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Maternity ward staff face complex situations, handling not only births, but sometimes also deaths. When a serious condition is revealed during the prenatal diagnosis, an abortion may be requested, but other parents choose to keep their disabled child. In such cases, healthcare professionals must support parents in learning about this "different" child.

Analgesics are required to prevent and treat postpartum pain, but breast-feeding may be contraindicated, because data on milk transfer are very limited. The present study was undertaken to quantify the transfer of ketoprofen and nalbuphine in milk. Eighteen patients gave their informed consent to participate and completed the study. Following delivery, they received ketoprofen (100 mg/12 hours) and nalbuphine (0.2 mg/kg/4 hours) as an intravenous bolus over 2 to 3 days for postpartum pain. Milk samples were collected during the 12 hours between the third and fourth ketoprofen administrations. Ketoprofen and nalbuphine concentrations were determined with high-performance liquid chromatography. The mean and maximum ketoprofen milk concentrations were 57+/-37 and 91+/-51 ng/mL, respectively. Assuming a milk volume of 150 mL/kg/day, the mean and maximum doses that a breast-fed neonate would ingest during one day are 8.5+/-5.5 and 13.6+/-7.6 microg/kg/day, respectively, and the relative infant dose is 0.31+/-0.17% of the weight-adjusted maternal daily dose. The mean and maximum nalbuphine milk concentrations were 42+/-26 and 61+/-26 ng/mL, respectively. Assuming a milk volume of 150 mL/kg/day, the mean and maximum doses that a breast-fed neonate would ingest during one day is 7.0+/-3.2 and 9.0+/-3.8 microg/kg/day, and the relative infant dose is 0.59+/-0.27% of the weight-adjusted maternal daily dose. Therefore, breast-feeding is permissible when ketoprofen and/or nalbuphine are administered to the mother to treat postpartum pain.

Background: Fetuses from mothers with Graves' disease may experience hypothyroidism or hyperthyroidism due to transplacental transfer of antithyroid drugs (ATD) or anti-TSH receptor antibodies, respectively. Little is known about the fetal consequences. Early diagnosis is essential to successful management. We investigated a new approach to the fetal diagnosis of thyroid dysfunction and validated the usefulness of fetal thyroid ultrasonograms., Methods: Seventy-two mothers with past or present Graves' disease and their fetuses were monitored monthly from 22 wk gestation. Fetal thyroid size and Doppler signals, and fetal bone maturation were determined on ultrasonograms, and thyroid function was evaluated at birth. Thyroid function and ATD dosage were monitored in the mothers., Results: The 31 fetuses whose mothers were anti-TSH receptor antibody negative and took no ATDs during late pregnancy had normal test results. Of the 41 other fetuses, 30 had normal test results at 32 wk, 29 were euthyroid at birth, and one had moderate hypothyroidism on cord blood tests. In the remaining 11 fetuses, goiter was visualized by ultrasonography at 32 wk, and fetal thyroid dysfunction was diagnosed and treated; there was one death, in a late referral, and 10 good outcomes with normal or slightly altered thyroid function at birth. The sensitivity and specificity of fetal thyroid ultrasound at 32 wk for the diagnosis of clinically relevant fetal thyroid dysfunction were 92 and 100%, respectively., Conclusion: In pregnant women with past or current Graves' disease, ultrasonography of the fetal thyroid gland by an experienced ultrasonographer is an excellent diagnostic tool. This tool in conjunction with close teamwork among internists, endocrinologists, obstetricians, echographists, and pediatricians can ensure normal fetal thyroid function.

Perinatal asphyxia is a common emergency for both obstetricians and pediatricians. A prospective study was conducted in 14 maternity hospitals (type II centres) in the Paris suburbs in order to assess pediatric activity and neonatal morbidity associated with supposed perinatal asphyxia in term newborns. Pediatricians were called in at birth very frequently: 1/20 deliveries. Intubation and/or resuscitation procedures were needed in 20% of cases and 20% of infants were referred to a neonatal unit for birth asphyxia or associated pathology. Moderate encephalopathy was observed in 1.5% of all term newborns who needed medical intervention for supposed birth asphyxia.

Despite sonographic detection of foetal goitre, uncertainty persists in the initial diagnosis of thyrotoxicosis and hypothyroidism. The aim of this study was to establish foetal and neonatal iodothyronine and thyrotrophin reference values for the ACS-180SE analyser. From 22 to 36 weeks of gestation, median foetal serum free thyroxine (FT4) levels increased from 6.0 pmol/L to 143 pmol/L, while free tri-iodothyronine (FT3) levels increased from 0.7 pmol/L to 1.9 pmol/L and mean thyrotrophin (TSH) levels remained stable (10.2 +/- 3.8mU/L; n = 33). At birth, concentrations were independent of gender and gestational age. Among the 10 cases of sonographically detected foetal goitre, serum TSH and FT4 were measured in five, showing hypothyroidism (3/5) or hyperthyroidism (2/5). Cord blood TSH levels reflected the efficacy of prenatal therapy. Measurement of foetal FT4 and TSH can be used to confirm foetal thyroid dysfunction, whereas treatment efficacy can be assessed sonographically and confirmed by measurement of TSH assay at birth.

Objective: Following recent data showing that an inflammatory response exists in the amniotic fluid of gastroschisis-affected fetuses, we hypothesized that amniotic fluid exchange or amnioinfusion would improve the prognosis of prenatally diagnosed gastroschisis., Methods: We compared the outcome of prenatally amnioinfused fetuses with gastroschisis to non-amnioinfused fetuses with gastroschisis. 10 patients undergoing this procedure were matched with 10 patients of our previous study. Comparisons were done on data including surgical procedure, follow-up in the NICU and the gastro-pediatric unit., Results: Our results show that gastroschisis-affected fetuses undergoing amnioinfusion had a lower duration of curarization after surgery (2.2 +/- 1.9 vs. 6.8 +/- 6.9 days, p = 0.019), a shorter delay before full oral feeding (49.7 +/- 21.5 vs. 72.3 +/- 56.6 days, NS), and a shorter overall length of hospitalization (59.5 +/- 19.7 vs. 88.5 +/- 73.6 days, NS). We confirmed our previous data showing that amniotic fluid displays a chronic inflammation profile., Conclusion: Our data suggest that amnioinfusion could improve the outcome of gastroschisis affected fetuses. The hypothesis by which this improvement could be due to a reduction of an inflammatory response remains to be proved.

The objective of this work is to investigate the neurotoxicty of low-level lead exposure in utero on infants and the possible involvement of dopaminergic and serotonergic neurotransmitters. The correlation analysis for cord blood lead level, the concentrations of dopamine metabolite homovanillic acid (HVA) and serotonin metabolite 5-hydroxyindoleacetic acid (5-HIAA) in cord plasma and the neurodevelopmental scales of infants were conducted on 244 9-month-old children. Both score of sociability subscale and 5-HIAA concentration were correlated with cord blood lead level. The sociability score was negatively correlated with the concentration of HVA, whereas both the coordination score and the global score were negatively correlated with the concentration of 5-HIAA. With partial correlation analysis, after taking HVA into account, the significant negative correlation between the sociability score and the cord blood lead level that existed in the linear correlation analysis disappeared, and the score of global scale correlated negatively with lead level in cord blood. When taking 5-HIAA into account, the scores of all the neurodevelopmental subscales except the language subscale were significantly negatively correlated with lead level in cord blood. The results indicated that low-level lead exposure in utero could produce a neurotoxic effect on the developing serotonergic system in infants. The neurotoxicity of low-level lead exposure in utero may affect the sociability of infants. Serotonergic activity was shown to have a potential effect on neurodevelopmental assessment. It may interfere with the association between low-level lead exposure in utero and other neurodevelopmental performances of 9-month-old children.

We described here three individual pregnancies in a euthyroid mother with a past history of Graves disease and high levels of thyrotropin receptor stimulating antibodies. Ten years prior to her first pregnancy the mother underwent a partial thyroidectomy for Graves disease and remained euthyroid since, but still produced high levels of thyrotropin receptor stimulating antibodies. Fetal and postnatal hyperthyroidism was not recognized for the first child who was referred to us at one year of age for craniostenosis. During the two next pregnancies fetal hyperthyroidism was suspected on the basis of fetal tachycardia, growth retardation, fetal goiter and fetal cord blood sampling confirmed high levels of free T3, free T4, suppressed fetal TSH levels, and high levels of fetal TRAb. The mother received propylthiouracil to control fetal hyperthyroidism. Neither baby was premature and each had a more favorable outcome than the first. Fetal cord blood sampling proved to be useful during these two pregnancies to ascertain the diagnosis of fetal hyperthyroidism and to monitor the dose of PTU administered to this euthyroid mother.

Background: The association of hyperthyroidism and pregnancy is a rare but serious condition which can jeopardize fetal outcome. Classical follow-up relies on: serial clinical and echographic assessment; serial funipuncture to determine fetal thyroid status, and maternal propylthiouracil (PTU) treatment to treat fetal and/or maternal hyperthyroidism., Case: We report the case of a euthyroid patient with Graves' disease who had already been delivered of two hyperthyroid fetuses; the present pregnancy revealed a hyperthyroid fetus diagnosed by funipuncture. Echography showed a fetal goiter at 28 weeks of gestation (WG) with important signal on colored Doppler echography. We observed an extinction of this signal as maternal PTU treatment was intensified. The patient was delivered of a mildly hyperthyroid newborn at 37 WG. Both newborn and patient are doing well., Conclusion: Fetal thyroid assessment by colored Doppler echography could help in the management of fetal thyroid dysfunction.

Seventy-seven live born children (September 1988 to May 1993) had prenatally detected morphological cardiac malformations (61 cases) and/or arrhythmias (17 cases). The outcome of these children was analysed with an average follow-up of 21.4 months (range: 1 day to 11 years). The parameters studied were age and condition of prenatal diagnosis, the term of pregnancy, the extracardiac malformations associated and the outcome of the live born children. Fifty-two children survived with a mean follow-up of 28.2 months (range: 5 months to 11 years) and 25 children died at a mean age of 3.3 months (range: 1 day to 32 months). The cardiac malformations correlated with the postnatal diagnosis in 59 children (60 cardiac malformations). They included left or right outflow tract obstruction in 22%, septal defects or Tetralogy of Fallot with or without pulmonary atresia in 18.4%, arterial malposition in 12.9% and arrhythmias or conduction defects in 20.7% of cases. The main reason for the high mortality was the complexity of the cardiac malformations with, in particular, ventricular hypoplasia with right or left outflow tract obstruction (41% of mortality). The functional consequences of these abnormalities were only partially appreciated at prenatal diagnosis. The extracardiac malformations, more easily diagnosed, contributed less to this mortality rate. The favourable prognosis of the arrhythmias or conduction defects diagnosed prenatally was confirmed but was, however, associated with a mortality rate of 12%.(ABSTRACT TRUNCATED AT 250 WORDS)

Background: Prolonged exposure of pregnant women to indomethacin for tocolysis may have significant effects on the fetus or neonate, but their incidence is still debated., Population and Methods: From January 1990 to July 1991, 83 pregnant women were prospectively given indomethacin for treatment of premature labor, after ineffective course of salbutamol. The initial dose of indomethacin was 100 mg, then the daily dose was 50 mg while salbutamol was continued. Indomethacin was discontinued beyond the 33rd week of gestational age. Efficacy of indomethacin was judged upon the disappearance of uterine contractions and the increased duration of pregnancy from the onset of treatment until delivery. Adverse effects of treatment were evaluated in the neonates., Results: The mean duration of indomethacin administration was 16 days (range: 1-62 days); the mean total dose was 900 mg (range: 100-4500 mg). The reason for discontinuation of the treatment was its efficacy (41 patients), a gestational age of 33 weeks (12 patients), oligoamnios (21 patients), demonstration of fetal abnormalities (two patients). The mean interval between discontinuation of treatment and delivery was 5 weeks. Fourty three of the 58 patients who were given indomethacin before the 30rd week were delivered after the 33rd week. There was no adverse effect in the women and babies; all oligoamnios were spontaneously reversible. One hundred and fifteen babies were born including 12 who died during the first post-natal days. The rate of admission in an intensive care unit was similar to that of untreated pregnancies., Conclusions: Indomethacin can be safely used for treatment of premature labor provided that its administration is carefully monitored.

During a systematic survey, maternal carriage of Proteus mirabilis was found over a 25-day period in 18 pregnant women admitted to the delivery ward of our hospital maternity. Five neonates born to these mothers were found to be colonized with P. mirabilis. We report here on the use of DNA fingerprinting by the arbitrarily primed polymerase chain reaction technique (AP-PCR) for the epidemiological investigation of this sudden outbreak. This approach was compared with the analysis of restriction fragment length polymorphisms of ribosomal DNA regions (ribotyping). Results of the AP-PCR and of ribotyping were in complete agreement in showing the genetic unrelatedness of the isolates obtained from each mother. Moreover, the results showed mother-to-infant vertical transmission of P. mirabilis in the neonates. AP-PCR is a rapid and discriminative method which seems particularly well suited to the epidemiological study of P. mirabilis.

Background: There have been several reports that prolonged exposure of pregnant women to indomethacin for tocolysis may have significant pharmacological effects on the fetus or newborn., Patients: Eighteen pregnant women were given indomethacin during the year 1989 for treatment of premature labor (n = 16) or polyhydramnios (n = 2). Treatment was started at gestational week 28.1 +/- 2.5 and was discontinued at gestational week 30.7 +/- 1.8. The mean age of the women at the onset of pregnancy was 30.6 +/- 5.3 years. The daily dose of indomethacin was initially 200 mg (2-3 mg/kg), then 107 +/- 59 mg. The cumulative dose was 1,820 +/- 2,370 mg. The duration of treatment was 18.1 +/- 16.4 days (less than 7 days in 8 women)., Results: The term at delivery was 33.4 +/- 3.3 weeks (11 after 32 weeks). The mean interval between discontinuation of treatment and delivery was 19.0 +/- 18.7 days. Indomethacin was effective in 10 cases of premature labor, and gestation was prolonged by 52.6 +/- 19.2 days. Among the 23 live-born neonates, 5 developed renal insufficiency attributed to indomethacin (4 premature labor, 1 hydramnios). The kidney failure with early hyperkalemia was cured within about 7 days in 4 cases. The remaining neonate also suffered from severe prolonged hypoxia and died on day 4., Conclusions: Administration of indomethacin for premature labor places the fetus at risk because of the short drug-free interval before birth. High daily or cumulative doses of indomethacin dit not result in adverse effects.

Restriction fragment length polymorphism (RFLP) analysis of total DNA and of ribosomal DNA (rDNA) regions (ribotyping) were used to document Streptococcus pyogenes vertical mother-to-infant transmission and to investigate the spread of S. pyogenes in an obstetric unit. Two isolates from a newborn, two isolates from his mother (patient 1), and two isolates from two other mothers (patients 2 and 3) were studied. RFLP of total DNA, both after HindIII and PvuII digestions and ethidium bromide staining, gave indistinguishable patterns for the strains isolated from the neonate, his mother, and patient 2. Strains from patient 3 and six unrelated strains studied for comparison showed different patterns. In our system, ribotyping was less discriminative than total DNA RFLP analysis. DNA RFLP analysis therefore provides a valuable molecular tool for studying S. pyogenes epidemiology.

The etiology and prevention of rickets in prematures infants are still controversial: insufficient storage or intake in minerals and/or vitamin D, immature vitamin D metabolism, necessitating early vitamin supplementation, for some associated with calcium and phosphate supplementation. The authors report a case of rickets which could be related to an immaturity of the tubular mechanisms of phosphate reabsorption, with a favourable outcome following an increase in calcium and phosphate intake.