Minimal brain dysfunction in children born in breech presentation

A Systematic Review and Meta-analysis of Prenatal, Birth, and Postnatal Factors Associated with Attention-Deficit/Hyperactivity Disorder in Children

Previous studies have shown mixed results on the relationship between prenatal, birth, and postnatal ("pregnancy-related") risk factors and attention-deficit/hyperactivity disorder (ADHD). We conducted meta-analyses to identify potentially modifiable pregnancy-related factors associated with ADHD. A comprehensive search of PubMed, Web of Science, and EMBASE in 2014, followed by an updated search in January 2021, identified 69 articles published in English on pregnancy-related risk factors and ADHD for inclusion. Risk factors were included in the meta-analysis if at least three effect sizes with clear pregnancy-related risk factor exposure were identified. Pooled effect sizes were calculated for ADHD overall, ADHD diagnosis, inattention, and hyperactivity/impulsivity. Odds ratios (OR) were calculated for dichotomous measures and correlation coefficients (CC) for continuous measures. Prenatal factors (pre-pregnancy weight, preeclampsia, pregnancy complications, elevated testosterone exposure), and postnatal factors (Apgar score, neonatal illness, no breastfeeding) were positively associated with ADHD overall; the findings for ADHD diagnosis were similar with the exception that there were too few effect sizes available to examine pre-pregnancy weight and lack of breastfeeding. Prenatal testosterone was significantly associated with inattention and hyperactivity/impulsivity. Effect sizes were generally small (range 1.1-1.6 ORs, -0.16-0.11 CCs). Risk factors occurring at the time of birth (perinatal asphyxia, labor complications, mode of delivery) were not significantly associated with ADHD. A better understanding of factors that are consistently associated with ADHD may inform future prevention strategies. The findings reported here suggest that prenatal and postnatal factors may serve as potential targets for preventing or mitigating the symptoms of ADHD.

Efficacy of metformin on pregnancy complications in women with polycystic ovary syndrome: a meta-analysis

OBJECTIVE

To evaluate the efficacy of metformin administration throughout pregnancy on pregnancy-related complications in women with polycystic ovary syndrome (PCOS).

STUDY DESIGN

MEDLINE and ScienceDirect were searched to retrieve relevant trials. The endpoint was the incidence of complications of pregnancy, gestational diabetes mellitus (GDM), pre-eclampsia (PE), miscarriage and premature birth included.

RESULTS

Five studies with 502 PCOS patients with metformin administration throughout pregnancy and 427 controls who used metformin just to get conception were included in our meta-analysis. In study group, a significantly lower change of emerging miscarriage and premature birth was observed, the pooled relative risk (RR) was 0.32 (95% confidence interval (CI): 0.19-0.56) for miscarriage and 0.40 (95%CI: 0.18-0.91) for premature birth. No significant difference was demonstrated in emerging GDM and PE.

CONCLUSIONS

Metformin therapy throughout pregnancy can reduce the RR of miscarriage and premature birth incidence in PCOS patients with no serious side effects.

Long-term outcome in term breech infants with low Apgar score--a population-based follow-up

OBJECTIVE

To investigate the relation between low Apgar score in breech infants and handicap in childhood.

STUDY DESIGN

A case-control study. A questionnaire to mothers of 323 non-malformed, singleton infants delivered in breech presentation at term, 105 cases with Apgar score below 7 at 5 min and 218 controls.

RESULTS

Four cases (4.6%) and one control (0.5%) had cerebral palsy. In infants without cerebral palsy, speech/language problems were more frequent than controls (10.6 versus 3.2%) (P=0.02). There were no differences in rates of deficits in attention, motor control and perception (DAMP), epilepsy, cognitive developmental delay or learning disabilities. Absence of any handicap or disability was reported in 65 cases (75%) compared to 172 controls (92%) (OR: 3.9; 95% CI: 1.9-7.9).

CONCLUSION

Even though low Apgar score indicates an increased risk of neurological sequelae, most (75%) breech infants with low Apgar score are without a handicap/disability at follow-up.

Delivery of breech presentation infants at term. An analysis of 304 breech-deliveries

304 breech presentation infants greater than or equal to 2.500 g were delivered at the University Women's Clinic, Kiel, between 1984 and 1987. Only 2 of the vaginally delivered infants died; both had severe malformations sonographically diagnosed prior to delivery. The umbilical cord arterial PH was found to be significantly (p less than 0.001) higher in infants delivered per Caesarean Section as compared to those vaginally delivered. The same ratio was found in a control group of vaginally delivered infants compared to sectioned infants in the vertex presentation. In 13.3% of cases post primary section and in 14.4% of cases post vaginal delivery from breech presentation we found an apgar of less than or equal to 7 one minute post-partum. The transfer rate to a paediatric unit of vaginally delivered infants (7.2%) appeared to be double that of the infants delivered per Caesarean Section (3.6%). However, the indication for transferral is principally independent of the mode of delivery. Taking the 3-12fold increased maternal mortality rate post section as compared to vaginal delivery into consideration, a vaginal delivery of a breech presentation infant at term appears to be justifiable under certain presuppositions: exclusion of cranio-pelvic disproportion, and normal progression of labour. The indication for secondary Caesarean Section should be generously applied in cases of a suspicious C.T.G. and a slow progression of labour.

Birth trauma and brain damage

Birth trauma is a rare primary cause of perinatal death, occurring at most only once in every 1000-2000 births. As a cause of brain damage and later handicap it is often difficult to dissociate injury at birth from the concomitant effects of asphyxia, growth retardation or preterm delivery. A continuum of reproductive casualty has been postulated, but for trauma is not proven. Among children with cerebral palsy and severe mental retardation trauma may be implicated in a few cases, possibly 1-2 of 1000 deliveries. Vaginal breech delivery has been related to a higher incidence of minimal brain damage syndromes and some of this damage probably has its origin in perinatal trauma. The pregnancies where there is particular risk of birth trauma include those where the infant is large for gestational age, has intrauterine growth retardation, is delivered preterm, is vaginally delivered in breech presentation or is from multiple gestation. Particular care must be given to diagnosis and preventive measures in these cases and competent handling is required if the disaster of brain damage caused by traumatic birth is to be minimized.

Role of asphyxia and slow intrauterine growth in morbidity among breech delivered infants

The outcome of breech delivery was evaluated by a neonatal neurological score and a follow-up examination at 18 months of age. The subjects were 132 children identified by ultrasound to be in breech presentation in the 33rd gestational week. 62 were born in breech presentation, while 70 turned to vertex presentation. During the early neonatal period, a neurological score was obtained based on the results of 29 items concerning posture, muscle tone, reflexes and reactions. Although there was no difference, in neurological score or in general development when the entire breech and vertex groups were compared, the SGA (small-for-gestational age) infants and the infants with low Apgar scores of the breech group had the poorest neurological scores. The contribution of certain maternal and fetal factors to postnatal condition was evaluated by a multiple linear regression analysis. Within the breech group, relationships were found between the neurological score and the variables intrauterine growth, fetal sex, and low Apgar score. A major part (66%) of the variation in neurological score was explained by the combination of these variables. These factors should therefore be taken into consideration when deciding on the mode of delivery in breech presentation.

Modern strategy for the term breech delivery--a study with a 4-year follow-up of the infants

In a comprehensive 4-year follow-up study the long-term outcomes in 709 singleton term breech born infants were evaluated. The outcome has been related to different management protocols during two consecutive study periods. In the first period (A, 1971-1974) the rate of cesarean section was 16.1% and in the second period (B, 1974-1977) 37.1%. The neonatal mortality rate was the same in both study periods (0.3%). The incidence of long-term neurodevelopmental handicaps was in period A 5.3% and in period B 2.4% at 4 years of age. Sequelae among infants in period A were in most cases labor-related, i.e. footling, extended arms or difficulty in descent of the fetal head. An antero-posterior diameter of less than 12 cm at the brim was common in these cases. In both study periods there was an increased risk of neurodevelopmental handicaps for infants with hyperextension of the head in the breech position delivered by the vaginal route. In period B the incidence of neurodevelopmental sequelae at the 4-year follow-up did not differ from that found in a group of infants born vaginally in vertex presentation. The rates of visual and auditory disorders, behaviour problems, enuresis and late speech development were not increased in the breeches neither in period A nor in period B.

Neurological, psychological and articulatory impairment in five-year-old children with a birthweight of 2000 g or less

The study comprised 324 children with a birthweight less than or equal to 2000 g born in 1971-1974 at the Institute of Midwifery, Helsinki. The low birthweight (LBW) infants totalled 1.46% of the live-born during that time. At the age of 5 years 197 children were investigated; 15 had severe handicaps while 182 were without any immediate noticeable defects. The rest were not investigated for the following reasons: 86 had died, seven were severely handicapped and 34 could not be traced or the parents did not want to participate in the examination. The 197 children were given a neurodevelopmental screening examination, psychological and articulatory tests. A score of greater than or equal to 23 in the neurodevelopmental screening examination was noted in 8% of the controls, in 87% of the severely handicapped and in 34% of children without severe handicaps. All psychological test results differed significantly from those of the controls. The articulatory tests showed that the speech problems were more common among the LBW children. According to the teachers' assessments at the age of 9 years, 32% of the LBW children were in need of special education, compared with 12% of the controls. A significant correlation was found between the test results at 5 years and the school achievement at the age of nine.

Has an increased cesarean section rate for term breech delivery reduced in incidence of birth asphyxia, trauma, and death?

To evaluate whether the dramatic rise in the cesarean section rate for breech presentation (from 22% in the decade 1963 to 1973 to 94% in 1978 and 1979) has been justified, 770 term breech deliveries at the Royal Victoria Hospital during the period 1963 to 1973 and during 1978 and 1979 have been reviewed. Neonatal outcome, as determined by one neonatologist during the entire period of this study, was analyzed according to vaginal or cesarean section breech deliveries of primiparous and multiparous women. For each method of delivery and state of parity the occurrence of asphyxia neonatorum, abnormal cerebral signs, postasphyctic congenital heart failure or renal failure, and intrapartum and neonatal deaths was studied. The most severe cases were individually reviewed. While breech presentation has become a virtual indication for cesarean section in many centers, to date , there has not been an evaluation of how effective this procedure is in reducing birth asphyxia and trauma. In this study we assessed whether the trend to perform cesarean section in all term breech presentations is justified and whether neonatal morbidity and mortality rates have actually improved as a result.