Cerebral palsy and placental infection: a case-cohort study

Clinical Chorioamnionitis and Neurodevelopment at 5 Years of Age in Children Born Preterm: The EPIPAGE-2 Cohort Study

OBJECTIVE

To assess the association between clinical chorioamnionitis and neurodevelopmental disorders at 5 years of age in children born preterm.

STUDY DESIGN

EPIPAGE 2 is a national, population-based cohort study of children born before 35 weeks of gestation in France in 2011. We included infants born alive between 240/7 and 346/7 weeks after preterm labor or preterm premature rupture of membranes. Clinical chorioamnionitis was defined as maternal fever before labor (>37.8°C) with ≥2 of the following criteria: maternal tachycardia, hyperleukocytosis, uterine contractions, purulent amniotic fluid, or fetal tachycardia. The primary outcome was a composite, including cerebral palsy, coordination disorders, cognitive disorders, sensory disorders, or behavioral disorders. We also analyzed each of these disorders separately as secondary outcomes. We performed a multivariable analysis using logistic regression models. We accounted for the nonindependence of twins and missing data by generalized estimating equation models and multiple imputations, respectively.

RESULTS

Among 2927 children alive at 5 years of age, 124 (3%) were born in a context of clinical chorioamnionitis. Overall, 8.2% and 9.6% of children exposed and unexposed, respectively, to clinical chorioamnionitis had moderate-to-severe neurodevelopmental disorders. After multiple imputations and multivariable analysis, clinical chorioamnionitis was not associated with the occurrence of moderate-to-severe neurodevelopmental disorders (aOR, 0.9; 95% CI, 0.5-1.8).

CONCLUSIONS

We did not find any association between clinical chorioamnionitis and neurodevelopmental disorders at 5 years of age in children born at <35 weeks of gestation after preterm labor or preterm premature rupture of membrane.

Balance between maternal antiviral response and placental transfer of protection in gestational SARS-CoV-2 infection

The intricate interplay between maternal immune response to SARS-CoV-2 and the transfer of protective factors to the fetus remains unclear. By analyzing mother-neonate dyads from second and third trimester SARS-CoV-2 infections, our study shows that neutralizing antibodies (NAbs) are infrequently detected in cord blood. We uncovered that this is due to impaired IgG-NAb placental transfer in symptomatic infection and to the predominance of maternal SARS-CoV-2 NAbs of the IgA and IgM isotypes, which are prevented from crossing the placenta. Crucially, the balance between maternal antiviral response and transplacental transfer of IgG-NAbs appears to hinge on IL-6 and IL-10 produced in response to SARS-CoV-2 infection. In addition, asymptomatic maternal infection was associated with expansion of anti-SARS-CoV-2 IgM and NK cell frequency. Our findings identify a protective role for IgA/IgM-NAbs in gestational SARS-CoV-2 infection and open the possibility that the maternal immune response to SARS-CoV-2 infection might benefit the neonate in 2 ways, first by skewing maternal immune response toward immediate viral clearance, and second by endowing the neonate with protective mechanisms to curtail horizontal viral transmission in the critical postnatal period, via the priming of IgA/IgM-NAbs to be transferred by the breast milk and via NK cell expansion in the neonate.

Organisational and individual readiness for change to respectful maternity care practice and associated factors in Ibadan, Nigeria: a cross-sectional survey

OBJECTIVES

This study assessed health providers' organisational and individual readiness for change to respectful maternity care (RMC) practice and their associated factors in Ibadan Metropolis, Nigeria.

DESIGN

A cross-sectional survey using standardised structured instruments adapted from the literature.

SETTING

Nine public health facilities in Ibadan Metropolis, Nigeria, 1 December 2019-31 May 2020.

PARTICIPANTS

212 health providers selected via a two-stage cluster sampling.

OUTCOMES

Organisational readiness for change to RMC (ORCRMC) and individual readiness for change to RMC (IRCRMC) scales had a maximum score of 5. Multiple linear regression was used to identify factors influencing IRCRMC and ORCRMC. We evaluated previously identified predictors of readiness for change (change valence, informational assessments on resource adequacy, core self-evaluation and job satisfaction) and proposed others (workplace characteristics, awareness of mistreatment during childbirth, perceptions of women's rights and resource availability to implement RMC). Data were adjusted for clustering and analysed using Stata V.15.

RESULTS

The providers' mean age was 44.0±9.9 years with 15.4±9.9 years of work experience. They scored high on awareness of women's mistreatment (3.9±0.5) and women's perceived rights during childbirth (3.9±0.5). They had high ORCRMC (4.1±0.9) and IRCRMC (4.2±0.6), both weakly but positively correlated (r=0.407, 95% CI: 0.288 to 0.514, p<0.001). Providers also had high change valence (4.5±0.8) but lower perceptions of resource availability (2.7±0.7) and adequacy for implementation (3.3±0.7). Higher provider change valence and informational assessments were associated with significantly increased IRCRMC (β=0.40, 95% CI: 0.11 to 0.70, p=0.015 and β=0.07, 95% CI: 0.01 to 0.13, p=0.032, respectively), and also with significantly increased ORCRMC (β=0.47, 95% CI: 0.21 to 0.74, p=0.004 and β=0.43, 95% CI: 0.22 to 0.63, p=0.002, respectively). Longer years of work experience (β=0.08, 95% CI: 0.01 to 0.2, p=0.024), providers' monthly income (β=0.08, 95% CI: 0.02 to 0.15, p=0.021) and the health facility of practice were associated with significantly increased ORCRMC.

CONCLUSION

The health providers studied valued a change to RMC and believed that both they and their facilities were ready for the change to RMC practice.

Contributions of maternal and fetal antiviral immunity in congenital disease

Viral infections during pregnancy can have devastating consequences on pregnancy outcomes, fetal development, and maternal health. In this review, we examine fetal and maternal immune defense mechanisms that mediate resistance against viral infections and discuss the range of syndromes that ensue when such mechanisms fail, from fetal developmental defects to establishment of chronic infection. Further, we highlight the role of maternal immune activation, or uncontrolled inflammation triggered by viral infections during pregnancy, and its potential downstream pathological effects, including tissue damage and fetal demise. Insights into the respective contributions of direct viral toxicity versus fetal and maternal immune responses that underlie the pathogenesis of congenital disease will guide future treatment strategies.

Cardiotocography and beyond: a review of one-dimensional Doppler ultrasound application in fetal monitoring

One-dimensional Doppler ultrasound (1D-DUS) provides a low-cost and simple method for acquiring a rich signal for use in cardiovascular screening. However, despite the use of 1D-DUS in cardiotocography (CTG) for decades, there are still challenges that limit the effectiveness of its users in reducing fetal and neonatal morbidities and mortalities. This is partly due to the noisy, transient, complex and nonstationary nature of the 1D-DUS signals. Current challenges also include lack of efficient signal quality metrics, insufficient signal processing techniques for extraction of fetal heart rate and other vital parameters with adequate temporal resolution, and lack of appropriate clinical decision support for CTG and Doppler interpretation. Moreover, the almost complete lack of open research in both hardware and software in this field, as well as commercial pressures to market the much more expensive and difficult to use Doppler imaging devices, has hampered innovation. This paper reviews the basics of fetal cardiac function, 1D-DUS signal generation and processing, its application in fetal monitoring and assessment of fetal development and wellbeing. It also provides recommendations for future development of signal processing and modeling approaches, to improve the application of 1D-DUS in fetal monitoring, as well as the need for annotated open databases.

Are Extremely Low Gestational Age Newborns Born to Obese Women at Increased Risk of Cerebral Palsy at 2 Years?

The authors hypothesized that the risk of cerebral palsy at 2 years in children born extremely preterm to overweight and obese women is increased relative to the risk among children born to neither overweight nor obese women. In a multicenter prospective cohort study, the authors created multinomial logistic regression models of the risk of diparetic, quadriparetic, and hemiparetic cerebral palsy that included the prepregnancy body mass index of mothers of 1014 children born extremely preterm, cerebral palsy diagnoses of children at 2 years, as well as information about potential confounders. Overweight and obese women were not at increased risk of giving birth to a child who had cerebral palsy. The risk ratios associated with overweight varied between 1.1 for quadriparesis (95% CI = 0.5, 2.1) to 2.0 for hemiparesis (95% CI = 0.4, 9.8). The risk ratios associated with obesity varied between 0.7 for diparesis (95% CI = 0.2, 2.5) to 2.5 for hemiparesis (95% CI = 0.4, 13).

Chorioamnionitis in the Development of Cerebral Palsy: A Meta-analysis and Systematic Review

CONTEXT

Chorioamnionitis (CA) has often been linked etiologically to cerebral palsy (CP).

OBJECTIVES

To differentiate association from risk of CA in the development of CP.

DATA SOURCES

PubMed, Cochrane Library, Embase, and bibliographies of original studies were searched by using the keywords (chorioamnionitis) AND ((cerebral palsy) OR brain).

STUDY SELECTION

Included studies had to have: (1) controls, (2) criteria for diagnoses, and (3) neurologic follow-up. Studies were categorized based on: (1) finding incidence of CP in a CA population, or risk of CP; and (2) incidence of CA in CP or association with CP.

DATA EXTRACTION

Two reviewers independently verified study inclusion and extracted data.

RESULTS

Seventeen studies (125 256 CA patients and 5 994 722 controls) reported CP in CA. There was significantly increased CP inpreterm histologic chorioamnionitis (HCA; risk ratio [RR] = 1.34, P < .01), but not in clinical CA (CCA). Twenty-two studies (2513 CP patients and 8135 controls) reported CA in CP. There was increased CCA (RR = 1.43, P < .01), but no increase in HCA in preterm CP. Increased HCA was found (RR = 4.26, P < .05), as well as CCA in term/near-term CP (RR = 3.06, P < .01).

CONCLUSIONS

The evidence for a causal or associative role of CA in CP is weak. Preterm HCA may be a risk factor for CP, whereas CCA is not. An association with term and preterm CP was found for CCA, but only with term CP for HCA.

Chorioamnionitis in the pathogenesis of brain injury in preterm infants

Chorioamnionitis (or placental infection) is suspected to be a risk factor for brain injury in premature infants. The suggested association between chorioamnionitis and cystic periventricular leukomalacia and cerebral palsy is uncertain because of the variability of study designs and definitions of chorioamnionitis. Improvements in neonatal intensive care may have attenuated the impact of chorioamnionitis on brain health outcomes. Large multicenter studies using rigorous definitions of chorioamnionitis on placental pathologies and quantitative magnetic resonance techniques may offer the optimal way to clarify the complex role of chorioamnionitis in modifying brain health and long-term outcomes.

Sequencing of the IL6 gene in a case-control study of cerebral palsy in children

Background

Cerebral palsy (CP) is a group of nonprogressive disorders of movement and posture caused by abnormal development of, or damage to, motor control centers of the brain. A single nucleotide polymorphism (SNP), rs1800795, in the promoter region of the interleukin-6 (IL6) gene has been implicated in the pathogenesis of CP by mediating IL-6 protein levels in amniotic fluid and cord plasma and within brain lesions. This SNP has been associated with other neurological, vascular, and malignant processes as well, often as part of a haplotype block.

Methods

To refine the regional genetic association with CP, we sequenced (Sanger) the IL6 gene and part of the promoter region in 250 infants with CP and 305 controls.

Results

We identified a haplotype of 7 SNPs that includes rs1800795. In a recessive model of inheritance, the variant haplotype conferred greater risk (OR = 4.3, CI = [2.0-10.1], p = 0.00007) than did the lone variant at rs1800795 (OR = 2.5, CI = [1.4-4.6], p = 0.002). The risk haplotype contains one SNP (rs2069845, CI = [1.2-4.3], OR = 2.3, p = 0.009) that disrupts a methylation site.

Conclusions

The risk haplotype identified in this study overlaps with previously identified haplotypes that include additional promoter SNPs. A risk haplotype at the IL6 gene likely confers risk to CP, and perhaps other diseases, via a multi-factorial mechanism.

Geospatial analyses to identify clusters of adverse antenatal factors for targeted interventions

BACKGROUND

Late antenatal care and smoking during pregnancy are two important factors that are amenable to intervention. Despite the adverse health impacts of smoking during pregnancy and the health benefits of early first antenatal visit on both the mother and the unborn child, substantial proportions of women still smoke during pregnancy or have their first antenatal visit after 10 weeks gestation. This study was undertaken to assess the usefulness of geospatial methods in identifying communities at high risk of smoking during pregnancy and timing of the first antenatal visit, for which targeted interventions may be warranted, and more importantly, feasible.

METHODS

The Perinatal Data Collection, from 1999 to 2008 for south-western Sydney, were obtained from the New South Wales Ministry of Health. Maternal addresses at the time of delivery were georeferenced. A spatial scan statistic implemented in SaTScan was then used to identify statistically significant spatial clusters of women who smoked during pregnancy or women whose first antenatal care visit occurred at or after 10 weeks of pregnancy.

RESULTS

Four spatial clusters of maternal smoking during pregnancy and four spatial clusters of first antenatal visit occurring at or after 10 weeks were identified in our analyses. In the maternal smoking during pregnancy clusters, higher proportions of mothers, were aged less than 35 years, had their first antenatal visit at or after 10 weeks and a lower proportion of mothers were primiparous. For the clusters of increased risk of late first antenatal visit at or after 10 weeks of gestation, a higher proportion of mothers lived in the most disadvantaged areas and a lower proportion of mothers were primiparous.

CONCLUSION

The application of spatial analyses provides a means to identify spatial clusters of antenatal risk factors and to investigate the associated socio-demographic characteristics of the clusters.

Birth weight for gestational age among Flemish twin population

OBJECTIVE

The aim of this study was to develop birth weight references for twins. Mean birth weights of individual twins are lower than those of singletons, hence singleton birth weight curves may not be suitable to assess twin birth weights.

STUDY DESIGN

Twin birth weight curves were developed according to gestational age, gender, parity and mode of -conception. The curves are based on population-based data of 40,494 twins born in Flanders, Belgium between 1987 and 2007.

RESULTS

A different growth potential was found comparing the birth weights of twins and singletons. Twins deviate from the singleton curve from 30 weeks gestational age on.

CONCLUSION

Our study underlines that singleton birth weight curves differ from twin birth weight curves. We developed specific twin birth weight curves can be used in clinical practice in order to follow growth patterns of twins in utero.

The Australian cerebral palsy research study--protocol for a national collaborative study investigating genomic and clinical associations with cerebral palsy

AIM

Previous studies have proposed a link between the presence of specific single nucleotide polymorphisms (SNPs) and cerebral palsy and the majority of these associations remain to be confirmed or rejected by prospective studies with sufficient statistical power. Prior studies have also given little attention to the interaction of genomic characteristics and clinical risk factors.

METHODS

This paper describes the design of a prospective case-control study to test these genetic associations in conjunction with more stringent data collection in respect to clinical features associated with pregnancy, particularly maternal infection. Here we consider the ethical requirements, our hypothesis that genetic susceptibility modifies the risk of cerebral palsy in the presence of perinatal environmental triggers, a priori primary and secondary aims, power calculations, participant recruitment strategies, data linkage, sampling methods of genetic material and subsequent SNP analysis, collection of clinical data and the proposed final statistical analysis.

Chorioamnionitis and brain damage in the preterm newborn

AIM

To evaluate the association between histological chorioamnionitis and brain damage (intraventricular hemorrhage and cystic periventricular leukomalacia) in the preterm newborn.

METHODS

This was a retrospective study on neonates born at less than 34 weeks gestational age, and their respective mothers, at three tertiary medical centers in the north of Portugal, from January 2001 to December 2002.

RESULTS

The study included 452 newborns (235 male/217 female; birth weight 1440 (515-2620) grams; gestational age 31 (23-33) weeks), 125 from mothers whose placenta showed signs of chorioamnionitis and 327 from mothers without the condition. The association between histological chorioamnionitis and: (1) intraventricular hemorrhage grades I-IV was OR 1.43 (95% CI 0.49-3.94); (2) intraventricular hemorrhage grades III and IV was OR 2.49 (95% CI 1.20-5.11); (3) cystic periventricular leukomalacia was OR 3.02 (95% CI 1.50-6.07). The association, adjusted for birth weight and gestational age, between chorioamnionitis and: (1) intraventricular hemorrhage grades III and IV was OR 0.94 (95% CI 0.39-2.28); (2) cystic periventricular leukomalacia was OR 1.94 (95% CI 1.03-4.61). The association between histological chorioamnionitis with funisitis and/or vasculitis and: (1) intraventricular hemorrhage grades I to IV was OR 1.27 (95% CI 0.52-3.10); (2) cystic periventricular leukomalacia was OR 2.08 (95% CI 0.72-5.98).

CONCLUSION

This study confirms the association between histological chorioamnionitis and cystic periventricular leukomalacia, but was unable to confirm the association between histological chorioamnionitis and intraventricular hemorrhage.

The genomic basis of cerebral palsy: a HuGE systematic literature review

Cerebral palsy has been associated with a number of candidate genes. To date, no systematic review has been conducted to synthesise genetic polymorphism associations with cerebral palsy. We apply the HuGE NET guidelines to search PubMed and EMBASE databases for publications investigating single nucleotide polymorphisms (SNPs) and cerebral palsy outcome. 22 papers were identified and are discussed in this review. Candidate genes were grouped as (1) thrombophilic, (2) cytokine, (3) apolipoprotein E or (4) other SNPs, largely related to cardiovascular physiology/pathophysiology and the functioning of the immune system. Of the studies identified, cohorts were usually small, without adequate control and ethnically diverse, making direct comparison between studies difficult. The most promising candidate genes include factor V Leiden, methylenetetrahydrofolate reductase, lymphotoxin-alpha, tumour necrosis factor-alpha, eNOS and mannose binding lectin. Large case-control studies are needed to confirm these candidates with attention given to cohort ethnicity, cerebral palsy subtype analysis and possible multiple gene and gene-environment interactions.

Placental cultures in the era of peripartum antibiotic use

BACKGROUND

Histological examination of the placenta can provide valuable information that aids diagnosis and management for both the mother and the fetus. Positive placental cultures may also provide the clinician with valuable information on which to base therapy.

AIMS

To determine the incidence of positive placental cultures, the association with chorioamnionitis and whether the rate is affected by antibiotic administration in the peripartum period.

METHODS

A retrospective study of placentas submitted for histopathology and microbiology culture in higher risk deliveries over a 12-month period in a laboratory at a tertiary facility. Data collected included gestation age, duration of rupture of membranes, maternal fever, group B Streptococcus status, intrapartum antibiotics, placental culture result and the histopathology result.

RESULTS

Of the 412 placentas submitted, 26% (106 of 412) had histological evidence of in utero inflammation. Sixty-three percent (259 of 412) of placentas were submitted for culture. Of these, only 4.6% (12 of 259) had a positive culture result, with 75% (nine of 12) having histological evidence of acute inflammation. Group B streptococcus and Escherichia coli were the most common isolates. Forty-two per cent (five of 12) of these women had received peripartum antibiotics.

CONCLUSIONS

Positive placental cultures are found in only a small number of placentas with histological evidence of chorioamnionitis and funisitis. The current method of placental swabbing and culture technique is highly specific but not sensitive. The value of performing current routine placental cultures appears limited.

Prevalence and pathogenesis of congenital anomalies in cerebral palsy

BACKGROUND

It has been hypothesised that cerebral palsy (CP) and other congenital anomalies are attributable to feto-fetal transfusion problems in a monochorionic multiple gestation. Thus more than one organ could be compromised leading to the coexistence of two or more anomalies in a fetus. Such anomalies in a singleton birth may be attributable to early demise of the co-conceptus as a vanishing twin.

AIM

To determine whether the coexistence of congenital anomalies and CP is greater than a chance finding by comparing the prevalence of congenital anomalies in children with CP with that in the general population of children.

METHODS

A population-based register of children with CP born in 1966-1991 in the counties of Merseyside and Cheshire, UK, comprised the index population. Coexisting congenital anomalies were recorded. For comparison the population prevalence of congenital anomalies was obtained from eight congenital malformation registers in the UK.

RESULTS

Children with CP were found to have highly significant increases in risk for microcephaly, isolated hydrocephaly, congenital anomalies of the eye, congenital cardiac anomalies, cleft lip and/or palate and congenital dislocation of the hips and talipes (p<0.001) and atresias of the oesophagus (p<0.001) and intestines (p<0.01). The relative risks ranged from 3.1 (95% CI 1.9 to 4.8; p<0.001) for congenital malformations of the cardiac septa to 116.09 (95% CI 84.0 to 162.3; p<0.001) for microcephaly.

CONCLUSIONS

Congenital anomalies in children with CP are found much more frequently than expected by chance. A common pathogenic mechanism may account for the coexistence of disparate congenital anomalies. A hypothesis is proposed for such a common pathogenic mechanism.

Mandatory folic acid fortification in Newfoundland and Labrador

PURPOSE

Dietary folic acid (FA) intakes were analyzed in random samples of 302 young women (aged 18 to 34) and 337 seniors (aged 65 to 74) residing in Newfoundland and Labrador (NL). The analyses were an attempt to estimate the amount of FA they would consume solely because of mandatory fortification of foods.

METHODS

Secondary analysis was performed on raw data collected through single 24-hour recalls as part of a larger study.

RESULTS

The dietary FA contributed by fortified foods eaten in the specified amounts was estimated to be 136 to 148 mcg/day (226 to 247 DFE/day) for young women and 151 to 160 mcg/day (252 to 267 DFE/day) for seniors. Most of this FA was contributed to the diet by enriched white flour.

CONCLUSIONS

Mandatory fortification of foods appears to have improved the total mean intake of folate by young women and seniors residing in NL.

Infections and other inflammatory conditions

The etiology of cerebral palsy and other related perinatal brain injuries is poorly understood. Infections of the central nervous system are rare but important causes of neurodisability. Recent evidence suggests that infections and other inflammatory conditions apparently limited to the placenta are also associated with an increased risk of neurologic impairment. A major hypothesis to explain this connection is that cytokines, activated inflammatory cells, and other mediators of the innate immune response are released into the fetal circulation where they can directly or indirectly affect the development or integrity of the central nervous system. This review surveys the organisms, mediators, and placental lesions that have been associated with perinatal brain injury.

Folate fortification, plasma folate, homocysteine and colorectal adenoma recurrence

In 1996, the US Food and Drug Administration mandated the fortification of grain products with folic acid, a nutrient that has been associated with lower risk of colorectal neoplasia. We assessed the relation of plasma folate and homocysteine and colorectal adenoma recurrence separately in 2 studies: the first involved an intervention of a cereal supplement that contained folic acid, wheat bran fiber (WBF), and the second was conducted primarily during postfortification of the food supply using ursodeoxycholic acid (UDCA). Analyses were stratified for multivitamin use. Results show that plasma folate and homocysteine concentrations were associated with adenoma recurrence among nonusers of multivitamins only. Among nonmultivitamin users, the odds ratio [OR] (95% confidence interval [CI]) for those in the highest versus the lowest folate quartile was 0.65 (0.40-1.06) for the WBF study and 0.56 (0.31-1.02) for the UDCA; likewise, individuals in the highest versus the lowest quartile of homocysteine had higher odds of adenoma recurrence, in both the WBF (OR = 2.25; 95% CI = 1.38-3.66) and UDCA (OR = 1.93; 95% CI = 1.07-3.49) populations. Analyses comparing multivitamin users to different plasma folate concentrations among nonusers show that odds of recurrence for supplement users was lower only when compared to nonusers who had lower concentrations. Our results show that higher plasma folate or lower homocysteine levels are associated with lower odds of recurrence among nonusers of multivitamins in both studies. Our finding, suggesting that multivitamins or supplemental folate only benefit individuals with lower plasma folate concentrations, should be taken into consideration when designing and interpreting results of intervention studies.

Placental assessment: Simple techniques to enhance best practice

BACKGROUND

The placenta provides a 'diary' of the pregnancy. The information provided from pathological assessment of the placenta may provide important clinical information for both the mother and the neonate.

AIMS

To develop tools to ensure histopathological assessment of appropriate placentas and uniform provision of clinical history to pathologists to enable clinicopathological assessment.

METHODS

A placenta information form was devised that included the following clinical criteria: gestational age, prolonged rupture of membranes at term, suspected maternal/fetal bacterial or viral infection, swabs taken for culture, intrauterine growth restriction, perinatal death, pre-eclampsia, essential hypertension, diabetes, placenta praevia, multiple pregnancy and cytogenetics. A table was introduced into the midwifery placenta policy indicating clinical criteria for microbiology, histopathological or cytogenetic assessment. A colourful reminder poster was designed and placed in the delivery suite and education sessions were provided. Six-month review periods were performed prior to and following the two interventions.

RESULTS

The number of placentas submitted for histopathological examination (and meeting the inclusion criteria) increased from 41 (120/296) to 61% (161/266) following the initial interventions and to 82% (262/319) with the introduction of the reminder poster and education sessions. Clinically relevant placental pathology was found in 55 (64%) of cases in these time intervals. Comprehensive clinical history on the pathology report improved from 45 to 98% over the assessment time.

CONCLUSIONS

Valuable information on a pregnancy can be provided by ensuring histopathological examination of appropriate placentas with the simple introduction of placental information sheets, updated midwifery policy, education sessions and a colourful reminder poster.

Neurotropic viruses and cerebral palsy: population based case-control study

OBJECTIVE

To investigate the association between cerebral palsy and direct evidence for perinatal exposure to neurotropic viruses.

DESIGN

Population based case-control study.

SETTING

Adelaide Women's and Children's Hospital Research Laboratory.

PARTICIPANTS AND MAIN OUTCOME MEASURES

Newborn screening cards of 443 white case patients with cerebral palsy and 883 white controls were tested for viral nucleic acids from enteroviruses and herpes viruses by using polymerase chain reaction. Herpes group A viruses included herpes simplex viruses 1 and 2 (HSV-1 and HSV-2), Epstein-Barr virus (EBV), cytomegalovirus (CMV), and human herpes virus 8 (HHV-8), and herpes group B viruses included varicella zoster virus (VZV) and human herpes viruses 6 and 7 (HHV-6 and HHV-7).

RESULTS

The prevalence of viral nucleic acids in the control population was high: 39.8% of controls tested positive, and the prevalence was highest in preterm babies. The detection of herpes group B viral nucleic acids increased the risk of developing cerebral palsy (odds ratio 1.68, 95% confidence interval 1.09 to 2.59).

CONCLUSIONS

Perinatal exposure to neurotropic viruses is associated with preterm delivery and cerebral palsy.

Chorioamnionitis and neonatal encephalopathy in term infants with fetal acidemia: histopathologic correlations

The aim of this study was to determine whether the presence or severity of histologic abnormalities of infection/inflammation such as chorioamnionitis, vasculitis, or funisitis confers an additional risk for neonatal encephalopathy in term infants delivered in the presence of severe fetal acidosis. The medical records as well as placental pathology of term infants (n = 51) born with a cord umbilical arterial pH <7.00 were reviewed. Abnormal outcome was predefined as Sarnat stage 2 or 3 neonatal encephalopathy in the first week of life or neonatal death as a consequence of severe brain injury. Consistent with prior data, the presence of severe fetal acidemia, a low 5-minute Apgar score, and need for cardiopulmonary resuscitation were significantly associated with neonatal encephalopathy. However, the presence of histologic chorioamnionitis had a poor predictive value and did not confer additional risk for the subsequent development of neonatal encephalopathy.

Lipopolysaccharide increases alveolar type II cell number in fetal mouse lungs through Toll-like receptor 4 and NF-κB

Chorioamnionitis is a major cause of preterm delivery. Infants exposed to inflammation in utero and then born preterm may have improved lung function in the immediate postnatal period. We developed a mouse model of chorioamnionitis to study the inflammatory signaling mechanisms that might influence fetal lung maturation. With this in vivo model, we found that Escherichia coli lipopolysaccharide (LPS) increased the number of alveolar type II cells in the fetal mouse lung. LPS also increased type II cell number in cultured fetal lung explants, suggesting that LPS could directly signal the fetal lung in the absence of maternal influences. Using immunostaining, we localized cells within the fetal mouse lung expressing the LPS receptor molecule Toll-like receptor 4 (TLR4). Similar to the signaling pathways in inflammatory cells, LPS activated NF-κB in fetal lung explants. Activation of the TLR4/NF-κB pathway appeared to be required, as LPS did not increase the number of type II cells in C.C3H- Tlr4 Lps-d mice, a congenic strain containing a loss of function mutation in tlr4. In addition, the sesquiterpene lactone parthenolide inhibited NF-κB activation following LPS exposure and blocked the LPS-induced increase in type II cells. On the basis of these data from our mouse model of chorioamnionitis, it appears that LPS specifically activated the TLR4/NF-κB pathway, leading to increased type II cell maturation. These data implicate an important signaling mechanism in chorioamnionitis and suggest the TLR4/NF-κB pathway can influence lung development.