Emeline Maisonneuve

Risk factors for severe neonatal acidosis.

OBJECTIVE: Neonatal asphyxia may have severe consequences in term newborns. Our purpose was to identify possible risk factors of severe acidosis during pregnancy and labor. METHODS: In a case–control study from January 2003 to December 2008 in three university perinatal centers (two French and one Canadian hospitals), we analyzed 226 women with term pregnancies complicated by severe neonatal acidosis (umbilical artery pH less than 7.00). Cases were individually matched with controls with a normal acid-base status (pH 7.15 or greater) paired by parity. Groups were compared for differences in maternal, obstetric, and fetal characteristics. Univariable and logistic conditional regression were used to identify possible risk factors. RESULTS: Among 46,722 births after 22 weeks, 6,572 preterm births and 829 stillbirths or terminations of pregnancy were excluded. From the 39,321 live term births, 5.30% of pH values were unavailable. Severe acidosis complicated 0.63% of 37,235 term structurally normal pregnancies. By using multivariate conditional regression, maternal age 35 years or older (35.0% compared with 15.5%; odds ratio [OR] 5.58, 95% confidence interval [CI] 2.51–12.40), prior neonatal death (3.5% compared with 0%), prior cesarean delivery (24.7% compared with 6.6%; OR 4.08, 95% CI 1.71–9.72) even after excluding cases of uterine rupture, general anesthesia (8.4 compared with 0.9%; OR 8.04, 95% CI 1.26–50.60), thick meconium (6.4% compared with 2.8%; OR 5.81, 95% CI 1.72–19.66), uterine rupture (4.4% compared with 0%), and abnormal fetal heart rate (66.1% compared with 19.8%; OR 8.77, 95% CI 3.72–20.78) were independent risk factors of severe neonatal acidosis. CONCLUSION: Prior cesarean delivery, maternal age 35 years or older, prior neonatal death, general anesthesia, thick meconium, uterine rupture, and abnormal fetal heart rate are independent risk factors of severe neonatal acidosis. LEVEL OF EVIDENCE: II

Oxidative conditions prevail in severe IUGR with vascular disease and Doppler anomalies.

Abstract Objective: Intrauterine growth restriction (IUGR) and prenatal exposure to oxidative stress are thought to lead to increased risks of cardiovascular disease later in life. The objective of the present study was to document whether cord blood oxidative stress biomarkers vary with the severity of IUGR and of vascular disease in the twin pregnancy model in which both fetuses share the same maternal environment. Methods: This prospective cohort study involved dichorionic twin pairs, with one co-twin with IUGR. Oxidative stress biomarkers were measured in venous cord blood samples from each neonate of 32 twin pairs, and compared, according to severity of IUGR (IUGR <5th percentile), Doppler anomalies of the umbilical artery and early onset IUGR (in the second trimester) of the growth restricted twin. Results: Oxidized Low-Density Lipoproteins (oxLDL) and Malondialdehyde (MDA) concentrations were increased proportionally in cases of severe IUGR. OxLDL concentrations were also increased in cases of IUGR with Doppler anomaly. Conclusion: Our data indicate that severe IUGR, is related to a derangement in redox balance, illustrated by increased venous cord blood oxidative stress biomarkers concentrations. Severe IUGR and IUGR with abnormal Doppler can be translated into conditions with intense oxidative stress.

Clinical input of anti-D quantitation by continuous-flow analysis on autoanalyzer in the management of high-titer anti-D maternal alloimmunization: ANTI-D QUANTITATION BY CFA

In addition to titration by indirect antiglobulin test most widely used, anti‐D quantitation by continuous‐flow analysis (CFA) may be performed to assess severity of maternal immunization. Only five studies have reported its added value in the management of pregnancies complicated by anti‐D immunization.

The Pubic Diastasis Measurement, a Key Element for the Diagnosis, Management, and Prognosis of the Bladder Exstrophy

Objective: To demonstrate the feasibility of measuring the fetal pubic diastasis (PD) distance on antenatal ultrasound in normal fetuses and to compare it to fetuses with bladder exstrophy. Methods: Firstly, a prospective multicentric study was conducted to determine the feasibility of the PD ultrasound measurement during the second half of pregnancy. Secondly, data from a single center were used to develop a nomogram for PD values in normal fetuses. Thirdly, retrospective PD measurements were collected from fetuses with bladder exstrophy, diagnosed in seven French Multidisciplinary Centers for Prenatal Diagnosis (MCPDs). Results: Operators from several MCPDs examined 868 fetuses and found that overall PD ultrasound measurement was feasible in 71% of cases and that the ossification of pubic points increased to be always visible from 27 weeks of gestation onward. Performed in a single center by a referring operator on 1,539 fetuses, the feasibility reached 94.74%. Both set of measurements were concordant (mean PD distance value of 5.42 ± 1.8 mm). Interestingly, all 23 fetuses with bladder exstrophy showed a significantly larger PD distance (mean 15.74 ± 3.9 mm). Conclusion: PD measurement in the fetus is feasible and reliable in the second half of gestation and can be used to support the antenatal diagnosis of bladder exstrophy with PD values exceeding 10 mm.

Fetal Brain Injury Associated with Parvovirus B19 Congenital Infection Requiring Intrauterine Transfusion

Background: Infection with parvovirus B19 (B19V) during pregnancy may cause severe fetal anemia, hydrops, and fe tal death. Furthermore, neurodevelopmental impairment among survivors may occur despite appropriate prenatal management, including intrauterine transfusion (IUT). Objectives: Our primary objective was to describe cerebral lesions on MRI in fetuses with severe anemia requiring IUT for B19V infection. Our secondary objective was to search for clinical and biological characteristics associated with the occurrence of such lesions. Study Design: We performed a retrospective review of data on fetuses infected with B19V and requiring at least one IUT between 2005 and 2016. Fetuses with abnormal cerebral MRI results in the 3rd trimester were compared to those with normal MRI results. Results: Of 34 transfused fetuses, 26 children were born at full term. Five intrauterine fetal deaths, 1 neonatal death, and 2 terminations of pregnancy occurred. Cerebral anomalies were observed in 7/27 fetuses on MRI, including cerebellar hemorrhage or a small cerebellum. Only viral load in fetal blood appeared to be associated with brain lesions (11.5 log10 copies/mL [10.5–12.5] in case of abnormal MRI results vs. 9.5 log10 copies/mL [7.8–10.0]; p = 0.05). Conclusions: Among the fetuses transfused for B19V infection, 26% presented with prenatal abnormal cerebral imaging results. In our study, viral load in fetal blood appeared to be the only factor associated with fetal brain lesions.

Accuracy of Middle Cerebral Artery Doppler Assessment between 34 and 37 Weeks in Fetuses with Red Cell Alloimmunization

Background: The Doppler measurement of middle cerebral artery peak systolic velocity (MCA-PSV) is considered the gold standard for the noninvasive detection of moderate to severe anemia. However, the accuracy of this test has not been evaluated so far, specifically beyond 34 weeks. Objectives: To assess the accuracy of MCA-PSV to detect moderate to severe fetal anemia and to identify risk factors associated with false-positive and false-negative MCA-PSV values after 34 weeks. Study Design: We studied a retrospective cohort of 150 pregnant women with severe alloimmunization who delivered between 2010 and 2014 and correlated MCA-PSV and fetal or neonatal hemoglobin levels. Results: Sensitivity to predict severe anemia was 69%, with a false-negative rate of 3.6%. When MCA Doppler assessment was normal, the identification of serosal effusions increased the detection rate of severe fetal anemia to 94%, with a false-negative rate of 0.8%. False-positive MCA-PSV measurements were more frequent in fetuses with 1 previous intrauterine transfusion (p = 0.0002), but were not associated with MCA resistance index, intrauterine growth restriction and fetal heart rate. Conclusions: Between 34 and 37 weeks, sensitivity of MCA-PSV Doppler assessment alone is 69% and increases to 94% when also considering signs of hydrops. False-positive MCA-PSV measurements are more frequent in case of former fetal transfusion.

First Case of Congenital Myeloproliferative Disorder in a Newborn DiagnosedWith Noonan Syndrome

Noonan syndrome (NS) is one of the most common genetic syndromes, but its diagnosis is difficult antenatally because prenatal ultrasound findings are unspecific. Infants with NS are predisposed to developing juvenile myelomonocytic leukaemia (JMML) or myeloproloferative disorders. We report a case of severe polyhydramnios and hydrops fetalis at 32+6 weeks gestation, complicated by preterm labour. Tocolysis, amnioreduction and pleuroamniotic shunt were performed. Fetal blood sampling showed: 1127 monocytes/mm3 and 245 metamyelocytes/mm3. The patient gave birth at 33 weeks and 4 days to a 2780 g male baby. Absolute monocyte count was maximum at 8000/mm3, without blasts in peripheral blood. Study of the PTPN11 gene identified a de novo heterozygous missense mutation. Chemotherapy could not be started due to the severity of the multiple organ failure. The patient died at 2 months old. The prenatal monocytosis >1000/μL is one of the criteria for JMML. We suggest performing a cordocentesis, including white cell blood count in order to search for myelomonocytic disorders, especially in cases of hydropic fetuses and severe pleural effusions, before placing pleuroamniotic shunts. This could help evoking the diagnosis of NS and anticipating the postnatal clinical course.

OC23.01: Severity of foetal growth restriction from placental insufficiency is associated with an oxidative stress markers response in umbilical cord blood

E. Maisonneuve1, E. Delvin2, E. Levy3, A. Ouellet5, E. Grenier3, L. Morin1, J. Dubé1, I. Boucoiran1, M. Bouity-Voubou3, J. Moutquin5, S. Klam6, J. Fouron4, L. Leduc1 1Obstetrics and Gynaecology, Université de Montréal and Research Center, CHU Sainte-Justine, Montreal, QC, Canada; 2Biochemistry, Université de Montréal and Research Center, CHU Sainte-Justine, Montreal, QC, Canada; 3Nutrition, Université de Montréal and Research Center, CHU Sainte-Justine, Montreal, QC, Canada; 4Cardiology, Université de Montréal and Research Center, CHU Sainte-Justine, Montreal, QC, Canada; 5Obstetrics and Gynaecology, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC, Canada; 6Obstetrics and Gynaecology, Jewish General Hospital, Montreal, QC, Canada