Biomedical subjects
Publications and source records attributed to E Papiernik.
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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.
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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.
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.
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.
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.
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.
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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.
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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.
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.
This study demonstrates the need for a confidential approach to medial information when the objective is to improve medical practices, as was the goal of the French National Committee for the reduction of maternal deaths. This approach is the exact opposite of a litigation where the goal is to determine "guilt". Confidential analysis of maternal deaths is not designed to find a guilty person, but rather to identify the mechanisms leading to a maternal death in order to correct the organizational or medical practice leading to failure. We review here similar actions taken to reduce other types of medical accidents such as anesthesia deaths. The confidential approach has been found to be pertinent in the perinatal audit conducted in the Seine-Saint-Denis region, including all fetal and neonatal deaths, that has shown measurable reduction in the number of fetal deaths.
OBJECTIVES: This article explores whether the impact of social and demographic risk factors for preterm birth differs for small for gestational age preterm births versus other preterm births. STUDY DESIGN: This was a European case control study of the determinants of preterm birth (4700 cases and 6460 controls). Small for gestational age and non-small for gestational age preterm births were compared with a control group of term births; relationships were explored further by stratifying preterm births into subgroups by mode of onset, the presence of hypertension, and gestational age. RESULTS: Of the social and demographic risk factors for preterm birth identified in this sample, high maternal age, smoking, and low and high maternal body mass index have a stronger effect on small for gestational age preterm births. In contrast, obstetric history, maternal education, and marital status have similar effects regardless of birth weight. Hypertension during pregnancy is strongly associated with small for gestational age preterm birth and contributes to an explanation of observed differences. CONCLUSIONS: These results underline the importance of considering fetal growth restriction in the analysis of risk factors for preterm birth.
OBJECTIVES: To assess whether systematic screening with an uterine artery Doppler in low risk pregnant women followed by the prescription of low dose aspirin in cases with abnormal results reduced the incidence of intrauterine growth restriction and pre-eclampsia. DESIGN: A multicentre randomised trial. POPULATION: 3,317 low risk pregnant women. In the Doppler group, the uterine artery Doppler was performed between 20 and 24 weeks. Women with abnormal results received 100 mg of aspirin daily until the 35th week. MAIN OUTCOME MEASURES: Intrauterine growth restriction was defined as birthweight below the tenth and the third centile according to gestational age. Pre-eclampsia was defined as hypertension associated with proteinuria > 0.5g/L. RESULTS: Intrauterine growth restriction, whether defined by the third or tenth centile, did not differ significantly between the two groups (RR = 1.22 [0.73 - 2.04] and 1.18 [0.93 - 1.51] respectively). Screening with uterine artery Doppler did not affect birthweight or any of the criteria of perinatal morbidity. There was no effect on the incidence of pre-eclampsia (RR = 1.99 [0.97 - 4.09]) or hypertensive disorders. These results were the same for nulliparae and multiparae. CONCLUSIONS: There is no justification for screening with uterine artery Doppler in a low risk population, even if abnormal results are followed by aspirin treatment and increased prenatal surveillance. Future studies must assess predictive tests that can be performed early in pregnancy and can identify populations at very high risk of pre-eclampsia and intrauterine growth restriction. Only when all of these conditions are fulfilled, aspirin or other treatments may prove its efficacy.
The study is a critical analysis of the decisions to induce labour or schedule cesareans in the practice of a third level referral centre, with as outcome criterion the reduction of fetal death. 783 women pregnant with twins were included from 1.1.1993 to 31.12.1998, in three groups: originally booked, referred for care during pregnancy, or transferred from another institution. The results show that an important proportion of preterm deliveries result from a medical decision to induce labour or from a scheduled cesarean in the originally booked group with even higher proportions in groups of referred and transferred women. These results are discussed in relation to fetal death rates and causes. Deaths related to fetal growth restriction were not observed in women originally booked for care. The hospital bias has been discussed. The conclusion is that decisions to minimize fetal deaths in twin pregnancies increased preterm deliveries by medical decision.