1
|
Chalak L, Redline RW, Goodman AM, Juul SE, Chang T, Yanowitz TD, Maitre N, Mayock DE, Lampland AL, Bendel-Stenzel E, Riley D, Mathur AM, Rao R, Van Meurs KP, Wu TW, Gonzalez FF, Flibotte J, Mietzsch U, Sokol GM, Ahmad KA, Baserga M, Weitkamp JH, Poindexter BB, Comstock BA, Wu YW. Acute and Chronic Placental Abnormalities in a Multicenter Cohort of Newborn Infants with Hypoxic-Ischemic Encephalopathy. J Pediatr 2021; 237:190-196. [PMID: 34144032 DOI: 10.1016/j.jpeds.2021.06.023] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 05/28/2021] [Accepted: 06/14/2021] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To examine the frequency of placental abnormalities in a multicenter cohort of newborn infants with hypoxic-ischemic encephalopathy (HIE) and to determine the association between acuity of placental abnormalities and clinical characteristics of HIE. STUDY DESIGN Infants born at ≥36 weeks of gestation (n = 500) with moderate or severe HIE were enrolled in the High-dose Erythropoietin for Asphyxia and Encephalopathy Trial. A placental pathologist blinded to clinical information reviewed clinical pathology reports to determine the presence of acute and chronic placental abnormalities using a standard classification system. RESULTS Complete placental pathologic examination was available for 321 of 500 (64%) trial participants. Placental abnormalities were identified in 273 of 321 (85%) and were more common in infants ≥40 weeks of gestation (93% vs 81%, P = .01). A combination of acute and chronic placental abnormalities (43%) was more common than either acute (20%) or chronic (21%) abnormalities alone. Acute abnormalities included meconium staining of the placenta (41%) and histologic chorioamnionitis (39%). Chronic abnormalities included maternal vascular malperfusion (25%), villitis of unknown etiology (8%), and fetal vascular malperfusion (6%). Infants with chronic placental abnormalities exhibited a greater mean base deficit at birth (-15.9 vs -14.3, P = .049) than those without such abnormalities. Patients with HIE and acute placental lesions had older mean gestational ages (39.1 vs 38.0, P < .001) and greater rates of clinically diagnosed chorioamnionitis (25% vs 2%, P < .001) than those without acute abnormalities. CONCLUSIONS Combined acute and chronic placental abnormalities were common in this cohort of infants with HIE, underscoring the complex causal pathways of HIE. TRIAL REGISTRATION ClinicalTrials.gov: NCT02811263.
Collapse
Affiliation(s)
- Lina Chalak
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX.
| | - Raymond W Redline
- Department of Pathology, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Amy M Goodman
- Department of Neurology, University of California San Francisco, San Francisco, CA
| | - Sandra E Juul
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
| | - Taeun Chang
- Department of Neurology, Children's National Hospital, George Washington School of Medicine, Washington, DC
| | - Toby D Yanowitz
- Division of Newborn Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh of UPMC and Magee Womens Hospital of UPMC, Pittsburgh, PA
| | - Nathalie Maitre
- Department of Pediatrics and Research Institute, Nationwide Children's Hospital, Columbus, OH
| | - Dennis E Mayock
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
| | | | - Ellen Bendel-Stenzel
- Division of Neonatal Medicine, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN
| | - David Riley
- Department of Pediatrics, Cook Children's Medical Center, Texas Christian University and University of North Texas Health Science Center School of Medicine, Fort Worth, TX
| | - Amit M Mathur
- Department of Pediatrics/Neonatal-Perinatal Medicine, Saint Louis University School of Medicine, St Louis, MO
| | - Rakesh Rao
- Division of Newborn-Medicine, Department of Pediatrics, Washington University School of Medicine, St Louis, MO
| | - Krisa P Van Meurs
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Palo Alto, CA
| | - Tai-Wei Wu
- Division of Neonatology, Fetal and Neonatal Institute, Children's Hospital Los Angeles, Los Angeles, CA; Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Fernando F Gonzalez
- Department of Pediatrics, University of California San Francisco, San Francisco, CA
| | - John Flibotte
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Ulrike Mietzsch
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA; Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | - Gregory M Sokol
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | | | - Mariana Baserga
- Division of Neonatology, Department of Pediatrics, University of Utah, Salt Lake City, UT
| | | | - Brenda B Poindexter
- Division of Neonatology, Department of Pediatrics, Children's Healthcare of Atlanta and Emory University, Atlanta, GA
| | - Bryan A Comstock
- Department of Biostatistics, University of Washington, Seattle, WA
| | - Yvonne W Wu
- Department of Neurology, University of California San Francisco, San Francisco, CA
| |
Collapse
|
2
|
Abstract
BACKGROUND Previous studies of the frequency of cerebral palsy in the United States have found excess prevalence in black children relative to other groups. Whether the severity of cerebral palsy differs between black and white children has not previously been investigated. METHODS A population-based surveillance system in 4 regions of the United States identified 476 children with cerebral palsy among 142,338 8-year-old children in 2006. Motor function was rated by the Gross Motor Function Classification System and grouped into 3 categories of severity. We used multiple imputation to account for missing information on motor function and calculated the race-specific prevalence of each cerebral palsy severity level. RESULTS The prevalence of cerebral palsy was 3.7 per 1000 black children and 3.2 per 1000 white children (prevalence odds ratio [OR] = 1.2 [95% confidence interval = 1.0-1.4]). When stratified by severity of functional limitation, the racial disparity was present only for severe cerebral palsy (black vs. white prevalence OR=1.7 [1.1-2.4]). The excess prevalence of severe cerebral palsy in black children was evident in term and very preterm birth strata. CONCLUSION Black children in the United States appear to have a higher prevalence of cerebral palsy overall than white children, although the excess prevalence of cerebral palsy in black children is seen only among those with the most severe limitations. Further research is needed to explore reasons for this disparity in functional limitations; potential mechanisms include racial differences in risk factors, access to interventions, and under-identification of mild cerebral palsy in black children.
Collapse
|
3
|
Epelman M, Daneman A, Chauvin N, Hirsch W. Head Ultrasound and MR imaging in the evaluation of neonatal encephalopathy: competitive or complementary imaging studies? Magn Reson Imaging Clin N Am 2011; 20:93-115. [PMID: 22118595 DOI: 10.1016/j.mric.2011.08.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Magnetic resonance (MR) imaging is superior to ultrasonography (US) for the evaluation and prognostication of neonates with neonatal encephalopathy (NE). Nonetheless, US may provide important information early in the course of NE and can be used to document the evolution of lesions. This article provides an overview of useful findings in the US evaluation of infants with NE. Although many of the findings do not appear as conspicuous or as extensively as they do on MR imaging, recognition and familiarity with subtle head US abnormalities may allow head US to play an important complementary role to MR imaging in the evaluation of infants with NE.
Collapse
Affiliation(s)
- Monica Epelman
- Department of Radiology, The Children's Hospital of Philadelphia, PA 19104, USA.
| | | | | | | |
Collapse
|
4
|
Boog G. [Cerebral palsy and perinatal asphyxia (II--Medicolegal implications and prevention)]. ACTA ACUST UNITED AC 2011; 39:146-73. [PMID: 21354846 DOI: 10.1016/j.gyobfe.2011.01.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2011] [Accepted: 01/18/2011] [Indexed: 01/18/2023]
Abstract
Obstetric litigation is a growing problem in developed countries and its escalating cost together with increasing medical insurance premiums is a major concern for maternity service providers, leading to obstetric practice cessation by many practitioners. Fifty-four to 74 % of claims are based on cardiotocographic (CTG) abnormalities and their interpretation followed by inappropriate or delayed reactions. A critical analysis is performed about the nine criteria identified by the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics in their task force on Neonatal Encephalopathy and Cerebral Palsy: four essential criteria defining neonatal asphyxia and five other suggesting an acute intrapartum event sufficient to cause cerebral palsy in term newborns. The importance of placental histologic examination is emphasized in order to confirm sudden catastrophic events occurring before or during labor or to detect occult thrombotic processes affecting the fetal circulation, patterns of decreased placenta reserve and adaptative responses to chronic hypoxia. It may also exclude intrapartum hypoxia by revealing some histologic patterns typical of acute chorioamnionitis and fetal inflammatory response or compatible with metabolic diseases. Magnetic resonance imaging (MRI) of the infant's damaged brain is very contributive to elucidate the mechanism and timing of asphyxia in conjunction with the clinical picture, by locating cerebral injuries predominantly in white or grey matter. Intrapartum asphyxia is sometimes preventable by delivering weak fetuses by cesarean sections before birth, by avoiding some "sentinel" events, and essentially by responding appropriately to CTG anomalies and performing an efficient neonatal resuscitation. During litigation procedures, it is necessary to have access to a readable CTG, a well-documented partogram, a complete analysis of umbilical cord gases, a placental pathology and an extensive clinical work-up of the newborn infant including cerebral MRI. Malpractice litigation in obstetric care can be reduced by permanent CTG education, respect of national CTG guidelines, use of adjuncts such as fetal blood sampling for pH or lactates, regular review of adverse events in Clinical Risk Management (CRM) groups and periodic audits about low arterial cord pH in newborns, admission to neonatal unit, the need for assisted ventilation and the decision-to-delivery interval for emergency operative deliveries. Considering the fast occurrence of fetal cerebral hypoxic injuries, and thus despite an adequate management, many intrapartum asphyxias will not be preventable. Conversely, well-documented hypoxic-ischemic brain insults during the antenatal period do not automatically exclude intrapartum suboptimal obstetric care.
Collapse
Affiliation(s)
- G Boog
- Service de gynécologie-obstétrique, hôpital Mère-et-Enfant, CHU de Nantes, 38 boulevard Jean-Monnet, Nantes cedex 1, France.
| |
Collapse
|
5
|
Abstract
CONTEXT Although preterm delivery is a well-established risk factor for cerebral palsy (CP), preterm deliveries contribute only a minority of affected infants. There is little information on the relation of CP risk to gestational age in the term range, where most CP occurs. OBJECTIVE To determine whether timing of birth in the term and postterm period is associated with risk of CP. DESIGN, SETTING, AND PARTICIPANTS Population-based follow-up study using the Medical Birth Registry of Norway to identify 1,682,441 singleton children born in the years 1967-2001 with a gestational age of 37 through 44 weeks and no congenital anomalies. The cohort was followed up through 2005 by linkage to other national registries. MAIN OUTCOME MEASURES Absolute and relative risk of CP for children surviving to at least 4 years of age. RESULTS Of the cohort of term and postterm children, 1938 were registered with CP in the National Insurance Scheme. Infants born at 40 weeks had the lowest risk of CP, with a prevalence of 0.99/1000 (95% confidence interval [CI], 0.90-1.08). Risk for CP was higher with earlier or later delivery, with a prevalence at 37 weeks of 1.91/1000 (95% CI, 1.58-2.25) and a relative risk (RR) of 1.9 (95% CI, 1.6-2.4), a prevalence at 38 weeks of 1.25/1000 (95% CI, 1.07-1.42) and an RR of 1.3 (95% CI, 1.1-1.6), a prevalence at 42 weeks of 1.36/1000 (95% CI, 1.19-1.53) and an RR of 1.4 (95% CI, 1.2-1.6), and a prevalence after 42 weeks of 1.44 (95% CI, 1.15-1.72) and an RR of 1.4 (95% CI, 1.1-1.8). These associations were even stronger in a subset with gestational age based on ultrasound measurements: at 37 weeks the prevalence was 1.17/1000 (95% CI, 0.30-2.04) and the relative risk was 3.7 (95% CI, 1.5-9.1). At 42 weeks the prevalence was 0.85/1000 (95% CI, 0.33-1.38) and the relative risk was 2.4 (95% CI, 1.1-5.3). Adjustment for infant sex, maternal age, and various socioeconomic measures had little effect. CONCLUSION Compared with delivery at 40 weeks' gestation, delivery at 37 or 38 weeks or at 42 weeks or later was associated with an increased risk of CP.
Collapse
Affiliation(s)
- Dag Moster
- Department of Public Health and Primary Health Care, University of Bergen, PO Box 7804, N-5020 Bergen, Norway.
| | | | | | | | | |
Collapse
|