1
|
Kazarian GS, Van Heest AE, Goldfarb CA, Wall LB. Cost Comparison of Botulinum Toxin Injections Versus Surgical Treatment in Pediatric Patients With Cerebral Palsy: A Markov Model. J Hand Surg Am 2021; 46:359-367. [PMID: 33745764 DOI: 10.1016/j.jhsa.2021.01.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 11/17/2020] [Accepted: 01/22/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to compare the cost-effectiveness of surgical release to botulinum toxin injections in the treatment of upper-extremity (UE) cerebral palsy (CP). METHODS A Markov transition-state model was developed to assess the direct and indirect costs as well as accumulated quality-adjusted life-years associated with surgery (surgery group) and continuous botulinum toxin injections (botulinum group) for the treatment of UE CP in children aged 7 to 12 years. Direct medical costs were obtained from institutional billing departments. The number of parental missed workdays associated with each treatment was estimated and previously published regressions were used to calculate indirect costs associated with missed work. Total costs, cost-effectiveness, and incremental cost-effectiveness ratios were calculated. Incremental cost-effectiveness ratios and willingness to pay thresholds were used to make decisions regarding society's willingness to pay for the incremental cost of each treatment given the incremental benefit. RESULTS The surgery group demonstrated lower direct, indirect, and total costs compared with the botulinum group. Direct costs were $29,250.50 for the surgery group and $50,596.00 for the botulinum group. Indirect costs were $9,467.46 for the surgery group and $44,428.60 for the botulinum group. Total costs were $38,717.96 for the surgery group and $95,024.60 for the botulinum group, a difference of $56,306.64. The incremental cost-effectiveness ratio was -$42,019.88, indicating that surgery is a less costly and more effective treatment and that botulinum injections fall outside the societal willingness to pay threshold. Excluding indirect costs associated with parental missed work during home occupational therapy did not have a significant impact on the model. CONCLUSIONS Surgery is associated with lower direct, indirect, and total costs, as well as a greater number of accumulated quality-adjusted life-years. Surgery provides a greater benefit at a lower cost, which suggests that botulinum injections should be used sparingly in this population. Treatment with surgery could represent savings of $5.6 to $11.3 billion annually in the United States. TYPE OF STUDY/LEVEL OF EVIDENCE Economic/Decision Analysis II.
Collapse
Affiliation(s)
- Gregory S Kazarian
- Department of Orthopaedic Surgery, Washington University School of Medicine, St Louis, MO
| | - Ann E Van Heest
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN
| | - Charles A Goldfarb
- Department of Orthopaedic Surgery, Washington University School of Medicine, St Louis, MO
| | - Lindley B Wall
- Department of Orthopaedic Surgery, Washington University School of Medicine, St Louis, MO.
| |
Collapse
|
2
|
Wilson ECF, Wastlund D, Moraitis AA, Smith GCS. Late Pregnancy Ultrasound to Screen for and Manage Potential Birth Complications in Nulliparous Women: A Cost-Effectiveness and Value of Information Analysis. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2021; 24:513-521. [PMID: 33840429 DOI: 10.1016/j.jval.2020.11.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Revised: 11/03/2020] [Accepted: 11/03/2020] [Indexed: 06/12/2023]
Abstract
BACKGROUND Fetal growth restriction is a major risk factor for stillbirth. A routine late-pregnancy ultrasound scan could help detect this, allowing intervention to reduce the risk of stillbirth. Such a scan could also detect fetal presentation and predict macrosomia. A trial powered to detect stillbirth differences would be extremely large and expensive. OBJECTIVES It is therefore critical to know whether this would be a good investment of public research funds. The aim of this study is to estimate the cost-effectiveness of various late-pregnancy screening and management strategies based on current information and predict the return on investment from further research. METHODS Synthesis of current evidence structured into a decision model reporting expected costs, quality-adjusted life-years, and net benefit over 20 years and value-of-information analysis reporting predicted return on investment from future clinical trials. RESULTS Given a willingness to pay of £20 000 per quality-adjusted life-year gained, the most cost-effective strategy is a routine presentation-only scan for all women. Universal ultrasound screening for fetal size is unlikely to be cost-effective. Research exploring the cost implications of induction of labor has the greatest predicted return on investment. A randomized, controlled trial with an endpoint of stillbirth is extremely unlikely to be a value for money investment. CONCLUSION Given current value-for-money thresholds in the United Kingdom, the most cost-effective strategy is to offer all pregnant women a presentation-only scan in late pregnancy. A randomized, controlled trial of screening and intervention to reduce the risk of stillbirth following universal ultrasound to detect macrosomia or fetal growth restriction is unlikely to represent a value for money investment.
Collapse
Affiliation(s)
- Edward C F Wilson
- Health Economics Group, Norwich Medical School, University of East Anglia, Norwich, UK; The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK.
| | - David Wastlund
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK; Parexel Access Consulting, Parexel International, Stockholm, Sweden
| | - Alexandros A Moraitis
- Department of Obstetrics and Gynaecology, University of Cambridge, NIHR Cambridge Biomedical Research Centre, Cambridge, UK
| | - Gordon C S Smith
- Department of Obstetrics and Gynaecology, University of Cambridge, NIHR Cambridge Biomedical Research Centre, Cambridge, UK
| |
Collapse
|
3
|
Smith GC, Moraitis AA, Wastlund D, Thornton JG, Papageorghiou A, Sanders J, Heazell AE, Robson SC, Sovio U, Brocklehurst P, Wilson EC. Universal late pregnancy ultrasound screening to predict adverse outcomes in nulliparous women: a systematic review and cost-effectiveness analysis. Health Technol Assess 2021; 25:1-190. [PMID: 33656977 PMCID: PMC7958245 DOI: 10.3310/hta25150] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Currently, pregnant women are screened using ultrasound to perform gestational aging, typically at around 12 weeks' gestation, and around the middle of pregnancy. Ultrasound scans thereafter are performed for clinical indications only. OBJECTIVES We sought to assess the case for offering universal late pregnancy ultrasound to all nulliparous women in the UK. The main questions addressed were the diagnostic effectiveness of universal late pregnancy ultrasound to predict adverse outcomes and the cost-effectiveness of either implementing universal ultrasound or conducting further research in this area. DESIGN We performed diagnostic test accuracy reviews of five ultrasonic measurements in late pregnancy. We conducted cost-effectiveness and value-of-information analyses of screening for fetal presentation, screening for small for gestational age fetuses and screening for large for gestational age fetuses. Finally, we conducted a survey and a focus group to determine the willingness of women to participate in a future randomised controlled trial. DATA SOURCES We searched MEDLINE, EMBASE and the Cochrane Library from inception to June 2019. REVIEW METHODS The protocol for the review was designed a priori and registered. Eligible studies were identified using keywords, with no restrictions for language or location. The risk of bias in studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool. Health economic modelling employed a decision tree analysed via Monte Carlo simulation. Health outcomes were from the fetal perspective and presented as quality-adjusted life-years. Costs were from the perspective of the public sector, defined as NHS England, and the costs of special educational needs. All costs and quality-adjusted life-years were discounted by 3.5% per annum and the reference case time horizon was 20 years. RESULTS Umbilical artery Doppler flow velocimetry, cerebroplacental ratio, severe oligohydramnios and borderline oligohydramnios were all either non-predictive or weakly predictive of the risk of neonatal morbidity (summary positive likelihood ratios between 1 and 2) and were all weakly predictive of the risk of delivering a small for gestational age infant (summary positive likelihood ratios between 2 and 4). Suspicion of fetal macrosomia is strongly predictive of the risk of delivering a large infant, but it is only weakly, albeit statistically significantly, predictive of the risk of shoulder dystocia. Very few studies blinded the result of the ultrasound scan and most studies were rated as being at a high risk of bias as a result of treatment paradox, ascertainment bias or iatrogenic harm. Health economic analysis indicated that universal ultrasound for fetal presentation only may be both clinically and economically justified on the basis of existing evidence. Universal ultrasound including fetal biometry was of borderline cost-effectiveness and was sensitive to assumptions. Value-of-information analysis indicated that the parameter that had the largest impact on decision uncertainty was the net difference in cost between an induced delivery and expectant management. LIMITATIONS The primary literature on the diagnostic effectiveness of ultrasound in late pregnancy is weak. Value-of-information analysis may have underestimated the uncertainty in the literature as it was focused on the internal validity of parameters, which is quantified, whereas the greatest uncertainty may be in the external validity to the research question, which is unquantified. CONCLUSIONS Universal screening for presentation at term may be justified on the basis of current knowledge. The current literature does not support universal ultrasonic screening for fetal growth disorders. FUTURE WORK We describe proof-of-principle randomised controlled trials that could better inform the case for screening using ultrasound in late pregnancy. STUDY REGISTRATION This study is registered as PROSPERO CRD42017064093. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 15. See the NIHR Journals Library website for further project information.
Collapse
Affiliation(s)
- Gordon Cs Smith
- Department of Obstetrics and Gynaecology, NIHR Cambridge Biomedical Research Centre, University of Cambridge, Cambridge, UK
| | - Alexandros A Moraitis
- Department of Obstetrics and Gynaecology, NIHR Cambridge Biomedical Research Centre, University of Cambridge, Cambridge, UK
| | - David Wastlund
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Jim G Thornton
- Division of Child Health, Obstetrics and Gynaecology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Aris Papageorghiou
- Nuffield Department of Obstetrics and Gynaecology, University of Oxford, Oxford, UK
| | - Julia Sanders
- School of Healthcare Sciences, Cardiff University, Cardiff, UK
| | - Alexander Ep Heazell
- Faculty of Biology, Medicine and Health, School of Medical Sciences, University of Manchester, Manchester, UK
| | - Stephen C Robson
- Reproductive and Vascular Biology Group, The Medical School, Newcastle University, Newcastle upon Tyne, UK
| | - Ulla Sovio
- Department of Obstetrics and Gynaecology, NIHR Cambridge Biomedical Research Centre, University of Cambridge, Cambridge, UK
| | - Peter Brocklehurst
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Edward Cf Wilson
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- Health Economics Group, Norwich Medical School, University of East Anglia, Norwich, UK
| |
Collapse
|
4
|
Therapeutic Evidence of Human Mesenchymal Stem Cell Transplantation for Cerebral Palsy: A Meta-Analysis of Randomized Controlled Trials. Stem Cells Int 2020; 2020:5701920. [PMID: 32765613 PMCID: PMC7387980 DOI: 10.1155/2020/5701920] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 05/31/2020] [Accepted: 06/04/2020] [Indexed: 01/01/2023] Open
Abstract
Cerebral palsy (CP) is a kind of movement and posture disorder syndrome in early childhood. In recent years, human mesenchymal stem cell (hMSC) transplantation has become a promising therapeutic strategy for CP. However, clinical evidence is still limited and controversial about clinical efficacy of hMSC therapy for CP. Our aim is to evaluate the efficacy and safety of hMSC transplantation for children with CP using a meta-analysis of randomized controlled trials (RCTs). We conducted a systematic literature search including Embase, PubMed, ClinicalTrials.gov, Cochrane Controlled Trials Register databases, Chinese Clinical Trial Registry, and Web of Science from building database to February 2020. We used Cochrane bias risk assessment for the included studies. The result of pooled analysis showed that hMSC therapy significantly increased gross motor function measure (GMFM) scores (standardized mean difference (SMD) = 1.10, 95%CI = 0.66‐1.53, P < 0.00001, high-quality evidence) and comprehensive function assessment (CFA) (SMD = 1.30, 95%CI = 0.71‐1.90, P < 0.0001, high-quality evidence) in children with CP, compared with the control group. In the subgroup analysis, the results showed that hMSC therapy significantly increased GMFM scores of 3, 6, and 12 months and CFA of 3, 6, and 12 months. Adverse event (AE) of upper respiratory infection, diarrhea, and constipation was not statistically significant between the two groups. This meta-analysis synthesized the primary outcomes and suggested that hMSC therapy is beneficial, effective, and safe in improving GMFM scores and CFA scores in children with CP. In addition, subgroup analysis showed that hMSC therapy has a lasting positive benefit for CP in 3, 6, and 12 months.
Collapse
|
5
|
TAK‑242 exerts a neuroprotective effect via suppression of the TLR4/MyD88/TRIF/NF‑κB signaling pathway in a neonatal hypoxic‑ischemic encephalopathy rat model. Mol Med Rep 2020; 22:1440-1448. [PMID: 32627010 PMCID: PMC7339810 DOI: 10.3892/mmr.2020.11220] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 04/06/2020] [Indexed: 12/29/2022] Open
Abstract
Neonatal hypoxic-ischemic encephalopathy (HIE) is one of the main causes of death and nervous system damage in neonates. The aim of the present study was to investigate the effect of the Toll-like receptor 4 (TLR4) antagonist TAK-242 on HIE. The Rice-Vannucci method was used for ligation of the left common carotid artery, followed by hypoxic treatment for 2.5 h to establish a neonatal HIE rat model. Rats were intraperitoneally injected with 7.5 ml/kg TAK-242 after hypoxia-ischemia. It was demonstrated that TAK-242 significantly reduced the infarct volume and cerebral edema content of neonatal rats after HIE, alleviating neuronal damage and neurobehavioral function deficits. Furthermore, TAK-242 decreased the protein expression levels of TLR4, MyD88, TIR-domain-containing adapter-inducing interferon-β (TRIF), NF-κB, tumor necrosis factor α (TNF-α) and interleukin-1β in the hippocampus. The present results suggested that TAK-242 may exert a neuroprotective effect after HIE by inhibiting the TLR4/MyD88/TRIF/NF-κB signaling pathway, and reducing the release of downstream inflammatory cytokines.
Collapse
|
6
|
Jiang LJ, Xu ZX, Wu MF, Dong GQ, Zhang LL, Gao JY, Feng CX, Feng X. Resatorvid protects against hypoxic-ischemic brain damage in neonatal rats. Neural Regen Res 2020; 15:1316-1325. [PMID: 31960818 PMCID: PMC7047798 DOI: 10.4103/1673-5374.272615] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Secondary brain damage caused by hyperactivation of autophagy and inflammatory responses in neurons plays an important role in hypoxic-ischemic brain damage (HIBD). Although previous studies have implicated Toll-like receptor 4 (TLR4) and nuclear factor kappa-B (NF-κB) in the neuroinflammatory response elicited by brain injury, the role and mechanisms of the TLR4-mediated autophagy signaling pathway in neonatal HIBD are still unclear. We hypothesized that this pathway can regulate brain damage by modulating neuron autophagy and neuroinflammation in neonatal rats with HIBD. Hence, we established a neonatal HIBD rat model using the Rice-Vannucci method, and injected 0.75, 1.5, or 3 mg/kg of the TLR4 inhibitor resatorvid (TAK-242) 30 minutes after hypoxic ischemia. Our results indicate that administering TAK-242 to neonatal rats after HIBD could significantly reduce the infarct volume and the extent of cerebral edema, alleviate neuronal damage and neurobehavioral impairment, and decrease the expression levels of TLR4, phospho-NF-κB p65, Beclin-1, microtubule-associated protein l light chain 3, tumor necrosis factor-α, and interleukin-1β in the hippocampus. Thus, TAK-242 appears to exert a neuroprotective effect after HIBD by inhibiting activation of autophagy and the release of inflammatory cytokines via inhibition of the TLR4/NF-κB signaling pathway. This study was approved by the Laboratory Animal Ethics Committee of Affiliated Hospital of Yangzhou University, China (approval No. 20180114-15) on January 14, 2018.
Collapse
Affiliation(s)
- Li-Jun Jiang
- Department of Neonatology, Children's Hospital of Soochow University, Suzhou; Department of Neonatology, Affiliated Hospital of Yangzhou University, Yangzhou, Jiangsu Province, China
| | - Zhen-Xing Xu
- Department of Neonatology, Affiliated Hospital of Yangzhou University, Yangzhou, Jiangsu Province, China
| | - Ming-Fu Wu
- Department of Neonatology, Affiliated Hospital of Yangzhou University, Yangzhou, Jiangsu Province, China
| | - Gai-Qin Dong
- Department of Neonatology, Affiliated Hospital of Yangzhou University, Yangzhou, Jiangsu Province, China
| | - Li-Li Zhang
- Department of Neonatology, Affiliated Hospital of Yangzhou University, Yangzhou, Jiangsu Province, China
| | - Jun-Yan Gao
- Department of Neonatology, Affiliated Hospital of Yangzhou University, Yangzhou, Jiangsu Province, China
| | - Chen-Xi Feng
- Department of Neonatology, Children's Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Xing Feng
- Department of Neonatology, Children's Hospital of Soochow University, Suzhou, Jiangsu Province, China
| |
Collapse
|
7
|
Roychoudhury S, Esser MJ, Buchhalter J, Bello-Espinosa L, Zein H, Howlett A, Thomas S, Murthy P, Appendino JP, Scott JN, Metcalfe C, Lind J, Oliver N, Kozlik S, Mohammad K. Implementation of Neonatal Neurocritical Care Program Improved Short-Term Outcomes in Neonates With Moderate-to-Severe Hypoxic Ischemic Encephalopathy. Pediatr Neurol 2019; 101:64-70. [PMID: 31047757 DOI: 10.1016/j.pediatrneurol.2019.02.023] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 02/26/2019] [Accepted: 02/27/2019] [Indexed: 01/30/2023]
Abstract
BACKGROUND Despite the introduction of therapeutic hypothermia, infants with moderate-to-severe hypoxic-ischemic encephalopathy remain at risk of mortality and morbidity. A dedicated service with standardized management protocols and improved communication may help improve care. We aimed to evaluate the impact of a dedicated neonatal neurocritical care service on short-term outcomes in infants with hypoxic-ischemic encephalopathy. METHODS We performed a retrospective cohort study (July 2008 to December 2017) on term and near-term infants admitted to two tertiary neonatal intensive care units with moderate-to-severe hypoxic-ischemic encephalopathy, before and after neonatal neurocritical care service implementation. The primary outcome was brain magnetic resonance imaging findings consistent with those of hypoxic-ischemic encephalopathy. Secondary outcomes included the cooling initiation rate, hospital stay duration, antiseizure medication use, and inotrope use. Regression analysis and interrupted time series analysis were performed after adjusting for confounding factors. RESULTS In total, 216 infants with moderate-to-severe hypoxic-ischemic encephalopathy were analyzed-109 before and 107 after neonatal neurocritical care implementation. After adjusting for confounding factors, there was a significant reduction in primary outcomes (adjusted odds ratio: 0.3, confidence interval: 0.15 to 0.57, P < 0.001) after neonatal neurocritical care implementation. Average hospital stay duration reduced by 5.2 days per infant (P = 0.03), identification of eligible infants for cooling improved (P < 0.001), antiseizure medication use reduced (P = 0.001), and early inotropes use reduced (P = 0.04). CONCLUSION Implementation of a neonatal neurocritical care service associated with decreased brain injury shortened the hospital stay duration and improved the care of infants with moderate-to-severe hypoxic-ischemic encephalopathy.
Collapse
Affiliation(s)
- Smita Roychoudhury
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Michael J Esser
- Section of Pediatric Neurology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Jeffrey Buchhalter
- Section of Pediatric Neurology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Luis Bello-Espinosa
- Section of Pediatric Neurology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Hussein Zein
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Alexandra Howlett
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Sumesh Thomas
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Prashanth Murthy
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Juan Pablo Appendino
- Section of Pediatric Neurology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - James N Scott
- Departments of Diagnostic Imaging and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Cathy Metcalfe
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Jan Lind
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Norma Oliver
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Silvia Kozlik
- Section of Pediatric Neurology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Khorshid Mohammad
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada.
| |
Collapse
|
8
|
Schifrin BS, Soliman M, Koos B. Litigation related to intrapartum fetal surveillance. Best Pract Res Clin Obstet Gynaecol 2015; 30:87-97. [PMID: 26227999 DOI: 10.1016/j.bpobgyn.2015.06.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Accepted: 06/30/2015] [Indexed: 10/23/2022]
Abstract
The role of intrapartum care including cardiotocography (CTG) monitoring in cases of perinatal neurological injury receives considerable debate in both clinical and medicolegal settings. The debate, however, has distracted attention from fundamental questions about the timing, mechanism, and preventability of perinatal injury. CTG tracings are used as a surrogate for asphyxia with the timing of intervention ("rescue") predicated on the presumed severity of asphyxia. Using CTG in this way has prevented intrapartum stillbirth, but it has not reduced the long-term injury in part, because, contrary to popular belief, the majority of intrapartum fetal injuries are unassociated with severe hypoxia or severe neonatal depression. This article describes the timing and mechanisms, including mechanical factors, of intrapartum perinatal injury and the benefit of using the CTG, not for the purpose of "rescue", but for identifying risk factors for fetal injury and keeping the fetus out of harm's way.
Collapse
Affiliation(s)
- Barry S Schifrin
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
| | - Mohamed Soliman
- Department of Obstetrics and Gynecology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Brian Koos
- Department of Obstetrics and Gynecology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| |
Collapse
|