Obstetrical-neonatal neurological relationship. A replication study

Prevalence of neurological soft signs and their neuropsychological correlates in typically developing Chinese children and Chinese children with ADHD

This study examined prevalence of soft signs in 214 typically developing Chinese children and investigated whether soft signs are associated with attention deficit hyperactivity disorder (ADHD) in this population. Chinese children with ADHD (N = 54) scored significantly higher than age-matched controls on all three soft signs subscales and motor coordination correlated significantly with Stroop interference. Logistic regression supported the utility of the soft sign scales in discriminating children with ADHD and controls. Children with ADHD had a significant excess of soft signs, which may be a useful marker of developmental disruption in this clinical condition.

High risk pregnancy monitored antenatally at home

OBJECTIVE

Is domiciliary antenatal fetal surveillance for selected high risk pregnancies, a feasible alternative for hospital admission?

DESIGN

A randomized controlled trial conducted at the Academical Medical Centre, Amsterdam, The Netherlands.

SUBJECTS

Between September 1992 and June 1994, 76 women were at random allocated to domiciliary care and 74 women to hospital care. Criteria for inclusion were hypertension (26%), fetal growth retardation (24%), post term pregnancy (23%), diabetes (24%), preterm rupture of membranes (2%) and previous recurrent antenatal death (1%).

MAIN OUTCOME MEASURES

Primary outcome measure was perinatal morbidity, measured by Prechtl's neonatal neurological optimality score. Secondary outcome variables were the occurrence of complications, obstetric interventions at labour, birthweight, gestational age at delivery and maternal and neonatal admission rates.

RESULTS

In both groups there was one case of perinatal mortality. In both treatment groups the median of the neurological optimality score was found at 59. Also secondary outcome variables did not show significant differences.

CONCLUSION

Domiciliary antenatal care for selected women with high risk pregnancy is feasible considering obstetric outcome.

Comparison of intrapartum electronic fetal heart rate monitoring versus intermittent auscultation in detecting fetal acidemia at birth

OBJECTIVE

Our purpose was to compare continuous intrapartum electronic fetal heart rate monitoring with intermittent auscultation for detecting fetal acidemia at birth.

STUDY DESIGN

Data from a previously published randomized trial of electronic fetal heart rate monitoring versus intermittent auscultation were analyzed to identify any differences between the two methods in detecting fetal acidemia at birth. Fetal acidemia at birth was defined as the presence of cord blood arterial pH < 7.15.

RESULTS

A total of 1419 patients with umbilical cord blood acid-base measurements were identified, 739 in the electronic FHR monitoring group and 680 in the auscultation group. Electronic FHR monitoring had significantly better sensitivity (97% vs 34%, p < 0.001), lower specificity (84% vs 91%, p < 0.001), higher positive predictive value (37% vs 22%, p < 0.05), and higher negative predictive value (99.5% vs 95%, p < 0.001) in detecting fetal acidemia at birth. In addition, electronic FHR monitoring was significantly better in detecting all types of acidemia: metabolic (95.5% vs 26.5%, p < 0.001), mixed (95% vs 37.5%, p < 0.001), and respiratory (100% vs 41.5%, p < 0.001).

CONCLUSION

These data suggest that electronic FHR monitoring is superior to intermittent auscultation in detecting fetal acidemia at birth.

Obstetric complications in histories of monozygotic twins discordant and concordant for schizophrenia

Histories of obstetric complications (OCs) during pregnancy, labor-delivery and the neonatal period were investigated by detailed maternal report for 23 monozygotic (MZ) twin pairs discordant for schizophrenia, 10 MZ twin pairs concordant for schizophrenia and 7 normal MZ control pairs. Statistically significant differences in OC rates were found across these 3 groups. OCs being most frequent in discordant pairs and least frequent in normal control pairs. Labor complications were significantly more frequent in discordant than concordant pairs. OC rates were equivalent in sick and well discordant twins. The results provide evidence for the role of OCs in the development of schizophrenia, complications at the time of birth being especially associated with the development of schizophrenia in discordant twins.

Acid-base status at birth and subsequent neurosensory impairment in surviving 500 to 1000 gm infants

OBJECTIVE

The purpose of this study was to assess, in infants born weighing < or = 1000 gm, if umbilical cord blood acid-base measures at birth are associated with an additional increase in neurosensory impairment.

STUDY DESIGN

Of 289 surviving infants with a birth weight of 500 to 1000 gm born from 1979 to 1989, 219 had umbilical cord acid-base status measured at birth and were followed prospectively for > or = 1 year. Measures of neurologic impairment used in this study included mental retardation, cerebral palsy, and major neurosensory impairment.

RESULTS

Gestational age was inversely associated with all neurosensory impairments and was a better predictor of subsequent impairment in this population than was birth weight. Very low umbilical cord pH values were also significantly related to adverse outcomes. There was also an inverse relationship between cord blood bicarbonate levels and major neurosensory impairment. The highly significant relationship between cord blood bicarbonate and pH values and the development of neurosensory impairments persisted in spite of adjustment for gestational age, birth weight, plurality, use of general anesthesia, maternal race, and presence of hypertension.

CONCLUSION

An adverse acid-base status at birth is additive to the effect of gestational age in predicting neurosensory impairment in infants weighing < or = 1000 gm.

Obstetrical complications in patients with bipolar disorder and their siblings

Although indirect evidence suggests that obstetric complications are risk factors for bipolar disorder, few studies have directly addressed this question. Probands with bipolar disorder and their adult siblings were diagnosed according to DSM-III-R criteria by clinicians who had no knowledge of the subjects' obstetrical histories. Hospital records on gestations and births of 16 probands and 20 of their siblings without major mood disorders were scored for obstetric complications without knowledge of diagnosis. The assessment of obstetrical history was based on rating scales that have proved reliable and that reflect the number and severity of complications. Overall complication scores were significantly more severe in probands than siblings. Differences were most marked for perinatal complications.

Minor neurological dysfunction from birth to 12 years. II: Puberty is related to decreased dysfunction

To determine whether puberty is related to decreased minor neurological dysfunction (MND), 174 children from the Groningen Perinatal Project who had had MND at nine years were re-examined at 12 years. No signs of MND could be demonstrated in 39 of the children, 33 of whom showed at least three signs of puberty. The presence of minor physical anomalies was associated with persisting MND. The authors hypothesise that puberty is related to a decrease in MND, and discuss the role of hormonal changes in relation to the decrease in minor signs. Re-examination at 14 years will be necessary to confirm this hypothesis, since 68 per cent of the children had not yet reached puberty. Children with MND reached puberty no later than those without.

Minor neurological dysfunction from birth to 12 years. I: Increase during late school-age

To study the hypothesis that the frequency of minor neurological dysfunction (MND) stabilizes around the age of nine years, two groups of the Groningen Perinatal Project (GPP) were re-examined at 12 years. The study group (N = 174) was selected on the basis of the presence of MND at nine years; the control group comprised 172 neurologically normal children. The hypothesis was rejected: extrapolation of the findings to the total GPP population showed that the over-all rate of MND increased. Control children who developed MND were mainly boys who had been neurologically abnormal at birth or were born preterm and/or had experienced an adversity in combination with asphyxia. Interval complications between nine and 12 years were related to the emergence of MND.

Hard neurologic signs and psychopathology in relatives of schizophrenic patients

Previous research found more hard neurologic signs (i.e., signs that have localizing significance and exclude likely artifacts) in the nonschizophrenic relatives of schizophrenic patients than in control subjects, and in the psychiatrically normal relatives of schizophrenic patients compared with their ill relatives. Using interview-based DSM-III-R diagnoses and standard clinical neurological examinations on new samples, we found a trend to more hard signs in the 52 nonschizophrenic relatives of schizophrenic patients than in 20 control subjects, and significantly more signs in psychiatrically normal relatives than in ill ones. When pooled with previous data, signs were significantly higher in (1) relatives vs. controls and (2) normal vs. ill relatives, suggesting neurologic signs reflect an etiologic factor that often runs in families of schizophrenic patients.

Nocturnal enuresis and minor neurological dysfunction at 12 years: a follow-up study

On follow-up at 12 years to assess the relationship between minor neurological dysfunction (MND) and primary nocturnal enuresis (NE), the frequency of NE was found to be significantly higher in children with MND (N = 167) than in those who were neurologically normal (N = 174). There was no relationship between NE and sex in the MND group, nor with the neonatal neurological condition. Among MND children, those with NE more often had language comprehension and arithmetic problems and they required special help for behavioural problems more than did those without such problems. The relationship between NE and MND was affected by socio-economic class and family history. It is concluded that children with MND are more vulnerable to NE, particularly in the presence of lower social class and a positive family history.

Neonatal neurological morbidity in relation to obstetrical and social conditions in Grenada (Caribbean)

Neonatal morbidity, in particular neurological morbidity is a more relevant measure of the effectiveness of obstetrical care than perinatal mortality. Neurological morbidity was assessed in a birth cohort in Grenada, and appeared to be lower than in a reference group examined in Groningen, the Netherlands, in 1975-1978. Perinatal mortality, however, was higher. The results support the thesis that some children may have died who, if they would have survived, would have been neurologically abnormal. It is concluded that whereas a decrease in perinatal deaths is an essential goal in Grenada, a concomitant increase in morbidity should be carefully avoided.

Acid-base status at birth and neurodevelopmental outcome at four and one-half years

Two hundred thirty term infants with measured acid-base status in umbilical arterial blood at birth were selected from 1210 consecutive deliveries for detailed neurodevelopmental follow-up at age 4 1/2 years; 203 were examined. Cutoff points approximately 1 SD from the mean (pH less than or equal to 7.10; base deficit greater than 12 mmol/L) were used to define acidosis. No statistically significant associations between acidosis and developmental outcome were found. The highest proportion of unimpaired children was found among those who were most severely acidotic at birth (pH less than or equal to 7.04; 2 SD below mean), but this finding was not statistically significant. These findings suggest that the ability of the fetus to produce an acidosis in response to the stress of labor may be beneficial to long-term outcome. The 10 nonacidotic babies with 1-minute Apgar scores of less than or equal to 3 showed statistically significant deficits in some areas. Coincident acidosis was not associated with a worse outcome for infants with low Apgar scores.

Perinatal correlates of major and minor neurological dysfunction at school age: a multivariate analysis

A prospective study was carried out on 747 infants: 147 neurologically abnormal, 300 with mild neurological abnormalities and 300 normal infants. They were re-examined at nine years of age, with special attention being paid to minor neurological dysfunction (MND). Extensive data on obstetrical history, neonatal course and interval complications were collected. Neurological handicap was not found on follow-up in the group of normal newborns. Other than neonatal neurological abnormality, risk factors contributing significantly to later handicap were low one-minute Apgar scores, a disturbed neonatal course, low social-class and interval complications; obstetrical events were conspicuous by their absence. Two aetiologically and clinically distinct kinds of MND were distinguished on the basis of a neurological cluster profile: MND-1 (one or two abnormal clusters) was only associated with a birthweight below the 2.3 centile and male gender, and MND-2 (more than two abnormal clusters) was associated with neonatal neurological findings, social class, obstetrical optimality score and gender.

Perinatal risk factors and minor neurological dysfunction: significance for behaviour and school achievement at nine years

A prospective study was carried out on 133 neurologically deviant infants, 205 with mild abnormalities and 230 normal newborns to compare behavioural and cognitive development with neonatal and nine-year-old neurological condition. Overtly handicapped children were excluded. Major determinants of school failure were the severity of minor neurological dysfunction (MND) and social class. Main risk factors for distractable and clumsy behaviour were MND classification and male sex; for troublesome behaviour male sex and interval complications after two years of age; and for timid behaviour, family adversity. Definite neonatal neurological deviancy contributed both directly and by its association with MND to problems in behaviour and scholastic abilities. Mild neonatal neurological abnormalities and adverse obstetrical events contributed only indirectly to behavioural and learning problems. Preterm birth (less than 34 weeks) was the sole obstetric variable directly related to some of the outcome variables. The difference between home and school perception of the children's behaviour is emphasized.

Preterm or small-for-gestational-age infants. Neurological and behavioural development at the age of 6 years

In 166 full term, small-for-gestational-age (FT-SGA), 53 preterm, appropriate-for-gestational-age (PT-AGA), 27 PT-SGA and 206 FT-AGA infants a neurological examination at the age of 6 years was carried out. Data were collected on behaviour and school achievement. Major and minor neurological abnormalities were more frequent in the three low birth weight groups, especially in the PT-SGA group. Multivariate analysis showed that the development of major and minor neurological abnormalities was explained by a varying set of risk factors, in which besides prematurity and growth retardation, neonatal neurological condition, social class, neonatal course and interval complications were preponderant. The results suggest a temporal difference in potentially harmful factors: for neurological handicap early in pregnancy, for minor neurological dysfunction (MND) the second half of gestation and the first 2 years of life. No striking behavioural differences were found between the three low birth weight groups and the FT-AGA group; behaviour was related to neonatal and follow-up neurological condition, sex, gestational age and birth weight to a limited extent only. Three (4%) of the preterms entered a special school (already at the age of 6). School achievement was mainly related to the present neurological condition and social class, which underlines the importance of the latter.

Hypotonia at six years in prematurely-born or small-for-gestational-age children

A neurological follow up study was done of 143 full-term infants who were small for gestational age based on intrauterine growth retardation and of 49 preterm appropriate-for-gestational-age (PTAGA) infants at the age of 6 years. Findings were compared with those of a reference group of 192 full-term appropriate-for-gestational-age (FTAGA) children. In 11% of the children of both study groups, hypotonia was found without any other neurological deviancy. This type of hypotonia was absent in the reference group, whereas minor neurological dysfunction consisting of hypotonia with other neurological signs was found in all the three groups of children. No relation was found with obstetrical or neonatal variables, including severity of growth retardation and gestational age, or with weight, body height or head circumference at 6 years. The possible interference of preterm birth or intrauterine growth retardation with, and the role of placental mechanisms in, fetal and early postnatal muscle development is discussed.

Abnormal antepartum fetal heart rate patterns and subsequent handicap

In this paper data on abnormal antepartum FHR patterns are related to the state of fetal oxygenation, fetal brain abnormalities and to neurological outcome. It is concluded that in IUGR fetuses changes in heart rate (and movement) patterns are late signs of impairment. Antepartum heart rate decelerations are usually the first of the abnormalities detected and are associated with fetal hypoxaemia. A fixed or flat FHR pattern might be indicative of congenital malformations of the brain or of prenatally acquired encephalopathy. Several studies have shown that antepartum FHR abnormalities (usually late decelerations) are associated with an increased risk of subsequent handicap. This risk is related to the degree of FHR abnormality, and especially applies to infants born preterm and/or growth-retarded. Late (ante partum) FHR decelerations seem to be more important than 'asphyxia' at birth in determining (neonatal) neurological outcome. In IUGR hypoxaemia is probably associated with deprivation of other nutrients, and thus brain damage in these infants is more likely to be due to chronic malnutrition (including hypoxaemia) than to hypoxaemia alone. This reasoning is supported by morphological findings in IUGR infants. In general fetuses should be delivered before antepartum signs of hypoxaemia appear. Doppler blood--velocity waveform analyses of fetal vessels may detect fetuses at risk for antepartum decelerations, but until now there has been insufficient information about false-positive abnormal velocity waveforms to depend absolutely on these. Furthermore, delivery at an earlier age may increase the risk of other neonatal complications.

Apgar score, meconium and acidaemia at birth in small-for-gestational age infants born at term, and their relation to neonatal neurological morbidity

Neonatal neurological morbidity was studied in relation to Apgar score, meconium stained amniotic fluid and acidaemia at birth in 247 small-for-gestational age (SGA) maturely born infants. SGA infants, and especially the severely SGA infants and those born abdominally, showed higher rates of neurological morbidity, acidaemia and meconium stained amniotic fluid than appropriate-for-gestational age (AGA) controls. The examined indicators of asphyxia at birth showed slightly higher correlation coefficients with the 'neonatal neurological optimality score' (NNOS) in SGA, than in AGA term infants, but the percentage of explained variance was low, except in the 23 infants born abdominally. In this group poor neurological outcome was restricted to the 14 infants who showed signs of fetal hypoxaemia diagnosed by decelerative fetal heart rate (FHR) patterns. In 11 of them, FHR decelerations occurred antepartum. These FHR abnormalities appear to be better predictors for the neonatal neurological outcome than indicators of asphyxia at birth.

The cognitive development of low-birthweight children

The cognitive development of 30 preterm infants and 40 growth-retarded infants was studied in comparison with 105 control children. Half of the study group had a neurologically suspect/abnormal diagnosis at birth, while the other half was neurologically normal. IQ tests of the low-birthweight group at age 4.5-6 years showed no delay in comparison with the group that was born at term and on-weight. Piagetian tests indicated an interaction effect in which the group which was born at term, on-weight and neurologically normal scored best. In the analysis of the whole cognitive battery, the neurologically suspect/abnormal group achieved significantly worse than the neurologically normal group.

Neurologically deviant newborns: neurological and behavioural development at the age of six years

Of 1655 newborns examined neurologically at term, 80 were found to be abnormal. 76 were traced at six years of age, together with a control group of 77 neonatally normal children. In the study group five children had died, six were severely handicapped and 21 had minor neurological dysfunction (MND). In the control group two had died and four had MND. Obstetrical and neonatal paediatric effects, as well as complications in the intervening years, appeared to have a cumulative effect on the relationship between the neonatal neurological condition and the neurological findings at six years. There were no large differences in behaviour between the study group and the controls, but the study-group MND children showed a stronger tendency for undesirable behaviour and poor school achievements. Although environmental influences are preponderant for the development of behaviour and school performance, a contribution of both neonatal and later neurological conditions seems likely.

Apgar score, meconium and acidaemia at birth in relation to neonatal neurological morbidity in term infants

The relation between Apgar score, meconium and acidaemia at birth and neonatal neurological morbidity was investigated in 805 vaginally born term infants whose birthweight was appropriate-for-dates (AFD). Presence or absence of meconium stained amniotic fluid was not related to the neonatal neurological condition. The 1-min and 3-min Apgar scores and the umbilical artery pH were related, but the variances explained in neonatal neurological optimality score were very low (0.9 and 0.5% respectively). Combination of Apgar score and pH slightly increased these percentages to 1.5. The highest frequency of neurologically deviant infants was, on the other hand, found in the group with a normal pH but low Apgar score. It is concluded that in AFD term infants nowadays the predictive value of a low Apgar score, acidaemia at birth and/or presence of meconium for the neonatal neurological morbidity is poor. Most neonatal neurological abnormalities must be due to other factors.

Long-term follow-up of children prenatally exposed to ritodrine

In a group of 78 6-year-old children exposed to ritodrine treatment during pregnancy for an average of 28.2 days and in two matched control groups, no statistically significant differences could be found regarding urinalysis, body-length, weight, head circumference, neurological findings, and general behaviour as perceived by parents and teachers. However, school performances of ritodrine-treated children, as estimated by the teacher of the infant school, were considered to be less good. Whether this difference can be attributed to exposure to ritodrine or should rather be explained by the less favourable obstetric situation, which led to imminent preterm delivery, is an unsolved question.

Neonatal outcome after treatment with ritodrine: a controlled study

Neonatal condition was assessed in a group of 82 infants born at term after maternal treatment with ritodrine for an average of 28.5 days, and compared with that in a matched control group of infants. No statistically significant differences were found in umbilical pH, Apgar scores, head circumference, and neurological condition. Although the difference was not statistically significant, doubt remains as to a possible icterogenic effect of ritodrine.