Publications

Abstract

Objective: To investigate the association between twin pregnancy and severe acute maternal morbidity, overall and by timing (before, during or after delivery) and underlying causal condition.

Methods: We conducted a cohort-nested case-control analysis from the EPIMOMS prospective study conducted in six French regions from 2012-2013 (N=182,309 deliveries). The case group comprised 2,500 women with severe acute maternal morbidity (defined by a national expert consensus process) occurring from 22 weeks of gestation and up to 42 days postpartum. A random sample of 3,650 women who gave birth without severe acute maternal morbidity made up the control group. The association between twin pregnancy and severe acute maternal morbidity was analyzed with multilevel multivariable logistic regression. The role of cesarean delivery as an intermediate factor between twin pregnancy and severe acute maternal morbidity was assessed by path analysis.

Results: The population-based incidence of severe acute maternal morbidity was 6.2% (n=197/3,202, 95% CI 5.3-7.1) in twin pregnancies, and 1.3% (n=2,303/179,107, 95% CI 1.2-1.3) in singleton pregnancies. After controlling for confounders, the risk of severe acute maternal morbidity was higher in twin than in singleton pregnancies (adjusted odds ratio [OR] 4.2, 95% CI 3.1-5.8), both antepartum and intrapartum or postpartum, and regardless of the category of causal condition (severe hemorrhage, severe hypertensive complications, or other conditions). The association was also found for the most severe near-miss cases (adjusted OR 5.1, 95% CI 3.5-7.3). In path analysis, cesarean delivery mediated 20.6% (95% CI 12.9-28.2) of the total risk of intrapartum or postpartum severe acute maternal morbidity associated with twin pregnancy.

Conclusion: Compared with women with singleton pregnancies, women with twin pregnancies have a fourfold increased risk for severe maternal complications both before and after delivery. About one fifth of the association between twin pregnancy and intrapartum or postpartum severe acute maternal morbidity may be mediated by cesarean delivery.

Abstract

Background: Parents of preterm neonates wish greater involvement in pain management; little is known about factors associated with this involvement. We aim to describe perceived maternal information on infants’ pain during hospitalization (PMIP), to study associations between PMIP and mothers’ attitudes during painful procedures, and to identify individual and contextual factors associated with PMIP.

Methods: Analyses of questionnaires from the French national cohort study of preterm neonates, EPIPAGE-2. PMIP was derived from mothers’ answers to questions about information perceived on both pain assessment and management.

Results: Among 3056 eligible neonates born before 32 weeks, 1974, with available maternal reports, were included in the study. PMIP was classified as « sufficient, » « little, not sufficient, » or « insufficient, or none » for 22.7, 45.9, and 31.3% of neonates, respectively. Mothers reporting PMIP as « sufficient » were more frequently present and more likely comforting their child during painful procedures. Factors independently associated with « sufficient » PMIP were high maternal education, gestational age <29 weeks, daily maternal visits, perception of high team support, and implementation of the neonatal and individualized developmental care and assessment program.

Conclusion: Perceived maternal information on premature infants’ pain reported as sufficient increased maternal involvement during painful procedures and was associated with some units’ policies.

PLoS One. 2019 Apr 25;14(4):e0215251. doi: 10.1371/journal.pone.0215251. eCollection 2019.

INTRODUCTION:

In France, midwives have been authorized to prescribe vaccines since 2016. Yet vaccination coverage among pregnant women remains low. Understanding the knowledge, attitudes and practices of midwives regarding influenza vaccination could help improve coverage.

METHODS:

A cross-sectional survey was conducted in 2017 among midwives practicing in the public and private sectors in Paris using an online questionnaire. Multivariate logistic regression analysis of the data was conducted.

RESULTS:

The response rate was 31% (n = 208/669). Overall, knowledge of influenza vaccine recommendations and of vaccine safety and effectiveness was high except regarding new-born immunity and influenza vaccine characteristics. Only 10% of midwives systematically prescribed the vaccine. Reported influenza vaccine uptake among midwives was 39%.

CONCLUSION:

Efforts to improve the knowledge of midwives regarding the safety and effectiveness of vaccinating pregnant women in order to prevent influenza infection in newborns are necessary. Increasing vaccine uptake in both midwives and pregnant women will require adjusting education strategies.

J Infect Dis. 2019 Apr 19;219(10):1642-1651. doi: 10.1093/infdis/jiy699.

Erratum in J Infect Dis. 2019

BACKGROUND:

According to the Developmental Origins of Health and Diseases paradigm, the fetal period is highly vulnerable and may have profound effects on later health. Few studies assessed the effect of small-for-gestational age (SGA), a proxy for fetal growth impairment, on risk of malaria during infancy in Africa.

METHODS:

We used data from a cohort of 398 mother-child pairs, followed from early pregnancy to age 1 year in Benin. Malaria was actively and passively screened using thick blood smear. We assessed the effect of SGA on risk of malaria infection and clinical malaria from birth to 12 months, after stratifying on the infant’s age using a logistic mixed regression model.

RESULTS:

After adjustment for potential confounding factors and infant’s exposure to mosquitoes, SGA was associated with a 2-times higher risk of malaria infection (adjusted odds ratio [aOR] = 2.16; 95% confidence interval [CI], 1.04-4.51; P = .039) and clinical malaria (aOR = 2.33; 95% CI, 1.09-4.98; P = .030) after age 6 months.

CONCLUSION:

Results suggest higher risk of malaria during the second semester of life in SGA infants, and argue for better follow-up of these infants after birth, as currently for preterm babies.

Anaerobe. 2019 Aug;58:6-12. doi: 10.1016/j.anaerobe.2019.04.005. Epub 2019 Apr 10.

Abstract

Necrotizing enterocolitis (NEC) is the most severe life threatening gastrointestinal disease among preterm neonates. NEC continues to account for substantial morbidity and mortality in neonatal intensive care units worldwide. Although its pathogenesis remains incompletely elucidated, NEC is recognized as a multifactorial disease involving intestinal unbalanced inflammatory response, feeding strategies, and bacterial colonization. Epidemiological studies, clinical signs, and animal models support the participation of anaerobic bacteria, particularly clostridia species, in NEC development. Colonization by clostridia seems particularly deleterious. The present review is the opportunity to propose an update on the role of clostridia and NEC.

Introduction

Stillbirth continues to be a major public health concern in high income countries as highlighted by recent international collaborations which have shown the need for more research and policy for prevention and support for parents experiencing stillbirth [1]. Furthermore, risks of stillbirth are marked by strong social and geographical inequalities [2]. Stillbirth rates in disadvantaged communities can be double those in more affluent areas [3, 4]. In general, stillbirth rates are higher for women with lower educational levels, income and also within migrant communities. Including women with these risk factors in research on prevention and bereavement care is therefore essential. […]

Abstract

Objective: To determine whether there is an association between severe intraventricular hemorrhage and early extubation in preterm infants born before 29 weeks of gestational age and intubated at birth.

Methods: This study included 1587 preterm infants from a nationwide French population cohort (EPIPAGE-2). Secondary data on intubated preterm infants were analyzed. After gestational age and propensity score matching (1:1) we built two comparable groups: an early extubation group and a delayed extubation group. Each neonate in one group was paired with a neonate in the other group having the same propensity score and gestational age. Early extubation was defined as extubation within 48 hours of life. Severe intraventricular hemorrhages were defined as grade III or IV hemorrhages according to the Papile classification.

Results: After matching, there were 398 neonates in each group. Using a generalized estimating equation model, we found that intraventricular hemorrhage was not associated with early extubation (adjusted OR 0.9, 95%CI 0.6-1.4). This result was supported by sensitivity analyses.

Conclusion: The practice of early extubation was not associated with an increased proportion of intraventricular hemorrhages. To complete these results, the long-term neurologic outcomes of these infants need to be assessed.

Abstract

Background: Short-term maternal complications of cesarean delivery remain uncertain because of confounding by indication. Our objective was to assess whether cesarean delivery is associated with severe acute intra- or postpartum maternal morbidity compared with vaginal delivery, overall and according to the timing of the cesarean.

Methods: We performed a case-control analysis using data from EPIMOMS, a prospective population-based study of deliveries at 22 gestation weeks or later from 6 regions of France in 2012-2013. Cases of intra- or postpartum severe acute maternal morbidity that were not a result of a condition present before delivery were compared with controls randomly selected in a 1/50 ratio. Associations between delivery modes and severe acute maternal morbidity were estimated in a propensity score-matched sample.

Results: Among 182 300 deliveries, we identified 1444 cases and 3464 controls. The proportion of cesarean delivery was significantly higher among cases than controls (36.0% v. 18.2%). In the propensity score-matched analysis, cesarean deliveries were significantly associated with a higher risk of severe acute maternal morbidity (adjusted odds ratio [OR] 1.8, 95% confidence interval [CI] 1.5-2.2). This association increased with maternal age and was particularly marked for women aged 35 years or older (adjusted OR 2.9, 95% CI 1.9-4.4). This increased risk was significant for cesarean deliveries during labour in women of all age groups and for those before labour only in women aged 35 years or older (adjusted OR 5.1, 95% CI 2.3-11.0).

Interpretation: Cesarean delivery is associated with a higher risk of severe acute maternal morbidity than vaginal delivery, particularly in women aged 35 years and older. Clinical decisions regarding delivery mode should account for this excess risk accordingly.

Editorial

Despite significant improvements in the survival of very preterm newborns in neonatal intensive care units (NICUs) over the last decade, significant racial and ethnic disparities exist for very preterm infants.^1–3 While these disparities are rooted in a complex web of factors, a growing body of evidence has documented the role of quality of care in creating disparities. Black and Hispanic very preterm infants are more likely to be born in hospitals with worse outcomes than white infants after adjustment for risk factors, and differences in hospital of birth explain a significant proportion of the black-white and Hispanic-white disparities for these vulnerable infants.² Additional research has documented that racial and ethnic disparities in quality exist between and within NICUs for very low-birth-weight infants. […]

Abstract

Objective: To analyze language skills in children born at 24-34 weeks of gestation at 2 years of corrected age and the association between language and other developmental domains.

Study design: We included 2424 children (64% of the eligible population) from the French population-based EPIPAGE 2 cohort study. At 2 years’ corrected age, children were screened with the French short version of the MacArthur-Bates Communication Developmental Inventories and the Ages and Stages Questionnaire completed by parents.

Results: Small lexicon size, <10th percentile of the calibration sample (ie, 28 words in a list of 100) was observed in 135 of 300 children (45%) born at 23-26 weeks, 484 of 1513 (32%) born at 27-31 weeks, and 165 of 611 (27%) born at 32-34 weeks of gestation. Small lexicon size was associated with 2 other language measures: word combination use and the Ages and Stages Questionnaire communication domain score. It was also significantly associated with the Ages and Stages Questionnaire score below the threshold in the other developmental domains (gross motor function, fine motor function, problem solving skills, and personal social skills) for all gestational age groups, after adjustment for potential confounders. Overall, 46% of children with a small lexicon size had ≥1 of these domains below the threshold, as compared with only 22% of children without a small lexicon size.

Conclusions: These results highlight the usefulness of the MacArthur-Bates Communication Developmental Inventories in preterm children, especially those who do not participate in specialized follow-up. A small lexicon size points to developmental difficulties in language and increased risk for other developmental and neurobehavioral functions.