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Evans MI, Britt DW, Devoe LD. Etiology and Ontogeny of Cerebral Palsy: Implications for Practice and Research. Reprod Sci 2024; 31:1179-1189. [PMID: 38133768 DOI: 10.1007/s43032-023-01422-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 12/04/2023] [Indexed: 12/23/2023]
Abstract
Cerebral palsy (CP) has been recognized as a group of neurologic disorders with varying etiologies and ontogenies. While a percentage of CP cases arises during labor, the expanded use of electronic fetal monitoring (EFM) to include prevention of CP has resulted in decades of vastly increased interventions that have not significantly reduced the incidence of CP for infants born at term in the USA. Litigation alleging that poor obstetrical practice caused CP in most of these affected children has led to contentious arguments regarding the actual etiologies of this condition and often resulted in substantial monetary awards for plaintiffs. Recent advances in genetic testing using whole exome sequencing have revealed that at least one-third of CP cases in term infants are genetic in origin and therefore not labor-related. Here, we will present and discuss previous attempts to sort out contributing etiologies and ontogenies of CP, and how these newer diagnostic techniques are rapidly improving our ability to better detect and understand such cases. In light of these developments, we present our vision for an overarching spectrum for proper categorization of CP cases into that the following groups: (1) those begun at conception from genetic causes (nonpreventable); (2) those stemming from adverse antenatal/pre-labor events (possibly preventable with heightened antepartum assessment); (3) Those arising from intrapartum events (potentially preventable by earlier interventions); (4) Those occurring shortly after birth (possibly preventable with closer neonatal monitoring); (5) Those that appear later in the postnatal period from non-labor-related causes such as untreated infections or postnatal intracranial hemorrhages.
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Affiliation(s)
- Mark I Evans
- Fetal Medicine Foundation of America, New York, NY, USA.
- Comprehensive Genetics, PLLC, New York, NY, USA.
- Departments of Obstetrics, Gynecology, and Reproductive Sciences, Icahn School of Medicine at Mt. Sinai, New York, NY, USA.
| | - David W Britt
- Fetal Medicine Foundation of America, New York, NY, USA
| | - Lawrence D Devoe
- Department of Obstetrics & Gynecology, The Medical College of Georgia at Augusta University, Augusta, GA, USA
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Bhorat I, Buchmann E, Frank K, Soma-Pillay P, Nicolaou E, Pistorius L, Smuts I. Clinical practice. S Afr Med J 2023; 113:22-24. [PMID: 37882127 DOI: 10.7196/samj.2023.v113i9.1063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Indexed: 10/27/2023] Open
Abstract
Basal ganglia and thalamus (BGT) hypoxic-ischaemic brain injury is currently the most contentious issue in cerebral palsy (CP) litigation in South Africa (SA), and merits a consensus response based on the current available international literature. BGT pattern injury is strongly associated with a preceding perinatal sentinel event (PSE), which has a sudden onset and is typically unforeseen and unpreventable. Antepartum pathologies may result in fetal priming, leading to vulnerability to BGT injury by relatively mild hypoxic insults. BGT injury may uncommonly follow a gradual-onset fetal heart rate deterioration pattern, of duration ≥1 hour. To prevent BGT injury in a clinical setting, the interval from onset of PSE to delivery must be short, as little as 10 - 20 minutes. This is difficult to achieve in any circumstances in SA. Each case needs holistic, multidisciplinary, unbiased review of all available antepartum, intrapartum and postpartum and childhood information, aiming at fair resolution without waste of time and resources.
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Affiliation(s)
- I Bhorat
- Subdepartment of Fetal Medicine, Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of KwaZulu-Natal, Durban, South Africa.
| | - E Buchmann
- Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
| | - K Frank
- Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
| | - P Soma-Pillay
- Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of Pretoria, South Africa.
| | - E Nicolaou
- Division of Fetal Medicine, Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
| | - L Pistorius
- Division of Fetal Medicine, Department of Obstetrics and Gynaecology, Stellenbosch University, Cape Town, South Africa.
| | - I Smuts
- Department of Paediatric Neurology, Faculty of Health Sciences, University of Pretoria, South Africa.
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Lear CA, Maeda Y, King VJ, Dhillon SK, Beacom MJ, Gunning MI, Lear BA, Davidson JO, Stone PR, Ikeda T, Gunn AJ, Bennet L. Circadian patterns of heart rate variability in fetal sheep after hypoxia-ischaemia: A biomarker of evolving brain injury. J Physiol 2023. [PMID: 37432936 DOI: 10.1113/jp284560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 06/23/2023] [Indexed: 07/13/2023] Open
Abstract
Hypoxia-ischaemia (HI) before birth is a key risk factor for stillbirth and severe neurodevelopmental disability in survivors, including cerebral palsy, although there are no reliable biomarkers to detect at risk fetuses that may have suffered a transient period of severe HI. We investigated time and frequency domain measures of fetal heart rate variability (FHRV) for 3 weeks after HI in preterm fetal sheep at 0.7 gestation (equivalent to preterm humans) until 0.8 gestation (equivalent to term humans). We have previously shown that this is associated with delayed development of severe white and grey matter injury, including cystic white matter injury (WMI) resembling that observed in human preterm infants. HI was associated with suppression of time and frequency domain measures of FHRV and reduced their circadian rhythmicity during the first 3 days of recovery. By contrast, circadian rhythms of multiple measures of FHRV were exaggerated over the final 2 weeks of recovery, mediated by a greater reduction in FHRV during the morning nadir, but no change in the evening peak. These data suggest that the time of day at which FHRV measurements are taken affects their diagnostic utility. We further propose that circadian changes in FHRV may be a low-cost, easily applied biomarker of antenatal HI and evolving brain injury. KEY POINTS: Hypoxia-ischaemia (HI) before birth is a key risk factor for stillbirth and probably for disability in survivors, although there are no reliable biomarkers for antenatal brain injury. In preterm fetal sheep, acute HI that is known to lead to delayed development of severe white and grey matter injury over 3 weeks, was associated with early suppression of multiple time and frequency domain measures of fetal heart rate variability (FHRV) and loss of their circadian rhythms during the first 3 days after HI. Over the final 2 weeks of recovery after HI, exaggerated circadian rhythms of frequency domain FHRV measures were observed. The morning nadirs were lower with no change in the evening peak of FHRV. Circadian changes in FHRV may be a low-cost, easily applied biomarker of antenatal HI and evolving brain injury.
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Affiliation(s)
- Christopher A Lear
- Department of Physiology, Fetal Physiology and Neuroscience Group, The University of Auckland, Auckland, New Zealand
| | - Yoshiki Maeda
- Department of Physiology, Fetal Physiology and Neuroscience Group, The University of Auckland, Auckland, New Zealand
- The Department of Obstetrics and Gynaecology, Mie University, Mie, Japan
| | - Victoria J King
- Department of Physiology, Fetal Physiology and Neuroscience Group, The University of Auckland, Auckland, New Zealand
| | - Simerdeep K Dhillon
- Department of Physiology, Fetal Physiology and Neuroscience Group, The University of Auckland, Auckland, New Zealand
| | - Michael J Beacom
- Department of Physiology, Fetal Physiology and Neuroscience Group, The University of Auckland, Auckland, New Zealand
| | - Mark I Gunning
- Department of Physiology, Fetal Physiology and Neuroscience Group, The University of Auckland, Auckland, New Zealand
| | - Benjamin A Lear
- Department of Physiology, Fetal Physiology and Neuroscience Group, The University of Auckland, Auckland, New Zealand
| | - Joanne O Davidson
- Department of Physiology, Fetal Physiology and Neuroscience Group, The University of Auckland, Auckland, New Zealand
| | - Peter R Stone
- The Department of Obstetrics and Gynaecology, The University of Auckland, Auckland, New Zealand
| | - Tomoaki Ikeda
- The Department of Obstetrics and Gynaecology, Mie University, Mie, Japan
| | - Alistair J Gunn
- Department of Physiology, Fetal Physiology and Neuroscience Group, The University of Auckland, Auckland, New Zealand
| | - Laura Bennet
- Department of Physiology, Fetal Physiology and Neuroscience Group, The University of Auckland, Auckland, New Zealand
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Grünebaum A, Bornstein E, McLeod-Sordjan R, Lewis T, Wasden S, Combs A, Katz A, Klein R, Warman A, Black A, Chervenak FA. The impact of birth settings on pregnancy outcomes in the United States. Am J Obstet Gynecol 2023; 228:S965-S976. [PMID: 37164501 DOI: 10.1016/j.ajog.2022.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Revised: 08/05/2022] [Accepted: 08/08/2022] [Indexed: 05/12/2023]
Abstract
In the United States, 98.3% of patients give birth in hospitals, 1.1% give birth at home, and 0.5% give birth in freestanding birth centers. This review investigated the impact of birth settings on birth outcomes in the United States. Presently, there are insufficient data to evaluate levels of maternal mortality and severe morbidity according to place of birth. Out-of-hospital births are associated with fewer interventions such as episiotomies, epidural anesthesia, operative deliveries, and cesarean deliveries. When compared with hospital births, there are increased rates of avoidable adverse perinatal outcomes in out-of-hospital births in the United States, both for those with and without risk factors. In one recent study, the neonatal mortality rates were significantly elevated for all planned home births: 13.66 per 10,000 live births (242/177,156; odds ratio, 4.19; 95% confidence interval, 3.62-4.84; P<.0001) vs 3.27 per 10,000 live births for in-hospital Certified Nurse-Midwife-attended births (745/2,280,044; odds ratio, 1). These differences increased further when patients were stratified by recognized risk factors such as breech presentation, multiple gestations, nulliparity, advanced maternal age, and postterm pregnancy. Causes of the increased perinatal morbidity and mortality include deliveries of patients with increased risks, absence of standardized criteria to exclude high-risk deliveries, and that most midwives attending out-of-hospital births in the United States do not meet the gold standard for midwifery regulation, the International Confederation of Midwives' Global Standards for Midwifery Education. As part of the informed consent process, pregnant patients interested in out-of-hospital births should be informed of its increased perinatal risks. Hospital births should be supported for all patients, especially those with increased risks.
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Affiliation(s)
- Amos Grünebaum
- Department of Obstetrics and Gynecology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Lenox Hill Hospital, New York, NY.
| | - Eran Bornstein
- Department of Obstetrics and Gynecology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Lenox Hill Hospital, New York, NY
| | - Renee McLeod-Sordjan
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hofstra Northwell School of Nursing and Physician Assistant Studies, Northwell Health, New York, NY
| | - Tricia Lewis
- Department of Obstetrics and Gynecology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, South Shore University Hospital, Bay Shore, NY
| | - Shane Wasden
- Department of Obstetrics and Gynecology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Lenox Hill Hospital, New York, NY
| | - Adriann Combs
- Department of Obstetrics and Gynecology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, North Shore University Hospital, Manhasset, NY
| | - Adi Katz
- Department of Obstetrics and Gynecology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Lenox Hill Hospital, New York, NY
| | - Risa Klein
- Department of Obstetrics and Gynecology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Lenox Hill Hospital, New York, NY
| | - Ashley Warman
- Division of Medical Ethics, Department of Medicine, Lenox Hill Hospital, New York, NY
| | - Alex Black
- Department of Obstetrics and Gynecology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Lenox Hill Hospital, New York, NY
| | - Frank A Chervenak
- Department of Obstetrics and Gynecology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Lenox Hill Hospital, New York, NY
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Vintzileos AM, Smulian JC. Abnormal fetal heart rate patterns caused by pathophysiologic processes other than fetal acidemia. Am J Obstet Gynecol 2023; 228:S1144-S1157. [PMID: 36964003 DOI: 10.1016/j.ajog.2022.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 05/02/2022] [Accepted: 05/02/2022] [Indexed: 03/19/2023]
Abstract
Fetal acidemia is a common final pathway to fetal death, and in many cases, to fetal central nervous system injury. However, certain fetal pathophysiological processes are associated with significant category II or category III fetal heart rate changes before the development of or in the absence of fetal acidemia. The most frequent of these processes include fetal infection and/or inflammation, anemia, fetal congenital heart disease, and fetal central nervous system injury. In the presence of significant category II or category III fetal heart rate patterns, clinicians should consider the possibility of the aforementioned fetal processes depending on the clinical circumstances. The common characteristic of these pathophysiological processes is that their associated fetal heart rate patterns are linked to increased adverse neonatal outcomes despite the absence of acidemia at birth. Therefore, in these cases, the fetal heart rate patterns may provide more insight about the fetal condition and pathophysiology than the acid-base status at birth. In addition, as successful timing of intrapartum interventions on the basis of evolution of fetal heart rate patterns aims to prevent fetal acidemia, it may not be logical to continue to use the fetal acid-base status at birth as the gold standard outcome to determine the predictive ability of category II or III fetal heart rate patterns. A more reasonable approach may be to use the umbilical cord blood acid-base status at birth as the gold standard for determining the appropriateness of the timing of our interventions.
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Affiliation(s)
- Anthony M Vintzileos
- Department of Obstetrics and Gynecology, Lenox Hill Hospital, Northwell Health, New York, NY.
| | - John C Smulian
- Department of Obstetrics and Gynecology, University of Florida College of Medicine, Gainesville, FL
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Descourvieres L, Ghesquiere L, Drumez E, Martin C, Sauvage A, Subtil D, Houfflin‐Debarge V, Garabedian C. Types of intrapartum hypoxia in the newborn at term with metabolic acidemia: A retrospective study. Acta Obstet Gynecol Scand 2022; 101:1276-1281. [PMID: 36004701 PMCID: PMC9812112 DOI: 10.1111/aogs.14436] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 07/18/2022] [Accepted: 07/22/2022] [Indexed: 01/07/2023]
Abstract
INTRODUCTION In the most recent recommendations of the International Federation of Gynecology and Obstetrics (FIGO), a chapter was dedicated to the physiological approach and to the description of fetal mechanisms developed to respond to hypoxia. Our objective was to classify the type of hypoxia in the case of metabolic acidemia and to describe the order of appearance of fetal heart rate abnormalities in cases of gradually evolving hypoxia. MATERIAL AND METHODS 132 neonates born between 2018 and 2020 with acidemia were included. We excluded preterm birth, fetuses with congenital anomaly and twin pregnancies. Intrapartum cardiotocography traces were assigned to one of these four types of labor hypoxia: acute, subacute, gradually evolving and chronic hypoxia. For gradually evolving hypoxia, fetal heart rate abnormalities were described according to the FIGO classification. RESULTS 36 cardiotocography traces (27.3%) were classified as acute hypoxia, 14 (10.6%) as subacute hypoxia, and 3 (3.2%) as chronic hypoxia; gradually evolving hypoxia occurred in 62 cases (47%). In 77.4% of cases of gradually evolving hypoxia, deceleration was the first anomaly to appear, with loss of variability and bradycardia appearing later. Increased fetal heart rate was observed immediately after late deceleration in 46.8% of cases and was followed by a loss of variability or saltatory rhythm in 37.1% of cases. CONCLUSIONS In cases of metabolic acidemia at term, the most frequent situation observed was gradually evolving hypoxia, with an initial occurrence of decelerations. The sequence of fetal heart rate modifications was variable.
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Affiliation(s)
| | | | - Elodie Drumez
- Department of Biostatistics, EA2694 Public Health: Epidemiology and Quality of CareUniversity of Lille, University Hospital Center (CHU) LilleLilleFrance
| | - Claire Martin
- Department of Biostatistics, EA2694 Public Health: Epidemiology and Quality of CareUniversity of Lille, University Hospital Center (CHU) LilleLilleFrance
| | - Audrey Sauvage
- Obstetrics CenterJeanne de Flandre Hospital, CHRU LilleLilleFrance
| | - Damien Subtil
- Obstetrics Center, EA 4489 – Perinatal Environment and HealthJeanne de Flandre Hospital, CHRU Lille, University LilleLilleFrance
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Evans MI, Britt DW, Evans SM, Devoe LD. Changing Perspectives of Electronic Fetal Monitoring. Reprod Sci 2022; 29:1874-1894. [PMID: 34664218 PMCID: PMC8522858 DOI: 10.1007/s43032-021-00749-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 09/24/2021] [Indexed: 12/26/2022]
Abstract
The delivery of healthy babies is the primary goal of obstetric care. Many technologies have been developed to reduce both maternal and fetal risks for poor outcomes. For 50 years, electronic fetal monitoring (EFM) has been used extensively in labor attempting to prevent a large proportion of neonatal encephalopathy and cerebral palsy. However, even key opinion leaders admit that EFM has mostly failed to achieve this goal. We believe this situation emanates from a fundamental misunderstanding of differences between screening and diagnostic tests, considerable subjectivity and inter-observer variability in EFM interpretation, failure to address the pathophysiology of fetal compromise, and a tunnel vision focus. To address these suboptimal results, several iterations of increasingly sophisticated analyses have intended to improve the situation. We believe that part of the continuing problem is that the focus of EFM has been too narrow ignoring important contextual issues such as maternal, fetal, and obstetrical risk factors, and increased uterine contraction frequency. All of these can significantly impact the application of EFM to intrapartum care. We have recently developed a new clinical approach, the Fetal Reserve Index (FRI), contextualizing EFM interpretation. Our data suggest the FRI is capable of providing higher accuracy and earlier detection of emerging fetal compromise. Over time, artificial intelligence/machine learning approaches will likely improve measurements and interpretation of FHR characteristics and other relevant variables. Such future developments will allow us to develop more comprehensive models that increase the interpretability and utility of interfaces for clinical decision making during the intrapartum period.
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Affiliation(s)
- Mark I Evans
- Fetal Medicine Foundation of America, New York, NY, USA.
- Comprehensive Genetics, PLLC, New York, NY, USA.
- Department of Obstetrics & Gynecology, Icahn School of Medicine at Mt. Sinai, New York, NY, USA.
| | - David W Britt
- Fetal Medicine Foundation of America, New York, NY, USA
| | - Shara M Evans
- Department of Maternal Child Health, Gillings School of Public Health, University of North Carolina, Chapel Hill, USA
| | - Lawrence D Devoe
- Department of Obstetrics and Gynecology, Medical College of Georgia, Augusta University, Augusta, GA, USA
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di Pasquo E, Commare A, Masturzo B, Paolucci S, Cromi A, Montersino B, Germano CM, Attini R, Perrone S, Pisani F, Dall'Asta A, Fieni S, Frusca T, Ghi T. Short-term morbidity and types of intrapartum hypoxia in the newborn with metabolic acidaemia: a retrospective cohort study. BJOG 2022; 129:1916-1925. [PMID: 35244312 PMCID: PMC9541157 DOI: 10.1111/1471-0528.17133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 02/13/2022] [Accepted: 02/26/2022] [Indexed: 11/30/2022]
Abstract
Objectives To assess labour characteristics in relation to the occurrence of Composite Adverse neonatal Outcome (CAO) within a cohort of fetuses with metabolic acidaemia. Design Retrospective cohort study. Setting Three Italian tertiary maternity units. Population 431 neonates born with acidaemia ≥36 weeks. Methods Intrapartum CTG traces were assigned to one of these four types of labour hypoxia: acute, subacute, gradually evolving and chronic hypoxia. The presence of CAO was defined by the occurrence of at least one of the following: Sarnat Score grade ≥2, seizures, hypothermia and death <7 days from birth. Main outcome measures To compare the type of hypoxia on the intrapartum CTG traces among the acidaemic neonates with and without CAO. Results The occurrence of a CAO was recorded in 15.1% of neonates. At logistic regression analysis, the duration of the hypoxia was the only parameter associated with CAO in the case of an acute or subacute pattern (odds ratio [OR] 1.3; 95% CI 1.02–1.6 and OR 1.04; 95% CI 1.0–1.1, respectively), whereas both the duration of the hypoxic insult and the time from PROM to delivery were associated with CAO in those with a gradually evolving pattern (OR 1.13; 95% CI 1.01–1.3 and OR 1.04; 95% CI 1.0–1.7, respectively). The incidence of CAO was higher in fetuses with chronic antepartum hypoxia than in those showing CTG features of intrapartum hypoxia (64.7 vs. 13.0%; P < 0.001). Conclusions The frequency of CAO seems related to the duration and the type of the hypoxic injury, being higher in fetuses showing CTG features of antepartum chronic hypoxia. Tweetable abstract This study demonstrates that in a large population of neonates with metabolic acidaemia at birth, the overall incidence of short‐term adverse outcome is around 15%. Such risk seems closely correlated to the duration and the type of hypoxic injury, being higher in fetuses admitted in labour with antepartum chronic hypoxia than those experiencing intrapartum hypoxia. This study demonstrates that in a large population of neonates with metabolic acidaemia at birth, the overall incidence of short‐term adverse outcome is around 15%. Such risk seems closely correlated to the duration and the type of hypoxic injury, being higher in fetuses admitted in labour with antepartum chronic hypoxia than those experiencing intrapartum hypoxia.
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Affiliation(s)
- Elvira di Pasquo
- Unit of Surgical Sciences, Obstetrics and Gynaecology Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Arianna Commare
- Unit of Surgical Sciences, Obstetrics and Gynaecology Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Bianca Masturzo
- Division of Obstetrics and Gynaecology, Department of Maternal-Neonatal and Infant Health, Ospedale degli Infermi, University of Turin, Biella, Italy
| | - Sonia Paolucci
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Antonella Cromi
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Benedetta Montersino
- Department of Obstetrics and Gynaecology, Città della Salute e della Scienza, Sant'Anna Hospital, Turin, Italy
| | - Chiara M Germano
- Department of Obstetrics and Gynaecology, Città della Salute e della Scienza, Sant'Anna Hospital, Turin, Italy
| | - Rossella Attini
- Department of Obstetrics and Gynaecology, Città della Salute e della Scienza, Sant'Anna Hospital, Turin, Italy
| | | | - Francesco Pisani
- Child Neuropsychiatry Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Andrea Dall'Asta
- Unit of Surgical Sciences, Obstetrics and Gynaecology Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Stefania Fieni
- Unit of Surgical Sciences, Obstetrics and Gynaecology Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Tiziana Frusca
- Unit of Surgical Sciences, Obstetrics and Gynaecology Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Tullio Ghi
- Unit of Surgical Sciences, Obstetrics and Gynaecology Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
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9
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Nakao M, Nanba Y, Okumura A, Hasegawa J, Toyokawa S, Ichizuka K, Kanayama N, Satoh S, Tamiya N, Nakai A, Fujimori K, Maeda T, Suzuki H, Iwashita M, Oka A, Ikeda T. Correlation between fetal heart rate evolution patterns and magnetic resonance imaging findings in severe cerebral palsy: A longitudinal study. BJOG 2022; 129:1574-1582. [PMID: 35007405 PMCID: PMC9545186 DOI: 10.1111/1471-0528.17089] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 11/17/2021] [Accepted: 11/24/2021] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To investigate the association between hypoxic-ischaemic insult timing and brain injury type in infants with severe cerebral palsy (CP). DESIGN Longitudinal study. SETTING Database of the Recurrence Prevention Committee, Japan Obstetric Compensation System for Cerebral Palsy. SAMPLE Infants with severe CP born at ≥34 weeks of gestation. METHODS The intrapartum fetal heart rate (FHR) strips were categorised as continuous bradycardia; persistently non-reassuring (NR-NR); reassuring-prolonged deceleration (R-PD); Hon's pattern (R-Hon); persistently reassuring (R-R); and unclassified. The brain magnetic resonance imaging (MRI) scans were categorised based on the predominant site involved: basal ganglia-thalamus (BGT); white matter (WM); watershed (WS); stroke; normal; and unclassified. MAIN OUTCOME MEASURES Manifestations of the brain MRI types and the association between FHR evolution pattern and MRI type were analysed. RESULTS Among 672 eligible infants, 76% had BGT-dominant injury, 5.4% WM, 1.2% WS, 1.6% stroke, 1.9% normal, and 14% unclassified. Placental abruption and small-for-gestational age were associated with an increased (adjusted odds ratio [aOR] 8.02) and decreased (aOR 0.38) risk of BGT injury, respectively. The majority of infants had BGT injury in most FHR groups (bradycardia, 97%; NR-NR, 75%; R-PD, 90%; R-Hon, 76%; and R-R, 45%). The risk profiles in case of BGT in the NR-NR group were similar to those in the R-PD and R-Hon groups. CONCLUSION BGT-dominant brain damage accounted for three-fourths of the cases of CP in term or near-term infants, even in prenatal onset cases. Hypoxic-ischaemic insult has a major impact on CP development during the antenatal period.
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Affiliation(s)
- Masahiro Nakao
- The Recurrence Prevention Committee, The Japan Obstetric Compensation System for Cerebral Palsy, Japan Council for Quality Health Care, Tokyo, Japan.,Department of Obstetrics and Gynaecology, Mie University Graduate School of Medicine, Tsu, Japan.,Department of Obstetrics and Gynecology, Sakakibara Heart Institute, Tokyo, Japan
| | - Yukiko Nanba
- The Recurrence Prevention Committee, The Japan Obstetric Compensation System for Cerebral Palsy, Japan Council for Quality Health Care, Tokyo, Japan.,Department of Paediatrics, National Rehabilitation Center for Children with Disabilities, Tokyo, Japan
| | - Asumi Okumura
- The Recurrence Prevention Committee, The Japan Obstetric Compensation System for Cerebral Palsy, Japan Council for Quality Health Care, Tokyo, Japan.,Department of Obstetrics and Gynaecology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Junichi Hasegawa
- The Recurrence Prevention Committee, The Japan Obstetric Compensation System for Cerebral Palsy, Japan Council for Quality Health Care, Tokyo, Japan.,Department of Obstetrics and Gynaecology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Satoshi Toyokawa
- The Recurrence Prevention Committee, The Japan Obstetric Compensation System for Cerebral Palsy, Japan Council for Quality Health Care, Tokyo, Japan.,Department of Public Health, The University of Tokyo, Tokyo, Japan
| | - Kiyotake Ichizuka
- The Recurrence Prevention Committee, The Japan Obstetric Compensation System for Cerebral Palsy, Japan Council for Quality Health Care, Tokyo, Japan.,Department of Obstetrics and Gynaecology, Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Naohiro Kanayama
- The Recurrence Prevention Committee, The Japan Obstetric Compensation System for Cerebral Palsy, Japan Council for Quality Health Care, Tokyo, Japan.,Department of Obstetrics and Gynaecology, Hamamatsu University School of Medicine, Shizuoka, Japan
| | - Shoji Satoh
- The Recurrence Prevention Committee, The Japan Obstetric Compensation System for Cerebral Palsy, Japan Council for Quality Health Care, Tokyo, Japan.,Maternal and Perinatal Care Centre, Oita Prefectural Hospital, Oita, Japan
| | - Nanako Tamiya
- The Recurrence Prevention Committee, The Japan Obstetric Compensation System for Cerebral Palsy, Japan Council for Quality Health Care, Tokyo, Japan.,Department of Health Services Research, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Akihito Nakai
- The Recurrence Prevention Committee, The Japan Obstetric Compensation System for Cerebral Palsy, Japan Council for Quality Health Care, Tokyo, Japan.,Department of Obstetrics and Gynaecology, Nippon Medical School, Tokyo, Japan
| | - Keiya Fujimori
- The Recurrence Prevention Committee, The Japan Obstetric Compensation System for Cerebral Palsy, Japan Council for Quality Health Care, Tokyo, Japan.,Department of Obstetrics and Gynaecology, Fukushima Medical University, Fukushima, Japan
| | - Tsugio Maeda
- The Recurrence Prevention Committee, The Japan Obstetric Compensation System for Cerebral Palsy, Japan Council for Quality Health Care, Tokyo, Japan.,Maeda Clinic, Incorporated Association Anzu-kai, Shizuoka, Japan
| | - Hideaki Suzuki
- The Recurrence Prevention Committee, The Japan Obstetric Compensation System for Cerebral Palsy, Japan Council for Quality Health Care, Tokyo, Japan.,The Japan Obstetric Compensation System for Cerebral Palsy, Japan Council for Quality Health Care, Tokyo, Japan
| | - Mitsutoshi Iwashita
- The Recurrence Prevention Committee, The Japan Obstetric Compensation System for Cerebral Palsy, Japan Council for Quality Health Care, Tokyo, Japan.,Kugayama Hospital, Tokyo, Japan
| | - Akira Oka
- The Recurrence Prevention Committee, The Japan Obstetric Compensation System for Cerebral Palsy, Japan Council for Quality Health Care, Tokyo, Japan.,Department of Paediatrics, Saitama Children's Medical Centre, Saitama, Japan
| | - Tomoaki Ikeda
- The Recurrence Prevention Committee, The Japan Obstetric Compensation System for Cerebral Palsy, Japan Council for Quality Health Care, Tokyo, Japan.,Department of Obstetrics and Gynaecology, Mie University Graduate School of Medicine, Tsu, Japan
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10
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Evans MI, Britt DW. Categorization of cerebral palsy cases: a different perspective. Am J Obstet Gynecol 2021; 225:210-211. [PMID: 33567328 DOI: 10.1016/j.ajog.2021.02.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Accepted: 02/04/2021] [Indexed: 02/02/2023]
Affiliation(s)
- Mark I Evans
- Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY.
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11
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Nakao M, Iwashita M, Ikeda T. Categorization of cerebral palsy cases: a different perspective. Am J Obstet Gynecol 2021; 225:211-212. [PMID: 33567330 DOI: 10.1016/j.ajog.2021.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 02/02/2021] [Indexed: 11/15/2022]
Affiliation(s)
- Masahiro Nakao
- The Recurrence Prevention Committee, Japan Obstetric Compensation System for Cerebral Palsy, Japan Council for Quality Health Care, Tokyo, Japan; Department of Obstetrics and Gynecology, Mie University Graduate School of Medicine, Mie, Japan; Department of Obstetrics and Gynecology, Sakakibara Heart Institute, Tokyo, Japan.
| | - Mitsutoshi Iwashita
- The Recurrence Prevention Committee, Japan Obstetric Compensation System for Cerebral Palsy, Japan Council for Quality Health Care, Tokyo, Japan; Kugayama Hospital, Tokyo, Japan
| | - Tomoaki Ikeda
- The Recurrence Prevention Committee, Japan Obstetric Compensation System for Cerebral Palsy, Japan Council for Quality Health Care, Tokyo, Japan; Department of Obstetrics and Gynecology, Mie University Graduate School of Medicine, Mie, Japan
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12
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Nakao M, Iwashita M, Ikeda T. Looking at the data in the right perspective. Am J Obstet Gynecol 2021; 225:106-107. [PMID: 33631110 DOI: 10.1016/j.ajog.2021.02.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 02/18/2021] [Indexed: 11/26/2022]
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13
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Fetal heart rate pattern in term or near-term cerebral palsy: looking at the data in the right perspective. Am J Obstet Gynecol 2021; 225:106. [PMID: 33662360 DOI: 10.1016/j.ajog.2021.02.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 02/19/2021] [Indexed: 12/22/2022]
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