate for the two postal questionnaires. The analysis includes 632 women who answered all three stages of the survey.MeasurementsPsychological distress was mainly assessed one year after birth by the 12-item General Health Questionnaire.ResultsAfter adjustment for unwanted pregnancy, marital conflicts, marital status, hospitalisation of the baby during the last year, lack of confiding relationship, depressive or anxious troubles before pregnancy, age, educational level and parity, unemployed women had an excess of psychological distress compared with employed women (OR = 1.87; 95%CI = 1.12, 3.13). The ratios for housewives were very close to those of employed women. Among the unemployed women, 60% had recently been without a job, since a few months before or after the birth. An excess of psychological distress among unemployed compared with employed women was observed in all social groups defined by the current or last occupation, but with various extents. Psychological distress was specially linked to the employment status in the group of women with the more qualified occupations.ConclusionEven after a birth, when women are very much involved in their maternal role, those seeking a job have worse mental health than those in a stable situation, either employed or housewives. In France, the unemployment rate among young women is high. It is specially important that social regulations protecting employment during and after pregnancy are adequately applied. Employers, legislators, such as medical doctors, have to be aware to this situation.

Identifier les facteurs précoces associés aux difficultés d’endormissement (DE), réveils nocturnes (RN) et insomnie (IS) à 1 an chez les enfants nés prématurés≤34SA.

La prévalence des naissances prématurées a augmenté ces dernières années, résultant en une augmentation du nombre d’enfants à risque de déficience chez les survivants. Les services de suivi facilitent la détection précoce des complications potentielles, et permettent une intervention précoce. Cependant, peu d’information existe sur les facteurs qui pourraient influencer l’utilisation de ces services en France. L’objectif était d’étudier les facteurs associés au suivi organisé entre la sortie de l’hôpital et l’âge de 1 an, chez les enfants issus de grossesse unique très (24 à 31 semaines d’aménorrhée) et modérément (32 à 34 semaines d’aménorrhée) prématurés.

Background: Being born small for gestational age (SGA) is associated with developmental disabilities but associations may vary depending on the definition of SGA.Aim: To analyse the impact of this definition on the relation between SGA and cognitive or school outcome.Methods: 980 singletons born before 33 weeks in 1997 in France, part of the Epipage study, free of cerebral palsy, were classified SGA when birth weight was < 10thpercentile, according to 3 French standards: 1. neonatal standard: nSGA or nAGA; 2. intrauterine standard using Hadlock's formula: fSGA or fAGA; 3. customised standard taking into account maternal characteristics: cSGA or cAGA.Outcomes were cognitive dysfunction at age 5 defined as a score < -1 SD for the term control group (K-ABC battery), and school difficulties at age 8.Results: 149 children were nSGA (15.2 %), 368 fSGA (37.6 %) and 378 (38.6 %) cSGA. All nSGA children were fSGA and cSGA. Cognitive dysfunction was present in 300 children (35.0 %) and school difficulties in 173 (25.1 %). Children nAGA/fSGA did not have a significant increase of cognitive dysfunction compared to children nAGA/fAGA. Compared to children nAGA/fAGA, children nSGA/fSGA had an adjusted OR of school difficulties of 2.48 [1.52;4.05] while it was 1.63 [1.05;2.55] for children nAGA/fSGA. Children fAGA/cSGA (N=18) had a higher rate of school difficulties compared to children fAGA/cAGA (p=0.03).Conclusions: Intratuerine standard for birth weight is more appropriate than neonatal one to predict school outcome for very preterm singletons. The utility of customisation should be clarified.

Background and aims: PTB and CHD are the two main causes of mortality, morbidity and disability of perinatal origin. There are little population-based data on the relation between CHD and PTB. The objective of this study was to estimate the prevalence of prematurity in newborns with CHD and to study specific associations between subcategories of CHD and PTB.Methods: We used data from the EPICARD study, a population-based cohort study of CHD in France, including 2349 livebirths with CHD. We used an anatomic and clinical classification of CHD based on the International Paediatric and Congenital Cardiac Code to categorise CHD into ten groups. Data on PTB from the French National Perinatal Survey were used to compare PTB in EPICARD to that of the general population.Results: 15% (95%CI, 13.6-16.5) of the newborns with CHD were PTB and the odds of PTB was more than two fold higher than for general population (OR 2.3 95%CI, 1.8-2.8). The higher risk of PTB, and particulary very PTB (< 32 weeks), associated with CHD persisted after exclusion of cases associated with chromosomal anomalies and/or non-cardiac defects and adjustement for maternal age, sociodemographic characteristics and diabetes. There were wide variations in PTB across the ten groups examined.Conclusion: In this population-based study, the risk of PTB and particulary very PTB was substancially higher for newborn with CHD. Risk of PTB varied highly for subcategories of CHD and the specific associations oberved may be helpful for generating hypotheses about the developemental links between CHD and PTB.

Background: It seems adequate to relieve pain in newborns and necessary to evaluate the benefit/risk ratio of this therapy.Is there a relationship between prolonged S/A and long-term outcome of extremely preterm infants?Objective: Evaluation of association between prolonged S/A and 4-year outcome of preterms in EPIPAGE cohort.Method: Based on a propensity score, preterms were divided in 2 groups according to the probability of needing prolonged S/A :low ( < 20 % ) or high probability ( >/=20 % ). Dependent variable was S/A. Independent variables were CRIB score, prematurity, ventilation, surgery and postnatal corticotherapy. 4-year outcome was classified as: death, alive at 4 years with or without difficulties (cerebral palsy, developmental problem considered by parents or difficulties at school).Results: Information on S/A was recorded in 2441 newborns alive at discharge. Without taking account propensity score, 35.5 % and 75.5 % of preterms with or without prolonged S/A respectively had no difficulties at 4-year follow-up.Conclusion: Prolonged S/A is associated with a poor 4-year outcome in preterm newborns.But this may be explained by the severity of the illness.

Background: The objectives of our study were to estimate the prevalence of cerebral palsy and sensorineural impairments in very preterm infants born between 22 and 32 weeks of gestation at two years of age and to study its variations according to gestational age and brain lesions in the neonatal period. The subtype and the level of severity of cerebral palsy are also studied.Methods: All births occurring from 22 to 32 weeks of gestation in all maternity wards of nine French regions in 1997 were included in the EPIPAGE cohort study. Neurodevelopmental status, including cerebral palsy, blindness and deafness, diagnosed at two years of age, were available for 1950 children (83% of the population enrolled in the follow-up). Impairments have been identified from the medical examination at two years of age.Results: The incidence of cerebral palsy was 8% [95% Confidence Interval CI: 7%–10%] in very preterm infants; 44% of the children had diplegia, 28% had tetraplegia, 9% had hemiplegia, 10% had monoplegia and 7% ataxia or dyskinesia. Two percent of the children have not been classified. Of all children with cerebral palsy, half did not walk at two years. The incidence of cerebral palsy decreased from 21% at 24–26 weeks, 12% at 27–28 weeks, 8% at 29–30 weeks to 5% at 31–32 weeks. The cerebral palsy rate was higher in boys (9%) than in girls (7%) (p=0.10) and was higher in twins (18%) than in singletons (14%) before 29 weeks. After 29 weeks, rates were the same (6%). Neonatal cerebral injuries were strongly associated with cerebral palsy: 74% of children with bilateral cystic leukomalacia and 60% of children with grade IV intraventricular hemorrhage had cerebral palsy. Only 4% of children without brain lesions had cerebral palsy. The overall rates of blindness and deafness were 0.5% [IC: 0.2%– 0.9%] and 0.8% [IC: 0.4%–1.2%] respectively.Conclusion: Our study evaluated the neurological outcome of a large cohort of very preterm infants, which is of particular interest given the recent advances in perinatal care and the question of the quality of survival.