Föräldrar är inte alltid förberedda inför att graviditeten avslutas i en förtidsbörd vilket kan försvåra det inledande föräldraskapet. Omkring tio procent av alla barn som föds i Sverige per år kräver vård på en neonatalavdelning varav sex procent av de som föds är prematura. En neonatalavdelning är utformad för att förutom att vårda prematurfödda barn även vårda barn som är påverkade i sitt hälsotillstånd, där föräldrar betraktas som en central del i barnets vård.  Syftet med studien var att beskriva föräldrars upplevelser av delaktighet i vården av sitt prematura barn på en neonatalavdelning och delaktighetens påverkan på anknytning.  Metoden som användes var en litteraturöversikt, även kallad integrativ litteraturstudie. Sex databassökningar gjordes i databaserna PubMed, CINAHL samt PsycInfo vilka genererade i 14 artiklar. Även en manuell sökning utfördes där två artiklar hittades. Totalt inkluderades 16 artiklar av kvalitativ ansats vilka initialt kvalitetsgranskades och därefter sammanställdes. Artiklarna analyserades sedan med hjälp av en integrerad analys.  Resultatet genererade i fyra huvudkategorier med vardera två underkategorier. Det visades att föräldrar kände sig delaktiga i sitt prematura barns vård när de fick möjlighet till närvaro eller fysisk kontakt med barnet vid olika omvårdnadsmoment. Att vara delaktig och ha möjlighet att närvara eller spendera natten på neonatalavdelningen var viktigt för föräldrarollen och anknytningsprocessen. Svårigheter till fysisk kontakt genom hud-mot- hud uppkom vid situationer där barnet behövde vårdas i kuvös vilket beskrevs som en stressig upplevelse. Stöd, uppmuntran och ett gott samarbete med vårdpersonal gjorde situationen hanterbar, underlättade föräldrars delaktighet och upplevdes stärkande för föräldraskapet. Miljön antingen främjade eller hämmade delaktigheten.  Slutsats kan dras att föräldrar upplever att delaktigheten i det prematura barnets vård på en neonatalavdelning stärker dem i föräldrarollen och gynnar anknytningen samt relationen till barnet. Genom delaktighet upplever föräldrar att de har en viktig roll för barnets välbefinnande. En god interaktion med vårdpersonal, ett inbjudande förhållningssätt vid vårdaktiviteter samt kontinuerligt stöd i omvårdnadsmoment upplevs betydande för att vårdandet av det prematura barnet ska kännas hanterbart och därmed underlätta barnets omvårdnad. Familjecentrerad vård ses som kärnan för att åstadkomma detta. / Parents are not always prepared for the fact that the pregnancy ends in a premature birth, which can complicate the initial parenting. Approximately ten percent of all children born in Sweden per year require care in a neonatal unit, of which six percent of those are premature. In addition to care for premature infants, a neonatal unit is also designed to care for infants who have health problems, where parents are considered as a central part in the care of the infant.  The aim of this study was to describe parents ́ experiences of participation in the care of their premature infant in a neonatal unit and the participation ́s influence on infant attachment.  The method used was a literature review, also called integrative literature review. Six database searches were made in the databases PubMed, CINAHL and PsycInfo which generated in 14 articles. A manual literature search was also performed which gave two articles. A total of sixteen articles of qualitative approach were included, which initially were quality reviewed and thereafter synthesized. The articles were then analyzed using an integrative analysis.  The result generated four main categories with two subcategories each. It showed that parents felt involved in their premature infants' care when they were given the opportunity to be present or have physical contact with the infant during various care activities. Being involved and having the opportunity to attend or stay over the night in the neonatal unit was important for the parenting role and the attachment process. Difficulties to enable physical contact through skin-to-skin emerged in situations where the infant needed to be cared for in an incubator and was described as a stressful experience. Support, encouragement and a good cooperation with care staff made the situation manageable, made the parents ́ participation easier and was perceived as strengthening for the parenthood. The environment either promoted or inhibited the participation.  Conclusion can be drawn that parents feel that the participation in the premature infants’ care in a neonatal unit strengthens them in the parental role and strengthens the infant attachment as well as the relationship with the infant. Through participation parents feel that they have an important role in the infant’s well-being. A good interaction with care staff, an inviting approach and continuous support in care activities are experienced to be important for parents to manage and ease the infant's care. Family-centered care is seen as essential to achieve this.

CONTEXTE : Les naissances prématurées sont une complication commune de la grossesse associée à un risque augmenté de survenue de désordres neurodéveloppementaux par rapport aux naissances à terme. Cependant, en raison de l’hétérogénéité des naissances prématurées, il est difficile d’identifier tôt les enfants à haut risque d’atteinte neurodéveloppementale, durant une période critique du développement où une intervention pourrait s’avérer efficace. Des études récentes ont montré les avantages d’analyser le placenta, qui reflète l’environnement intra-utérin, pour prédire le développement neurologique de l’enfant. Notre objectif était d’investiguer l’association entre l’histopathologie du placenta et le neurodéveloppement pendant les deux premières années de vie des enfants prématurés tardifs nés de 29 à 36 semaines de gestation. MÉTHODES : Cette étude de cohorte observationnelle prospective a été conduite sur 149 dyades mère-enfant avec un âge gestationnel entre 29 et 36 semaines de gestation. Des échantillons de placenta et de membranes fœtales ont été obtenus, fixés dans le formaldéhyde et inclus en paraffine. L’analyse histopathologique des tissus a été effectuée et le phénotypage ciblé des cellules immunitaires a été réalisé par l’utilisation des marqueurs immunohistochimiques CD45 pour les leucocytes totaux, et CD68/CD163 pour la polarisation inflammatoire des macrophages. Les données démographiques et obstétricales ont été obtenues à partir des dossiers médicaux. Le neurodéveloppement des enfants a été évalué à 24 mois d’âge corrigé en utilisant des tests standardisés par un évaluateur aveugle aux résultats placentaires. La présence de grossesses gémellaires, le sexe de l’enfant et le type de travail ont été corrélés au nombre de cellules inflammatoires dans le placenta et les membranes fœtales. RÉSULTATS : Aucune corrélation n’a été trouvée entre le type de lésion placentaire et le neurodéveloppement. Cependant, un nombre augmenté de cellules immunitaires totales CD45+ dans le placenta a été corrélé à un retard de langage et de communication réceptive à 24 mois. Une augmentation des macrophages pro-inflammatoires CD68+ dans les membranes foetales a été corrélée avec un neurodéveloppement anormal à 24 mois. Une diminution du nombre de cellules CD45+ et une augmentation des macrophages CD68+ ont été observées dans le placenta et les membranes foetales dans les cas de naissances prématurées spontanées et de ruptures prématurées des membranes. CONCLUSION : Des marqueurs inflammatoires spécifiques au niveau du placenta ont été associés avec un risque de neurodéveloppement anormal. Cela suggère que le placenta pourrait se révéler utile pour raffiner la stratification du risque chez les enfants prématurés, mais que son analyse histopathologique classique sans marqueurs immunohistochimiques ne permet pas de distinguer les enfants à haut risque dans un groupe de prématurés tardifs. Ce travail inclue une analyse approfondie des placentas et une corrélation avec les causes obstétricales de la prématurité. / RATIONALE: Preterm birth (PTB) is a common complication of pregnancy associated with a higher risk of neurodevelopmental impairment vs full-term births. However, because of the heterogeneity of PTB, it is difficult to identify high-risk infants early, during a critical period of development when meaningful intervention could be used. Recent studies have shown the advantages of using the placenta, which reflets the in-utero environment, to infer child development. Our objective was to investigate the association between placental histopathology and neurodevelopment during the first two years of life in late preterm infants. METHODS: This prospective observational cohort study was conducted on 149 mother-infant dyads with deliveries between 29-36 weeks’ gestational age. Formalin-fixed paraffin-embedded placenta/fetal membranes samples were obtained. Histopathological analysis of the tissues and phenotyping of immune cells by immunohistochemical marking of CD45 for total leucocytes, and CD68 and CD163 for inflammatory polarization of macrophages were performed. Maternal demographics and obstetrical data were obtained from the medical chart. Infant neurodevelopment was evaluated at 24 months of corrected age using standardized tests by an assessor blinded to placental results. Twin pregnancies, infant sex and type of delivery were associated with inflammatory cells placental and membranes numbers. RESULTS: No correlation was found between type of placental lesion and outcome. However, increased CD45+ immune cells in the placenta were correlated with language and receptive communication delay at 24 months. Increased pro-inflammatory CD68+ cells in fetal membranes were correlated with abnormal outcome at 24 months. Decreased CD45+ cells and increased CD68+ macrophages were seen in placenta and fetal membranes in cases of spontaneous delivery and premature rupture of membranes. CONCLUSION: Inflammatory markers specific to the placenta are associated with risk of abnormal neurodevelopment. This indicates that the placenta could prove useful in refining risk stratification in preterm infants, but that its classical histopathological analysis without immunohistochemistry is not enough to single out infants at high risk in a group of late preterm. Our work will include in-depth analysis of the placentas and correlation with obstetrical causes of prematurity.

Introduction : Les troubles hypothyroïdiens au cours de la grossesse sont associés à des complications obstétricales et fœtales comme l’accouchement prématuré. Cependant, il n’est pas clair jusqu’à présent si leur prise en charge par la lévothyroxine affecte le risque d’accouchement prématuré. Méthodologie : Une étude cohorte a été conduite dans la Cohorte des grossesses du Québec en incluant des grossesses ayant une hypothyroïdie entre le 1er janvier 1998 et le 31 décembre 2015. Dans les analyses primaires, l’exposition à la lévothyroxine (oui/non), la durée totale d’exposition, la dose journalière moyenne et la dose cumulative dans les deux derniers mois avant l’accouchement (en cas d’accouchement prématuré) ou avant la 37e semaine de gestation (en cas d’accouchement à terme) ont été considérées. Dans les analyses secondaires, la dose de lévothyroxine avant et après le début du deuxième trimestre de gestation ont été comparées et les grossesses ont été catégorisées en un groupe pour lequel la dose était augmentée et un groupe pour lequel la dose était maintenue constante. Enfin, une exposition journalière à la lévothyroxine dépendante du temps a été considérée à partir de la 14e semaine de gestation jusqu’à l’accouchement (en cas d’accouchement prématuré) ou la 37e semaine de gestation (en cas d’accouchement à terme). L’accouchement prématuré a été défini par un accouchement avant la 37e semaine de gestation. Les accouchements à terme ont été censurés à partir de la 37e semaine de gestation, vu qu’ils n’étaient plus à risque d’accouchement prématuré par la suite. Les équations d’estimations généralisées et un modèle de Cox ajustés pour des facteurs de confusion potentiels ont été utilisés pour calculer les rapports de risque ajustés (RRa) et les rapports de risque instantanés ajustés (HRa), respectivement. Résultats : 9 489 personnes enceintes ayant une hypothyroïdie étaient incluses. Parmi elles, 6 667 (70.3 %) étaient exposées à la lévothyroxine dans les deux mois de la période d’intérêt. Après ajustement pour les facteurs de confusion potentiels, l’exposition à la lévothyroxine n’était pas associée au risque d’accouchement prématuré relativement à une absence d’exposition (RRa, 0.98; IC à 95%, 0.81 – 1.20). En plus, la durée d’exposition à la lévothyroxine (>= 30 jours: RRa, 0.99; IC à 95%, 0.81–1.21), la dose cumulative (>= 7 125 microgrammes: RRa, 0.97; IC à 95 %, 0.73– 1.27) et la dose journalière moyenne (> 125 microgrammes/jour: RRa, 0.95; IC à 95 %, 0.72-1.26) n’étaient pas associées au risque d’accouchement prématuré relativement à une absence d’exposition. Enfin, le risque n’a pas varié entre le groupe de grossesses qui a reçu une augmentation de dose et celui pour lequel la dose était maintenue constante (RRa, 0.84; IC à 95 %, 0.67-1.05). D’une manière similaire, le modèle de Cox considérant une exposition journalière à la lévothyroxine dépendante du temps n’a montré aucune association entre l’exposition et le risque d’accouchement prématuré (HRa, 0.95; IC à 95 %, 0.81–1.11). Conclusion : Une supplémentation en lévothyroxine à la fin de la grossesse auprès des personnes ayant une hypothyroïdie n’a pas été associée au risque d’accouchement prématuré. Par conséquent, la lévothyroxine peut être considérée pour réduire les complications de l’hypothyroïdie pendant la gestation. Mots-clés : troubles hypothyroïdiens, grossesse, lévothyroxine, accouchement prématuré. / Background: Hypothyroidism in pregnancy is associated with obstetrical and fetal complications such as prematurity. However, whether its management by levothyroxine affects the risk of prematurity is not yet clear. Methodology: We conducted a cohort study within the Quebec Pregnancy Cohort including pregnancies with hypothyroidism from January 1, 1998, through December 31, 2015. In primary analyses, we considered levothyroxine exposure (yes/no), total duration, mean daily dose and cumulative dose in the 2 months period before delivery (for preterm deliveries) or before 37th weeks’ gestation (for term deliveries). Secondly, levothyroxine dosage before and after the beginning of the second trimester were compared, and pregnancies were categorized in increased or constant dosage groups. Lastly, levothyroxine was also defined as a time-varying daily exposure from the 14th weeks’ gestation until delivery or 37th weeks’ gestation, whichever came first. Prematurity was defined as giving birth before the 37th weeks’ gestation. Term pregnancies were censored at 37th weeks’ gestation because they were no longer at risk of prematurity afterwards. Generalized estimating equations and Cox-proportional hazard models, adjusted for potential confounders, were used to calculate adjusted relative risks (aRRs) and hazard ratios (aHRs), respectively. Results: 9,489 pregnant individuals with hypothyroidism were included. Among them, 6,667 (70.3%) were exposed to levothyroxine in the 2-months time-window. Adjusting for potential confounders, no association was observed between levothyroxine exposure (aRR, 0.98; 95%CI, 0.81–1.20) and the risk of prematurity compared to non-exposed. Also, no association between levothyroxine duration (>=30 days: aRR, 0.99; 95%CI, 0.81–1.21), cumulative dose (>=7,125 micrograms: aRR, 0.97; 95%CI, 0.73–1.27) or mean daily dose (>125 micrograms/day: aRR, 0.95; 95%CI, 0.72-1.26) and the risk of prematurity was observed, compared to non-exposure. Finally, the risk of prematurity did not vary between increased or constant dosage groups (aRR, 0.84; 95% CI, 0.67-1.05). Similarly, time-varying exposure analysis did not show any association between levothyroxine exposure and the risk of prematurity (aHR, 0.95; 95%CI, 0.81–1.11). Conclusion: Levothyroxine supplementation in late pregnancy among individuals with hypothyroidism was not associated with the risk of prematurity. Hence, it may be considered as a safe treatment to reduce the complications of hypothyroidism during gestation.

Stockholm Neonatal Project is a longitudinal population-based study of children born prematurely in 1988-93, with a very low birth weight (&lt;1500 g), who have been followed prospectively from birth through adolescence. A matched control group was recruited at age 5 ½ years. The overall aim was to investigate long-term developmental outcome, paying particular attention to executive functions (EF) in relation to degree of prematurity, birth weight and medical risks. Study I showed a disadvantage in visuo-motor development at 5 ½ years, especially among the preterm boys. Visuo-motor skills were highly related to IQ, and also to EF. In Study II, neuropsychological profiles typical of preterm children and term born children, respectively, were identified through cluster analysis. The general level of performance corresponded well with IQ, motor functions and parental education in both groups, but preterm children had overall lower results and exhibited greater variability across domains. Study III showed that extremely preterm birth (w. 23-27) per se poses a risk for cognitive outcome at age 18, particularly for EF, and that perinatal medical complications add to the risk. By contrast, adolescents born very preterm (w. 28-31) performed just as well as term-born controls in all cognitive domains. However, adolescents born moderately preterm (w. 32-36) and small for gestational age showed general cognitive deficits. Study IV found that cognitive development was stable over time, with parental education and EF at 5 ½ years as significant predictors for cognitive outcome at age 18. Among preterm children, perinatal medical risks and being small for gestational age had a continued negative impact on cognitive development from 5 ½ to 18 years. Study V demonstrated that neuropsychological scoring of Bender drawings, developed in study I, predicted cognitive outcome in adolescence, indicating that the method  may be useful in developmental screening around school entry. / <p>At the time of the doctoral defense, the following papers were unpublished and had a status as follows: Paper 3: Manuscript. Paper 4: Manuscript. Paper 5: Submitted.</p>

Background: Optical coherence tomography (OCT), multifocal electroretinography (mfERG) and full-field electroretinography (ffERG) give important information about retinal structure and function. Purpose: To collect normative data of macular Cirrus Spectral domain (SD)-OCT assessments and of mfERG measurements of healthy children (papers I and II). To assess the macular thickness with Cirrus SD-OCT and the retinal function with ffERG in 6.5-year-old children born extremely preterm and in children born at term (papers III and IV). Methods: Study participants aged 5-15 years and living in Uppsala County were randomly chosen from the Swedish Birth Register (papers I and II). In papers III and IV, the study participants consisted of children born extremely preterm and children born at term – all were aged 6.5 years. In paper III, the children were living in Stockholm and Uppsala health care regions and, in paper IV, in Uppsala health care region only. Macular thickness was assessed with Cirrus SD-OCT and macular function with mfERG, using the Espion Multifocal system and DTL-electrodes. The retinal function was assessed with ffERG and DTL-electrodes, using the Espion Ganzfield system. Results: Altogether, 58 children participated in paper I and 49 children in paper II. In paper I, the repeatability and reproducibility of the OCT assessments were good. In paper II, the results of the mfERG measurements were in accordance with retinal cone density and there were no significant differences between the right and left eyes. In paper III, 134 preterm children and 145 children born at term constituted the study population. The central macular thickness was significantly thicker in the preterm group than in the control group. Within the preterm group, gestational age (GA), former retinopathy of prematurity (ROP) and male gender were all important risk factors for an increased macular thickness. In paper IV, 52 preterm children and 45 control children constituted the study population. Significantly lower amplitudes and prolonged implicit times of the combined rod and cone responses, as well as of the isolated cone responses, were found in the preterm group when compared with the control group. In paper IV, there was no association between GA, ROP or male gender and the ffERG assessments. Conclusion: Normative data of Cirrus SD-OCT and mfERG assessments were reported. The results of the assessments were reliable. Children aged 6.5 years, born extremely preterm, had a significantly thicker central macula and both rod and cone function were significantly reduced in comparison to children born at term. ROP had an influence on retinal structure but not retinal function in the present cohorts. Our results suggest that retinal development is abnormal in children born extremely preterm. Long-term follow-up studies are necessary in order to evaluate the functional ophthalmological outcome in this vulnerable population of children growing up today.

La prématurité, définie par un accouchement avant 37 semaines d'aménorrhée, ne cesse de croître en France. Elle a des facteurs de risque médicaux et socio-économiques. Elle se trouve au coeur des enjeux de la sécurité de la naissance et de l'efficience du système de santé, au nom desquelles les maternités de proximité sont fermées progressivement depuis 1998, sans égard pour une équité spatiale des populations. L'étude de l'impact de ces restructurations sur un vaste territoire comme la Bourgogne est d'autant plus intéressante que cette dernière cumule des facteurs de dispersion avec un peuplement en périphérie de ses limites régionales, une moyenne montagne centrale difficile à franchir, le Morvan, et une faible densité de population et de professionnels de santé. Notre travail a permis de confirmer la répartition hétérogène du taux d'accouchement prématuré en Bourgogne. Pour expliquer cette disparité, et à l'aide principalement de données individuelles du PMSI (Programme de Médicalisation des Systèmes d'Information) et contextuelles de l'INSEE (Institut National de la Statistique et des Études Economiques), nous avons étudié séparément ses relations avec l'accessibilité physique, la distance socio‐économique et l'organisation des soins, avec un accent sur les réseaux de santé périnatale qui caractérisent cette région. Nous avons enfin réuni tous les facteurs explicatifs pertinents dans une analyse multi niveaux dont les modèles hiérarchiques linéaires sont les plus adaptés pour prendre en compte simultanément des données individuelles et des données contextuelles agrégées. Les résultats identifient des clusters de prématurité et montrent que la disparité de la prématurité repose essentiellement sur la disparité spatiale du désavantage socio‐économique et sur la situation d'isolement du Morvan central. Ce travail devrait permettre d'intervenir auprès de ces territoires pour améliorer ou compenser leurs facteurs de risque de prématurité / Prematurity, defined as a birth occurring before 37 weeks of gestation, is increasing in France. It has medical and socio‐economic risk factors. It is of concern to issues about birth security and healthcare efficiency, according to which the local maternity units have been gradually closed since 1998, regardless of spatial equity for the population. The study of the impact of the restructuring on such a vast area as Burgundy is all the more interesting that Burgundy combines factors of dispersion such as its settlement on the edge of its regional boundaries, a central mountain Morvan difficult to drive through, and the low density of its population and of its health professionals. Our work has confirmed the heterogeneous distribution of the rate of preterm delivery in Burgundy. To explain this disparity, in mainly using individual data from PMSI (Programme de Medicalization of Information Systems) and contextual data from INSEE (National Institute for Statistics and Economic Studies), we studied separately the prematurity relationships with physical accessibility, with socio‐economic distance and with perinatal care organization, with a special focus on perinatal health networks that characterize this region. We finally gathered all the relevant explanatory factors in a multilevel analysis with hierarchical linear models that are best suited to take into account both individual and aggregate contextual data. The results identify prematurity clusters and show that prematurity disparity is mainly based on spatial disparity of socio‐economic disadvantage and on the situation of isolation of central Morvan. This work should cause interventions to be carried out within these areas to improve or compensate their risk factors

Os primeiros meses de vida são críticos para o desenvolvimento normal do sistema visual. Nesse período, os recém-nascidos desenvolvem habilidades visuais, algumas delas presentes ao nascimento, que serão refinadas durante a infância e utilizadas ao longo de toda a vida. A literatura mostra que em recém-nascidos as habilidades visuais, como fixação visual e acuidade visual, são desenvolvidas em períodos diferentes. Embora o desenvolvimento da acuidade visual seja semelhante entre recém-nascidos prematuros e termos quando se considera a idade corrigida para a prematuridade (IGc), ou seja, o tempo em semanas que o recém-nascido teria se nascesse com 40 semanas, não se sabe ao certo como se desenvolvem outras habilidades que dependem do sistema visual nesses recém-nascidos. O presente estudo, de caráter observacional, avaliou o desempenho visual através da medida do tempo de fixação visual para a face humana, baseado nos estímulos desenvolvidos por Fantz - face construída com padrões internos semelhantes à face humana (FC) e face desconstruída com padrões internos que não formavam face humana (FD), mas com contraste e luminância idênticos à face construída. Foram incluídos no estudo apenas os recém-nascidos com acuidade visual de resolução de grades, medida através dos cartões de Teller, dentro do esperado para a idade corrigida. Os participantes foram 50 recém-nascidos, 21 (idade média = 13,1 ± 7,1 semanas; peso ao nascimento = 3109 ± 468,9 g), nascidos a partir de 37 semanas de gestação (termo; idade média = 39,1 ± 1,2 semanas), e 29 (idade média = 11,1 ± 6,8 semanas; peso ao nascimento = 1544,3 ± 505,5g), nascidos antes de 37 semanas de gestação (prematuros; idade média = 31,7 ± 2,6 semanas). Os recém-nascidos foram avaliados no Setor de Neonatologia e Pediatria do Hospital Universitário da Universidade de São Paulo (HU-USP) e no Serviço de Neonatologia e Pediatria do Hospital das Clínicas de São Paulo (HCFMUSP). Durante a avaliação os recém-nascidos eram posicionados no bebê conforto, semi-elevados frente a um anteparo que impedia visualização do entorno para o teste de fixação das características faciais e no colo do responsável durante o teste de acuidade visual de Teller. O tempo médio de fixação à FC (termo = 56,9 ± 54,4 segundos; prematuros = 49,3 ± 42,8 segundos) e à FD (termo = 34,8 ± 41,5 segundos; prematuros = 44,1± 31,1 segundos) foi semelhante para recém-nascidos a termo e prematuros (FC: p = 0,723 e FD: p = 0,637). Entretanto, o tempo de fixação à FC foi estatisticamente superior (p = 0,014) ao tempo de fixação à FD para os recém-nascidos a termo, enquanto prematuros apresentaram tempos semelhantes (p = 0,75). A atenção às características faciais humanas possui papel fundamental no contexto diário dos recém-nascidos, pois influencia o desempenho de algumas habilidades que serão desenvolvidas posteriormente, como a comunicação e a interação visual, o reconhecimento de objetos, a resposta social e a orientação espacial. Os resultados do presente estudo mostram que contrariamente aos recém-nascidos a termo cuja preferência pela face humana construída é estatisticamente maior que pela face desconstruída, recém-nascidos prematuros não apresentam preferência pela face humana construída. Os achados indicam os efeitos da prematuridade na fixação à face humana e ressaltam a importância de se identificar alterações em habilidades que poderiam ser estimuladas precocemente / The first months of life are critical for the normal development of the visual system. In this period, newborns develop visual skills, some of which are present at birth, which will be refined during childhood and used throughout the life. The literature shows that in newborns some visual abilities, such as visual fixation and visual acuity, are developed in different periods. Although the development of visual acuity is similar between preterm newborns and terms when considering the corrected age for prematurity (the time in weeks that the newborn would have been born at 40 weeks), the development of other abilities that depend on the visual system in these preterm newborns is unknown. The present observational study evaluated visual performance by measuring the time of visual fixation to the human face, based on the Fantz real face with internal patterns similar to the human face and scrambled face with internal patterns that do not form a face, but with contrast and luminance identical to the real face. Only newborns with visual acuity as expected for the corrected age, as measured by Teller cards, were included in the study. Participants were 50 infants, 21 (mean age = 13.1 ± 7.1 weeks, birth weight = 3109 ± 468.9g) born after 37 weeks gestation (terms, mean age = 39.1 ± 1.2 weeks), and 29 (mean age = 11.1 ± 6.8 weeks, birth weight = 1544.3 ± 505.5g), born before 37 weeks gestation (preterms, mean age = 31, 7 ± 2.6 weeks). The newborns were evaluated in the Neonatology and Pediatrics Sector of the University Hospital (HU-USP) and in the Neonatology and Pediatrics Service of the Hospital das Clinicas de São Paulo (HCFMUSP) at the University of São Paulo. During the evaluation the newborns were placed in the comfort baby, semi-elevated against a bulkhead that prevented visualization of the surroundings to test the time of fixation for the facial characteristics and in the lap of his/her responsible during the visual acuity test. The mean fixation time to the real face (term = 56.9 ± 54.4 seconds, premature = 49.3 ± 42.8 seconds) and to the scrambled face (term = 34.8 ± 41.5 seconds, preterm = 44.1 ± 31.1 seconds) was similar for term and preterm newborns (p = 0.723 and FD: p = 0.637). However, the fixation time to the real face was statistically superior (p = 0.014) to the fixation time to the scrambled face for term newborns, whereas preterm infants presented similar times (p = 0.75). Fixation to human facial features plays a key role in the daily context of newborns, as it influences the performance of some skills that are in development, such as communication and visual interaction, object recognition, social response and spatial orientation. The results of the present study show that, contrary to the term newborns whose preference for the real human face is significantly higher than the scrambled face, preterm newborns have no preference for the real human face. The findings indicate the effects of prematurity on fixation to the human face and emphasize the importance of identifying changes in abilities that could be early stimulated

Objetivos: O presente estudo teve como objetivo comparar a frequência das contrações uterinas em gestações gemelares em uso da progesterona natural e de placebo. Método: Estudo randomizado, duplo-cego, placebo controlado, realizado no período de 01 de junho de 2007 a 31 de outubro de 2013. Participaram do estudo 341 gestantes, com 170 randomizadas no grupo progesterona e 171 no grupo placebo. Todas as gestantes realizaram exame de tocografia no período de 24 a 34 semanas e 6 dias, com duração de trinta minutos, a cada três semanas. A contração uterina foi definida como uma elevação da linha de base com amplitude acima de 5 mm e duração mínima de trinta segundos. Na comparação da frequência das contrações uterinas entre os grupos, nas diferentes idades gestacionais, utilizou-se o teste t de Student. O modelo de análise GEE - modelo generalizado de equações de estimação - foi utilizado na comparação, entre os grupos, da frequência das contrações uterinas em relação à idade gestacional no parto, e também na avaliação da interação da frequência das contrações uterinas com a medida do colo uterino e a corionicidade. Resultados: As características epidemiológicas e gerais das gestantes foram semelhantes nos dois grupos. A frequência média das contrações uterinas diferiu entre os grupos apenas na 34ª semana (P = 0,005), com frequência maior de contrações no grupo progesterona (4,81±3,24) em relação ao grupo placebo (2,73 ± 2,06). Não houve diferença significativa na comparação da frequência média das contrações uterinas e a idade gestacional no parto (< 28 sem, < 32 sem, < 34 sem e < 37 semanas) entre os grupos. Não foi observada interação da frequência das contrações uterinas com a medida do colo uterino ou com a corionicidade da gestação, em relação aos grupos progesterona ou placebo. Conclusão: O uso da progesterona natural não interfere na frequência das contrações uterinas nas gestações gemelares abaixo de 34 semanas gestacionais / Objectives: The aim of this study was to comparate uterine contraction frequency in twin pregnancies in use of natural progesterone and placebo. Methods: Randomized, double-blind, placebo-controlled study, conducted between June 1, 2007 to October 31, 2013. The study included 341 twin pregnancies, with 170 randomized in the progesterone group and 171 in the placebo group. All pregnancies had uterine contraction registration by tocodinamometry every three weeks, during 30 minutes between 24 to 34 weeks and 6 days. Uterine contraction was defined as an amplitude greater than 5 mm, from baseline registration, and a duration longer than 30 seconds. Comparison of contraction frequency between the groups at different gestational ages was examined using the parametric student t test. The model GEE - generalized estimating equation model - was used in the comparison, between the groups, the uterine contraction frequency according gestational age at delivery, and also for evaluating the interaction of the frequency contractions with cervical length and chorionicity. Results: Epidemiological and general characteristics of the pregnant woman were similar in both groups. At the 34 weeks, was only gestational age that presented difference (P = 0.005) in the mean uterine contraction frequency between progesterone (4.81 ± 3.24) and placebo (2.73 ± 2.06) groups. No difference in the mean uterine contraction frequency was observed between progesterone and placebo groups in relation to gestational age at delivery. Cervical length measurement and chorionicity did not influence the uterine contraction frequency according to progesterone or placebo. Conclusion: The use of natural progesterone in twin pregnancies does not affect the uterine contraction frequency before 34 weeks gestation

Objetivo. Este estudo teve como objetivo analisar os resultados de um programa de triagem auditiva neonatal em recém-nascidos pré-termos de um hospital público do município de Itapetininga, Estado de São Paulo. Métodos. A triagem auditiva neonatal foi realizada em 230 neonatos com idade gestacional variando de 28 a 37 semanas, por meio do exame de emissão otoacústica evocada produto de distorção, utilizando-se o equipamento AUDX Biologics. Foram analisados os seguintes aspectos do programa: a) as condições operacionais da realização da triagem auditiva no hospital pesquisado; b) as características da prematuridade presentes na população estudada; c) os resultados do programa de triagem em relação à identificação de casos com alterações auditivas; d) as amplitudes médias de resposta da emissão otoacústica evocada produto de distorção encontradas na população avaliada. Resultados. Foram avaliados 90,55% dos prematuros nascidos num período de 15 meses de coleta. Verificou-se que as condições operacionais para a realização do programa foram adequadas. Não foram encontrados casos de alterações auditivas. As amplitudes médias de respostas da emissão otoacústica evocada produto de distorção (PD-RF) variaram de 11 a 17 dBNPS, nas freqüências de 2 a 5 kHz; tendo sido observadas respostas superiores para as orelhas direitas do sexo feminino. Conclusões. Os prematuros constituíram uma população de baixo risco para deficiência auditiva. As amplitudes de respostas da emissão otoacústica com equipamento portátil mostraram-se semelhantes às obtidas com equipamentos clínicos. O programa de triagem auditiva neonatal pode ser realizado no hospital estudado. Porém, modificações na rotina devem ser realizadas para que possa ser implantado um programa universal. / Objective. The aim of this paper is to analyze the results of a newborn hearing screening programme applied to preterm infants from the city of Itapetininga, state of São Paulo. Methods. Newborn hearing screening was performed to 230 preterm newborns with gestational age from 28 to 37 weeks. The equipment used was AUDX Biologics performing the registry of otoacoustic emissions distortion product. The presence of cocleopalpebral reflex was performed too. It were analyzed: a) operational conditions of newborn hearing screening programme; b) the characteristics of infant?s prematurity; c) incidence of hearing impairment; d) amplitude of otoacoustic emissions distortion product responses (PD-NR). Results. The operational conditions of newborn hearing screening are suitable. No hearing impairment was identified, probably because the prematurity characteristics had load this group to low risk for hearing loss. The mean values from amplitude (PD-NR) extended from 11 to 17 dBSPL from 2 to 5 kHz. They were observed superior values to right ears of the female group. Conclusions. Newborn?s characteristics of prematurity showed low risk for hearing impairment in this study. Portable equipment responses are similar to clinic ones. Newborn hearing screening programme is feasible to be implemented at that kind of hospital. However, some adjusts need to be done in order to extends it to the universal protocol.

Ce projet traite de la programmation développementale de l'hypertension artérielle (HTA) à travers des influences néonatales précoces pouvant moduler le développement vasculaire. Les bébés prématurés présentent des défenses antioxydantes diminuées comparés aux nouveau-nés à terme et sont exposés à la naissance à des concentrations élevées en oxygène (O2) engendrant la production d'espèces réactives de l'O2 (ERO). Les conséquences vasculaires à long terme de dommages liés aux ERO en période néonatale et les mécanismes impliqués sont très partiellement compris. Les précédents résultats du laboratoire ont montré qu'un stress hyperoxique néonatal conduit chez le rat adulte à de l'HTA, une dysfonction endothéliale et une rigidité artérielle, éléments de vieillissement vasculaire. Nous émettons l'hypothèse qu'un stress hyperoxique néonatale conduit à long terme à l'altération de la structure vasculaire et à un vieillissement vasculaire précoce. Nous avons démontré une diminution de la prolifération cellulaire, une capacité angiogénique altérée, des dommages à l'ADN et une augmentation de l'expression de protéines de sénescences (des indices de sénescence cellulaire) au-delà de la période néonatale suite à une exposition brève à l'O2 au niveau vasculaire dans un modèle animal (ratons Sprague-Dawley exposés à 80 % d'O2 du 3ème au 10ème jour de vie comparés à des ratons restés à l'air ambiant) et cellulaire (cellules musculaires lisses d'aortes thoraciques d'embryon de rat exposées à 40% O2 pendant 24h ou 48h, puis remises en normoxie pendant 96h). De plus, des altérations des composants de la structure vasculaire indiquant un remodelage vasculaire aortique ont été mises en évidence. Ces changements précèdent tous l'HTA et la dysfonction vasculaire observées dans le modèle animal à l'âge adulte et pourraient y contribuer. L'étude de jeunes adultes nés < 29 semaines comparés à des jeunes adultes nés à terme indique une augmentation de marqueurs de rigidité artérielle (indices d'un vieillissement vasculaire précoce) chez la population prématurée. L'ensemble des résultats démontre un vieillissement vasculaire précoce après une exposition néonatale transitoire à un stress hyperoxique permettant une meilleure compréhension des mécanismes physiopathologiques impliqués dans la survenue des troubles vasculaires retrouvés chez l'adulte et contribue à la mise en place de moyens de prévention chez des patients prématurés / The scope of this thesis is developmental programming of arterial high blood pressure (HBP) hypertension through early neonatal stimuli that may alter vascular development. Premature newborns have decreased antioxidant defenses compared to term babies and are exposed upon birth to high oxygen (O2) concentration, causing reactive oxygen species (ROS) production. Long term vascular consequences of ROS related damage during the neonatal period and the mechanisms involved remain unknown. Recent data from the laboratory show that neonatal hyperoxic stress leads in adult rat to HBP, endothelial dysfunction and arterial rigidity, characteristic features of vascular aging. We hypothesize that a neonatal hyperoxic stress leads to long term vascular structure alteration explained by an early aging of the vascular system. We showed a decreased proliferation rate, an altered angiogenic capacity, as well as long term DNA damage and increased expression of senescence proteins at a vascular level following O2 exposure in the animal (male Sprague-Dawley pups kept at 80% O2 from postnatal days 3 to 10 vs. rats remained in room air) and cellular models (embryonic vascular smooth muscle cells from rat thoracic aorta exposed to 40% O2 for 24h or 48h followed by 96h recovery in control conditions). In addition, alterations of vascular structure components indicating vascular remodeling was shown before the onset of the HBP at adult age. Those changes precede the HBP and vascular dysfunction observed in our animal model at adult age and could contribute to them. Study of young adults born before 29 weeks vs. young adults born at term showed that young adults born preterm present indices of arterial stiffness vs. term controls. Results of the present thesis demonstrate a major role of premature vascular aging in the surge of vascular diseases in adulthood and contribute to a better understanding of the patho-physiological mechanisms involved and could put into practice new prevention strategies among preterm patients