Birth trauma in insulin-dependent diabetic pregnancies

Infants of insulin-dependent diabetic mothers are considered to be at high risk for birth trauma, presumably due to macrosomia. With current management of diabetes in pregnancy, including strict glycemic control, the rate and the severity of macrosomia should be decreased. The frequent use of ultrasound to assess fetal growth and weight and the use of cesarean delivery in case of fetal macrosomia should further decrease the risk for birth trauma in these infants. We therefore undertook this study to test the null hypothesis that with current management, insulin-dependent diabetic mothers have a rate of birth trauma similar to that of infants of nondiabetic mothers (normal glucose challenge test at 28 weeks' gestation) matched for gestational age at birth, presence or absence of labor, delivery method (vaginal versus cesarean), and race. We studied 118 insulin-dependent diabetic mothers (White classes B-RT) and 354 control subjects (three matches for each insulin-dependent diabetic mother). The rate of birth trauma was 3.4% in insulin-dependent diabetic mothers, not significantly different from controls (2.5%). Logistic regression analysis in which birth trauma was the dependent variable and diabetes, race, presence or absence of labor, mode of delivery (vaginal versus cesarean), infant weight, and infant head circumference were independent variables revealed that only vaginal delivery was a significant risk factor for birth trauma in infants in both groups (p = 0.01). Most frequently observed birth traumas were brachial plexus injury, facial nerve injury, and cephalohematoma. Of the three infants with brachial plexus injury (insulin-dependent diabetic mothers, two; controls, one), two were delivered with use of midforceps.(ABSTRACT TRUNCATED AT 250 WORDS)

Pediatric spinal cord and vertebral column injury

Between January 1, 1970, and December 31, 1988, 179 children (birth to age 16) were treated for spinal cord and/or vertebral column injury by the Neurosurgical Service at the University of Iowa Hospitals and Clinics. Pediatric injuries accounted for 9% of all spinal trauma seen during this period. The mean age was 10.2 years. Sixty-two children were between birth and 8 years of age and 117 were between ages 9 and 16. The cause, distribution, type of injury, and severity of neurological injury varied with age. Neurological outcome was dependent on the severity of the initial neurological injury. Children with complete or severe incomplete myelopathy uniformly remained with severe neurological dysfunction; children with mild to moderate injuries recovered normal or nearly normal neurological function. Surgical versus nonoperative management had no bearing on neurological outcome. Twelve percent of the children with severe spinal cord injuries developed posttraumatic spinal deformity. We conclude that spinal injury patterns differ between preadolescent and older children. Most injuries can be successfully managed with nonoperative therapy. Prognosis is primarily correlated with the severity of the initial neurological insult. Finally, children with severe spinal cord injury must have close, long-term follow-up to monitor the development of posttraumatic spinal deformity.

Perinatal audit of one hundred consecutive vacuum extractions in Maputo

The extraordinary demands on obstetrical services that prevail in many developing countries necessitate critical reviews of existing norms for obstetrical management. Vacuum extractions were studied in this context as a part of the regular perinatal audit carried out at the Maputo Central Hospital, the only hospital in Maputo with emergency surgery catering to the 43,000 annual deliveries. Extractions performed with the fetal head above the ischiatic spines were associated with a high number of complications and an 81% risk of neonatal asphyxia and also with a number of severe neonatal traumas. The risk of intracranial hemorrhage tended to be higher with extractions of fetuses with the head at or above the ischiatic spines, particularly when there was concomitant intrapartum asphyxia. It is concluded that a frequent perinatal audit of selected risk deliveries is a useful monitoring tool for examining prevailing indications for various obstetric interventions.

Clinical Relevance of a Dipole Field in Rolandic Spikes

The clinical presentation of 366 children with rolandic spikes was examined to determine whether the presence of a temporal-frontal dipole field is associated with a lower incidence of clinical abnormality. Comparisons were made between the clinical presentation of 99 children with temporal-frontal dipole discharges versus 267 children with nondipole rolandic discharges. Criteria examined were birth history, developmental milestones, school history, total number of seizures, neurological examination, and computed tomography (CT) findings. For all clinical parameters, except birth history and CT finding, there was a lower incidence of clinical abnormality in the group with dipole discharges (p less than 0.001). The clinical profile seen with temporal-frontal dipole discharges was very different than with nondipole rolandic spikes. Children with dipole discharges less often presented with frequent seizures (10%), developmental delay (18%), school difficulties (34%), or abnormal neurological exam (22%). In contrast, children with nondipole rolandic discharges often presented with a history of frequent seizures (55%), developmental delay (55%), school difficulties (60%), and an abnormal neurological exam (63%). The incidence of clinical abnormalities in the nondipole group exceeded that found in our control population in all areas. Temporal-frontal dipole discharges are associated with a lower incidence of clinical abnormality than are nondipole rolandic spikes. These discharges may represent a benign functional focus.

[Handicaps due to perinatal causes in Trento newborn infants (1979-1988)]

A survey on perinatal handicaps must follow some standards: a) homogeneous population; b) univoc method of evaluation; c) 7 years follow-up; d) case control study. From ethnic and geographical point of view, Trentino is in a favorable condition; all pathologic cases come in the only 3th Level Center (Trento), and all neurological evaluations were made from the same specialist up to primary school. Now case control survey is starting. In district of Trento neonates without congenital malformations have risk for severe residual handicaps of 0.08%; under 1500 g the risk is 6.5% while in the group 1500-2499 the risk is 0.53%. A better prevention program during pregnancy and in Intensive Care Unity may reduce the severe outcome in the 1500-2499 group of neonates.

Brachial plexus injuries in Malaysian neonates: incidence and associated risk factors

A prospective study was carried out on 26,176 Malaysian neonates born in the Maternity Hospital, Kuala Lumpur over a 12-month period to determine the incidence and associated risk factors of brachial plexus injuries. This condition was found in 42/26,176 neonates (1.6 per 1000 livebirths). Multiple logistic regression analysis of affected and control neonates from a nested case-control study showed that increasing birth weights and breech deliveries were the significant risk factors. Our study suggests that to reduce the occurrence of this condition, there is a need for: (i) better assessment of fetal size and maternal pelvimetry to enable earlier diagnosis of cephalo-pelvic disproportion, and (ii) review of the indications and techniques of breech delivery.

Shoulder dystocia and birth trauma in gestational diabetes: a five-year experience

Over a 5-year period, 210 patients with gestational diabetes mellitus were delivered of offspring weighing greater than or equal to 3500 gm. Only three primary cesarean sections were performed electively because of suspected macrosomia. One hundred twenty patients were delivered vaginally. There were 15 shoulder dystocias but only one permanent brachial plexus injury. Seven of the 15 shoulder dystocias occurred in offspring weighing less than 4000 gm. Of variables examined, only the use of forceps was clearly associated with an increased risk of shoulder dystocia (odds ratio, 5.1). A policy to deliver by cesarean section all fetuses estimated to weigh greater than 4000 gm would considerably increase the number of cesarean sections with minimal fetal benefit.

Pregnancy outcome following ultrasound diagnosis of macrosomia

Both elective cesarean and early induction have been proposed for pregnancies in which the fetus is suspected to be macrosomic by ultrasound examination. We studied 242 nondiabetic women with estimated fetal weights (EFWs) by ultrasound of at least 4000 g or the 90th percentile for gestational age at 36 or more weeks' gestation. In 66 of 86 women (77%) delivering within 3 days of ultrasound examination, EFW exceeded birth weight. In only 41 of these 86 women (48%) were the EFWs within the corresponding 500-g category of birth weight. A trial of labor resulted in vaginal delivery in 76 of 106 women (72%). There were five cases of shoulder dystocia but no birth trauma. Estimated fetal weights and birth weights were not significantly different between the women who had a trial of labor and those who did not. Our results do not support cesarean delivery or early induction as a means of preventing infant morbidity when fetal macrosomia (weight of 4000 g or more or the 90th percentile for gestational age) is diagnosed by ultrasound.

Childhood blindness in the Republic of Ireland: a national survey

We completed a national study of blindness in children under 16. Approximately 80% of the blind children (that is, with vision of 3/60 or less) in the Republic of Ireland (172 children) were seen, 93 males and 79 females. The survey was carried out between July 1989 and June 1990. It is the first such study to be carried out. Ninety seven (56%) children had lesions due to factors acting before the perinatal period. Of these, 28 (16% of the total number surveyed) had lesions due to genetic causes; 69 (40%) had lesions due to factors operating in the prenatal period other than genetic factors. Forty six (27%) had lesions due to factors acting in the perinatal period. Twenty two (13%) had lesions due to factors acting in childhood. (4% could not be categorised in this way). The commonest single primary diagnoses were birth asphyxia in 19 (11%) cases and retinopathy of prematurity in 19 (11%) cases.

Macrosomic babies

A review of 3,241 delivery records was made to study the obstetrics and the neonatal outcomes of 129 macrosomic (greater than or equal to 4,000g) babies. They were found to have a nearly 6-fold increase in the neonatal morbidity rate compared with normosomic babies. The emergency Caesarean section rate for nulliparas and parous women with macrosomic babies was 41.3% and 8.4% respectively. Among macrosomic babies, shoulder dystocia was not associated with maternal stature, induction of labour, use of oxytocin or abnormal labour patterns, but was associated with instrumental delivery. Macrosomic babies with shoulder dystocia after instrumental delivery had a higher neonatal morbidity rate than those delivered spontaneously.

Birth injuries: incidence and predisposing factors

The incidence of birth-associated major injuries among 14.265 live born infants during seven years is presented. The occurrence of major trauma was 3.16% or 441 injuries in 437 children. The most usual injury was fracture of the clavicle, which occurred in 3.0%, after that brachial plexus injury with occurrence of 0.11%, and fracture of long bones with 0.03%. In addition to that there was one child with facial nerve palsy. Four children had two birth injuries each. The most important causes of brachial plexus injury were macrosomia and shoulder dystocia. Eight of 16 children with brachial plexus injury had shoulder dystocia and six of 16 macrosomia. The frequency of macrosomia in our material of 14.265 children was 4.7%, which is much higher than earlier reports by other authors.

[Routine examination of the mature newborn infant. Incidence of frequent "minor findings"]

From 1st January to 31st August 1989 2,248 healthy, mature infants were delivered at the Department of Obstetrics and Gynaecology in Graz, Austria. They were routinely examined on day 1 and before discharge from hospital on day 4. Attention was paid to the presence or absence of minor abnormalities such as skin lesions, eruptions or rashes, cephalhaematoma, tongue tie, undescended testis, increased physiological jaundice, heart murmurs, talipes calcaneo-valgus, hip click, fracture of the clavicle and other common abnormalities and limb deformities. 20.9% of the investigated babies had no such findings whatsoever. In 79.1% of the subjects with one or more abnormalities, minor lesions due to birth trauma dominated with 24.2%, followed by postural deformities of the lower extremities in 20.5% and hip clicks and/or asymmetric skin-folds in 12.9%. Dislocation of the hip, however, was found in only 17%. Elevated serum bilirubin levels were noted in 33.0%, and in many of the jaundiced infants bruising or haematoma due to birth trauma was evident. Traumatic lesions were much rarer in infants delivered by caesarean section than in infants born vaginally.

Clavicle fractures in the newborn

A retrospective review of 21,632 live births from January 1982 to July 1987 was performed to determine the incidence and risk factors associated with fractures of the clavicle in the newborn. Fifty-eight fractures (57 patients) were identified, for an incidence of 2.7 clavicle fractures per 1000 live births. Fractures of the clavicle were associated with heavy neonates and shoulder dystocia. Three patients had concurrent clavicular fractures and Erb's palsy. These findings suggest that the incidence of clavicle fractures in the newborn may be reduced by identifying the macrosomic fetus and by minimizing shoulder dystocia. When clavicle fractures occur, a brachial plexus injury should be ruled out.

Congenital brachial palsy in the eastern province of Saudi Arabia

The clinical features of 57 patients (31 males, 26 females) with congenital brachial palsy seen at the King Fahd Hospital of the University over a 5-year period are described. Delivery was difficult in 32 (56%), 20 (35%) were large babies (birth weight greater than 3,600 g), and 20 deliveries required either forceps or vacuum extraction. The presentation at delivery was vertex in 45, breech in five, and shoulder in four. Associated injuries or features, encountered in 14 cases, were fractures of the clavicle and humerus (six cases each), and skull fracture and Horner's syndrome in one patient each. The right and left sides were involved in 31 and 24 cases, respectively, and both sides in only two cases. All the muscle groups of the affected limb were most commonly involved (40%), and hand muscles alone were affected in only one patient. Although 60% of the cases presented late to the hospital, functional recovery was observed in 63%. The major predisposing factors identified in this study were technically difficult deliveries, large infants, and breech or shoulder presentation with assisted delivery. It is suggested that early identification of these factors and improvement in obstetric care of both the mothers and babies during delivery would reduce the incidence and severity of this disability.

Birth-injured infants: legal definitions, claims frequency in Virginia

This review of claims supports the findings of an earlier study on the incidence of injuries defined by the Injured Infant Act. Assignment of children to Virginia's definition of injury was associated with death in the neonatal period and preexisting maternal conditions likely to contribute to a poor outcome. Expanding the definition was more likely to capture living children needing substantial assistance in all phases of daily living. Further refinement of the definition appears advisable to assure that those receiving support meet the Act's intent.

Testicular injury in breech delivery: possible implications

In a prospective study of 166 male breech babies, 13 babies delivered by cesarean section did not show damage to the genital area. Of the 134 delivered vaginally, 19 showed injury to buttocks, scrotum, or testis. Ten babies (6.5%) showed damage to testis. On follow-up of three months to four years, the testis became normal to palpation in only 3 babies. In 1 baby, the testis became impalpable, leaving an empty scrotum. The testicular injury is more likely to occur in babies with a birth weight of greater than or equal to 2,500 g and born to primipara. The breech babies delivered vaginally should be examined and followed up for possible damage to testis. To avoid costly investigation and risky exploration, a history of breech delivery should be obtained in all cases presenting as anorchia, undescended testis, delayed sexual maturation, or male infertility.

Ethnic determinants of perinatal statistics of Chinese: demography of China, Hong Kong and Singapore

Despite limited health resources, the Chinese have achieved reasonably good perinatal and neonatal mortality rates comparable to those of many developed countries. China, Hong Kong and Singapore, areas with different socioeconomic structures, have shared the same favourable ethnic determinants of perinatal mortality. The Chinese have much lower incidence of very low birthweight babies (less than 1000 g) and lethal congenital anomalies. The former is probably related to the rarity of teenage pregnancy, maternal smoking and alcohol consumption. Asphyxia remains a major contributor to perinatal deaths. The perinatal mortality rate in mainland China has remained relatively unchanged in contrast to the dramatic falling trend in Hong Kong and Singapore in the past two decades. This may be accounted for by differences in socioeconomic conditions despite their identical ethnic origin. Studying the Chinese sociocultural pattern may have a great impact on perinatal mortality by preventing low birthweight babies.

Injured Infants Act: study compares definition, newborn records

In a study of a teaching hospital's newborn records 1986-1987, the definition of severe neurological injury in Virginia's Injured Infants Act was found to be associated with neonatal death, prematurity, and a preexisting maternal condition likely to contribute to poor outcome. The incidence of severe neurologic injury did not approach the prevalence of severe mental retardation and cerebral palsy. Thus the ability of the Act to preempt litigation substantially is questionable, the authors state, and they recommend a broader definition.

Brachial-plexus palsy in the newborn

Twenty-one patients who had twenty-three brachial-plexus palsies resulting from trauma at birth were studied over a three and one-half year period, between July 1983 and December 1986. The incidence of this group of injuries was 2.5 per 1,000 live births. There were fourteen palsies of the fifth and sixth cervical nerves; eight of the fifth, sixth, and seventh cervical nerves; and one of the entire brachial plexus. Two patients were lost to follow-up shortly after birth. Of the remaining nineteen patients (twenty-one palsies), fifteen (seventeen palsies) had full recovery at an average of three months (range, two weeks to twelve months), and four (four palsies) had residual paralysis of the upper extremity at more than twenty-six months. We concluded that the newborn who has a brachial-plexus palsy has a favorable prognosis for complete recovery.