Sophie Parat

Sensitivity and Specificity of Prenatal Features of Physiological Shunts to Predict Neonatal Clinical Status in Transposition of the Great Arteries

Background—Although prenatal diagnosis of transposition of the great arteries (TGA) reduces neonatal mortality, the preoperative course can be complicated in infants with a restrictive foramen ovale (FO) or a ductus arteriosus (DA) constriction. We sought to determine the specificity and sensitivity of prenatal features of physiological shunts in predicting postnatal clinical status in prenatally diagnosed TGA in babies delivered in a tertiary care center providing all facilities for neonatal urgent care. Methods and Results—The outcomes of 130 fetuses with TGA were reviewed over a period of 5.5 years. Restriction of the FO and/or constriction of the DA could be analyzed in 119/130 fetuses at 36±2.7 weeks of gestation. Twenty-four out of 119 had at least 1 abnormal shunt (23 FO, 5 DA, and 4 both). Thirteen of 130 neonates had profound hypoxemia (PaO2<25 mm Hg) and metabolic acidosis (pH <7.15) in the first 30 minutes and required immediate balloon atrioseptostomy. Two who had abnormal FO and DA died despite aggressive resuscitation. The specificity and sensitivity of the fetal echo in predicting neonatal emergency were 84% and 54%, respectively. The specificity and sensitivity of a combination of restrictive FO and DA constriction were 100% and 31%, respectively. Conclusions—Restriction of the FO and/or of the DA has a high specificity to predict the need for emergency neonatal care in fetuses with TGA, but the sensitivity is too low to detect all high-risk fetuses. Exceptional procedures should be considered for fetuses that have a combination of restrictive FO and DA constriction.

Prospective Identification of Congenital Cytomegalovirus Infection in Newborns Using Real-Time Polymerase Chain Reaction Assays in Dried Blood Spots

BACKGROUND Congenital cytomegalovirus (CMV) infection is a public health issue, and implementation of neonatal screening has been debated. Detection of CMV DNA by polymerase chain reaction (PCR) of dried blood spots (DBS) routinely collected for metabolic screening from all newborns has been proposed for congenital CMV infection screening. The goal of this study was to prospectively assess the performance of 2 CMV PCR assays of DBS for CMV neonatal screening in a selected population of neonates. METHODS We studied prospective congenital CMV screening in a population of neonates either born with symptoms compatible with congenital CMV or born to mothers with a history of primary infection during pregnancy. For each neonate, 2 CMV PCR assays of DBS were blindly performed in parallel with a gold standard technique (ie, CMV PCR of a urine sample). RESULTS Two hundred seventy-one neonates were studied, and CMV infection, defined by a positive urine sample in the first week of life, was confirmed in 64 (23.6%). Nineteen infected (29.7%) neonates were symptomatic, and 45 (70.3%) were asymptomatic. The ranges of sensitivity, specificity, positive predictive value, and negative predictive value for the 2 CMV PCR assays of DBS were 95.0%-100%; 98.1%-99.0%; 94.1%-96.9%, and 98.5%-100%, respectively. CONCLUSIONS The sensitivity and specificity of both CMV PCR assays of DBS to identify congenital CMV were very high in this population of neonates with a high risk of sequelae. These new data should be considered in the ongoing debate on the appropriateness of the use of DBS as a sample to screen for congenital CMV infection.

La mise en œuvre pratique des soins palliatifs dans les différents lieux de soins : 3e partie des réflexions et propositions autour des soins palliatifs en période néonatale☆

Palliative care in newborns may take place in the delivery room and then continued either in maternity wards or in the neonatal unit. For babies developing a chronic condition, going home may be advantageous. The population concerned includes babies born with a severe intractable congenital malformation and certain extremely preterm newborn babies at the limits of viability. Care procedures as well as withholding and withdrawing treatments are reviewed.

Experience in the Management of Eighty-Two Newborns With Congenital Diaphragmatic Hernia Treated With High-Frequency Oscillatory Ventilation and Delayed Surgery Without the Use of Extracorporeal Membrane Oxygenation

The aim of this study is to analyze neonatal outcome of isolated congenital diaphragmatic hernia and to identify prenatal and postnatal prognosis-related factors. A retrospective single institution series from January 2000 to November 2005 of isolated congenital diaphragmatic hernia neonates was reviewed. Respiratory-care strategy was early high-frequency oscillatory ventilation, nitric oxide in pulmonary hypertension, and delayed surgery after respiratory and hemodynamic stabilization. Survival rate at 1 month was 65.9%. None of the prenatal factors were predictive of neonatal outcome, except an intra-abdominal stomach in left diaphragmatic hernia. Preoperative pulmonary hypertension was more severe in the nonsurvivor group and was predictive of length of ventilation in the survivors. During the first 48 hours of life, the best oxygenation index above 13 and the best PaCO2 above 45 were predictive of poor outcome. When treating isolated congenital diaphragmatic hernia with early high-frequency ventilation and delayed surgery but excluding extracorporeal membrane oxygenation, survival rates compare favorably with other reported series, and the respiratory morbidity is low.

Soins palliatifs dans les situations issues du diagnostic prénatal

La legislation francaise est une des plus liberales au monde en permettant depuis une trentaine d’annees maintenant, l’interruption medicale de grossesse (IMG) quel que soit le terme, sur demande de la mere et apres avis de deux experts d’un Centre pluridisciplinaire de diagnostic prenatal (CPDP) (1). On recense entre 6 000 et 7 000 IMG par an en France. Depuis quelques annees, on rencontre dans les CPDP une nouvelle demande des couples : leur souhait est de ne pas recourir a l’IMG, laisser evoluer la grossesse malgre la gravite de l’atteinte fœtale, vivre un accouchement normal, rencontrer l’enfant et l’accompagner vers sa mort spontanee. Comme la mere ou le couple ne demandent pas l’IMG, l’enfant naitra en general a terme et, s’il est vivant, les pediatres le prendront en charge, avec une esperance de vie spontanee variable.

Assurer le confort de l’enfant

La priorite en soins palliatifs est centree sur la qualite de vie et le confort de l’enfant. Assurer le confort, c’est mener successivement, ou idealement en parallele, une reflexion sur chaque therapeutique curative mise en œuvre (pouvant conduire a la desescalade therapeutique) et une reflexion sur le soulagement de chaque symptome. Le soulagement des symptomes associe des moyens pharmacologiques, des techniques non medicamenteuses et une amelioration de l’environnement affectif ; ce, tout au long de la vie de l’enfant.

Principales sources de difficultés avec les familles

Depuis 1975, grâce a l’echographie, les medecins ont developpe une strategie de diagnostic antenatal, au benefice de la prise en charge precoce d’un certain nombre de pathologies fœtales. Lorsque le fœtus est atteint d’une pathologie d’une particuliere gravite, cette strategie peut conduire a l’interruption de grossesse, si la mere ou le couple le demande, dans le strict respect de la loi. Confrontes a la meme situation, d’autres couples ne souhaitent pas interrompre la grossesse et sollicitent davantage le corps medical.

New approach for congenital CMV infection diagnosis in neonates: sensibility and specificity of CMV detection in dried blood spots

Address: 1Hopital Necker-Enfants-malades, AP-HP, National Reference Center for Cytomegalovirus, Paris, France, 2Hopital Antoine Beclere, APHP, Virologie, Clamart, France, 3Hopital Necker-Enfants malades, Maternite, Paris, France, 4Hopital de Poissy, Maternite, Poissy, France, 5Institut de Puericulture, Neonatalogie, Paris, France and 6Universite Paris-Descartes EA 36-20, Paris, France * Corresponding author