Neonatal brachial plexus palsy with vaginal birth after cesarean delivery: a case-control study

[Obstetrical brachial plexus palsy (PBOPP): epidemiological, therapeutic and evolutionary features of patients at the Bouaké University Hospital, Ivory Coast]

Introduction

la paralysie obstétricale du plexus brachial est une affection relativement rare mais qui n´a pas disparu malgré les importants progrès en obstétrique. L´objectif de cette étude était de décrire les aspects épidémiologiques, thérapeutiques et évolutifs de cette affection dans notre contexte.

Méthodes

analyse rétrospective sur deux ans des dossiers de nouveau-nés ayant présenté une paralysie obstétricale du plexus brachial et pris en charge au Centre Hospitalier Universitaire de Bouaké. Les enfants reçus après l´âge de 3 mois n´ont pas été inclus. Les variables étudiées étaient d´ordre épidémiologique, thérapeutique et évolutif.

Résultats

soixante patients ont été colligés, soit une fréquence de 28,5%. Il y avait 31 (52%) filles. L´âge moyen était de 8 jours [J0 et J35]. Les mères étaient multipares dans 94% des cas. L´accouchement a eu lieu dans un centre de santé dans 97% des cas. Tous les enfants étaient nés à terme avec 57 (95%) présentations céphaliques. L´accouchement était eutocique dans 74% des cas. Le poids moyen de naissance était de 3604g [2150g et 4500g]. Il y avait 47 cas (78%) de paralysie C5-C6. L´immobilisation coude au corps associée à la rééducation a été réalisée chez 51 enfants (85%). La rééducation a été réalisée immédiatement chez 9 enfants (15%). La récupération fonctionnelle du membre lésé a été complète chez 50 enfants (83%) après un recul de 6 mois.

Conclusion

la paralysie obstétricale du plexus brachial demeure une affection obstétricale d´actualité. Son traitement conservateur, seule alternative dans notre contexte donne de bons résultats.

Predictors of neonatal brachial plexus palsy subsequent to resolution of shoulder dystocia

OBJECTIVE

The objective was to ascertain factors among deliveries complicated by shoulder dystocia (SD) and neonatal brachial plexus palsy (NBPP).

METHODS

At 11 hospitals, deliveries complicated by SD were identified. The inclusion criteria were vaginal delivery of non-anomalous, singleton at 34-42 weeks. Adjusted odds ratios (aOR) with 95% confidence intervals (CI) were calculated. Receiver operating characteristic (ROC) curves were created to evaluate the predictive value of the models for NBPP.

RESULTS

Of the 62,939 individuals who delivered vaginally, 1,134 (1.8%) had SD and met other inclusion criteria. Among the analytic cohort, 74 (6.5%) had NBPP. The factor known before delivery which was associated with NBPP was diabetes (aOR = 3.87; 95% CI = 2.13-7.01). After delivery, the three factors associated with NBPP were: (1) birthweight of at least 4000 g (aOR = 1.83; 95% CI = 1.05-3.20); (2) calling for help during the SD (aOR = 4.09, 95% CI = 2.29-7.30), and (3) the duration of SD ≥120 sec (aOR = 2.47, 95% CI = 1.30-4.69). The AUC under the ROC curve for these independent factors was 0.79 (95% CI = 0.77 - 0.82).

CONCLUSIONS

Few factors were identified that were associated with NBPP after SD, but they could not reliably predict which neonates will experience the complication.

The Epidemiology of Brachial Plexus Birth Palsy in the United States: Declining Incidence and Evolving Risk Factors

BACKGROUND

The epidemiology of brachial plexus birth palsy (BPBP) in the United States may be changing over time due to population-level changes in obstetric care.

METHODS

The Kids' Inpatient Database from 1997 to 2012 was analyzed. Annual estimates of BPBP incidence and disease determinant distribution were calculated for the general population and the study population with BPBP. Long-term trends were analyzed. A multivariate logistic regression model was used to quantify the risk associated with each determinant.

RESULTS

The database yielded a combined total of 5,564,628 sample births extrapolated to 23,385,597 population births. The population incidence of BPBP dropped 47.1% over the 16-year study period, from 1.7 to 0.9 cases per 1000 live births (P<0.001). Female, black, and Hispanic subgroups had moderately increased risks of BPBP. Among children with BPBP, 55.0% had no identifiable risk factor. Shoulder dystocia was the strongest risk factor for BPBP in the regression model [odds ratio (OR), 113.2; P<0.001], although the risk of sustaining a BPBP in the setting of shoulder dystocia decreased from 10.7% in 1997 to 8.3% in 2012 (P=0.006). Birth hypoxia was independently associated with BPBP (OR, 3.1; P<0.001). Cesarean delivery (OR, 0.16; P<0.001) and multiple gestation birth (OR, 0.45; P<0.001) were associated with lower incidence of BPBP. Notably, the rate of cesarean delivery increased by 62.8% during the study period, from 20.9% in 1997 to 34.0% in 2012 (P<0.001).

CONCLUSIONS

Over a 16-year period, the incidence of BPBP fell dramatically, paralleled by a significant increase in the rate of cesarean delivery. Systemic changes in obstetric practice may have contributed to these trends. As more than half of BPBP cases have no identifiable risk factor, prospective investigation of established risk factors and characterization of new disease determinants are needed to more reliably identify infants at greatest risk. Racial and geographic inequalities in disease burden should be investigated to identify interventional targets.

LEVEL OF EVIDENCE

Level III-case series.

Characteristics and outcomes of obstetric brachial plexus palsy in a single Saudi center: an experience of ten years

BACKGROUND

Obstetric brachial plexus palsy (OBPP) is considered a rare, unpredictable, and unavoidable injury of the upper limb. In this study, we presented a retrospective cohort study over a period of ten years in King Faisal Specialists Hospital and Research Centre (KFSH&RC), Riyadh, Saudi Arabia, to assess the characteristics and functional outcomes of OBPP.

METHODS

Between January 2005 and December 2015, we carried out 125 repairs of OBPP in KFSH&RC. Out of 71 girls and 54 boys, two babies died of unrelated causes, so they were excluded from the review. All medical records of the patients who attended OBPP clinic at KFSH&RC were reviewed, and relative data were extracted. Descriptive measures for categorical variables and categorical variables were presented. Student's t test and Pearson's χ² test were used. The level of statistical significance was set at P ≤ 0.05.

RESULTS

A total of 123 patients were included in the study with a mean follow-up of 6.1 ± 2.4 years. Of those, 71 (57.7%) were females. Mean age at presentation was 4.2 ± 2.7 months with a birth weight of 3965.9 ± 629.6 g. More than half of the patients (56.1%) sustained the injury in the right side, and 62 patients (50.4%) were classified as Narakas I. Most of the surgeries (96.7%) were nerve grafting. Only 32 (26.0%) patients needed one or more secondary interventions. In the last visit, the mean total score of Mallet was 16.6 ± 2.8. Also, passive external rotation in adduction improved to 38.3 ± 14.5. Last Raimondi hand function grade was 2 ± 1.

DISCUSSION

Our experience demonstrated the value of primary and secondary surgeries in patients with OBPP. Also, we presented the patterns of injury in Saudi patients presented to KFSH&RC.