Are Are Neonatal EncephalopathyNeonatal Encephalopathy

& & Cerebral PalsyCerebral Palsy

Obstetric malpractice?Obstetric malpractice?

Dr. Ashraf FoudaDr. Ashraf Fouda

Demiatte General HospitalDemiatte General Hospital

Neonatal encephalopathyNeonatal encephalopathy• CClinical syndrome of:linical syndrome of:

Disturbed neurological functionDisturbed neurological function during the first week after birthduring the first week after birth..

• TType of brain damage associated with ype of brain damage associated with inflammationinflammation, or , or swelling swelling of the brain.of the brain.

• MMay or may not result in ay or may not result in permanentpermanent neurological problems. neurological problems.

Neonatal EncephalopathyNeonatal EncephalopathyIs manifested byIs manifested by::

1.1. DDifficulty breathingifficulty breathing , , 2.2. PPoor muscle tone and reflexesoor muscle tone and reflexes , , 3.3. AAbnormal consciousnessbnormal consciousness , ,

and often: and often:4.4. SSeizures eizures

Cerebral palsyCerebral palsy

Permanent non pregressive Permanent non pregressive neurological disorderneurological disorder

• ““PalsyPalsy”” – means weakness or – means weakness or paralysis or lack of muscle control.paralysis or lack of muscle control.

• TThe most common physical disability he most common physical disability in childhood.in childhood.

Symptoms of Cerebral PalsySymptoms of Cerebral Palsy• Difficulty with balance or walking• Involuntary movements• Sensory problems• May have seizures ( Epilepsy )• Mental Retardation

–50-70% of cerebral palsy cases have mental retardation

Timing of diagnosis of cerebral palsy

• Typically not at birth.• The more mild the case ( like Slurred

speech)... the older the child at diagnosis.

• The more severe the case ( like Quadreplegia ....the earlier the diagnosis.

Cerebral palsyCerebral palsy

Cerebral palsyCerebral palsy

Newborn encephalopathy Newborn encephalopathy and cerebral palsy and cerebral palsy

are associated with are associated with significant mortality ratessignificant mortality rates

and and long-term morbiditylong-term morbidity

For much too longFor much too long

all neonatal encephalopathy has all neonatal encephalopathy has been assumed to bebeen assumed to be

hypoxic hypoxic

and unfortunatelyand unfortunately,, documented and coded in that way documented and coded in that way

in medical recordsin medical records

The assumption that labor and delivery

caused these conditions has been a

huge medicolegal problem for obstetricians

It was also stated that It was also stated that cerebral palsy and mental cerebral palsy and mental

retardationretardationcould be could be

reduced byreduced by 50%50% with the use of with the use of

electronic FHR monitoringelectronic FHR monitoring

This assumption lead toThis assumption lead torapid acceptance of rapid acceptance of

electronic FHR monitoringelectronic FHR monitoring with subsequent with subsequent

increases in cesareanincreases in cesarean deliveries deliveries for fetal distressfor fetal distress

But does the use of these precautions decrease the

incidence of Newborn encephalopathy Newborn encephalopathy

and cerebral palsy ?and cerebral palsy ?

Unfortunately the incidence Unfortunately the incidence of cerebral palsyof cerebral palsy

remains unchangedremains unchanged,, even witheven with

the tremendous improvements in the tremendous improvements in obstetric, neonatal and surgical careobstetric, neonatal and surgical care

in the last 30 yearsin the last 30 years

Developed and Developed and underdeveloped underdeveloped countries have countries have

identicalidentical cerebral palsy ratescerebral palsy rates

Studies of cerebral palsy prevalence in China, Malta, Slovenia, and India

demonstrate rates identical to those of developed countries

The availability of electronic fetal monitoring

and the capability of emergent cesarean within 30 minutes is generally lacking in these countries

This suggest that cerebral palsy is primarily

a developmental event, not influenced by

current obstetric technologies available in

developed countries

ACOG task force from leaders of

obstetrics, pediatrics, neurology, pathology,

started at 1999 and

reviewed this debatable issue

They worked They worked many hundreds of hoursmany hundreds of hours

to study & reviewto study & review the mechanisms and timingthe mechanisms and timing

of etiologic events that lead toof etiologic events that lead to neonatal encephalopathyneonatal encephalopathy

and cerebral palsyand cerebral palsy

They developed a report issued on January 31, 2003

by the American College of Obstetricians and Gynecologists

(ACOG) and the American Academy of

Pediatrics (AAP)

Over 75 % of cases of neonatal encephalopathy

have no clinical signs

of intrapartum hypoxia

(ACOG) and (AAP) Report - January 31, 2003

It is now well known thatIt is now well known that hypoxic-ischemic hypoxic-ischemic encephalopathy encephalopathy

(HIE)(HIE)

is only one type of is only one type of neonatal encephalopathyneonatal encephalopathy

(ACOG) and (AAP) Report - January 31, 2003

• PPrenatal strokes renatal strokes (like trauma),(like trauma), • IIntrauterine infections ntrauterine infections (like rubella),(like rubella), • CCerebral malformations, erebral malformations, • GGenetic, enetic, • AAnd many other conditionsnd many other conditions

Other types of encephalopathyOther types of encephalopathy arise fromarise from: :

The best available evidence suggestsThe best available evidence suggests

an incidence rate ofan incidence rate of Pure HIEPure HIE

(Hypoxic Ischemic Encephalopathy)(Hypoxic Ischemic Encephalopathy) (i.e., with intrapartum hypoxia in the absence of (i.e., with intrapartum hypoxia in the absence of

any other preconceptional or antepartum any other preconceptional or antepartum abnormalities)abnormalities)

is approximatelyis approximately

1-2 per 10,000 births1-2 per 10,000 births

(ACOG) and (AAP) Report - January 31, 2003

When HIE is combined with neonatal encephalopathy

from all other causes the incidence is

2 - 3 per 1,000 births (ACOG) and (AAP) Report - January 31, 2003

incidenceincidence

Pure HIE All types< 3 per 1,000 births< 2 per 10,000 births< 2 per 10,000 births

Neonatal encephalopathyNeonatal encephalopathy

(ACOG) and (AAP) Report - January 31, 2003

Therefore Therefore only about only about

10%10% of neonatal encephalopathy of neonatal encephalopathy

is due to is due to hypoxia / ischemiahypoxia / ischemia

(ACOG) and (AAP) Report - January 31, 2003

Any Any cerebral palsycerebral palsy resulting from resulting from acute intrapartum asphyxiaacute intrapartum asphyxia

is even less frequent is even less frequent (less than 10%)(less than 10%)

becausebecause Not all HIE, result in cerebral palsy

(ACOG) and (AAP) Report - January 31, 2003

Essential intrapartum criteria Essential intrapartum criteria sufficient to cause cerebral palsy are sufficient to cause cerebral palsy are

(must meet all four)(must meet all four)1.1. EEvidence of a metabolic acidosis in fetal umbilical cord,vidence of a metabolic acidosis in fetal umbilical cord,2.2. EEarly onset of severe or moderate neonatal arly onset of severe or moderate neonatal

encephalopathy in infants born atencephalopathy in infants born at 34 34 or more weeks of or more weeks of gestation, gestation,

3.3. CCerebral palsy of the spastic quadriplegia,erebral palsy of the spastic quadriplegia,4.4. EExclusion of other identifiable etiologies such as xclusion of other identifiable etiologies such as trauma, trauma,

coagulation disorders, infectious conditions, or genetic coagulation disorders, infectious conditions, or genetic disorders.disorders.

(ACOG) and (AAP) Report - January 31, 2003

1.1. AA hypoxic event occurring immediately before or during hypoxic event occurring immediately before or during labor labor

2.2. AA sudden and sustained fetal bradycardia or the sudden and sustained fetal bradycardia or the absence of fetal heart rate variability in the presence of absence of fetal heart rate variability in the presence of persistent, late, or variable decelerationspersistent, late, or variable decelerations

3.3. AApgar scores ofpgar scores of 0-3 0-3 beyond beyond 5 minutes5 minutes 4.4. OOnset of multisystem involvement within nset of multisystem involvement within 72 hours72 hours of of

birth birth 5.5. EEarly imaging study showing evidence of acute nonfocal arly imaging study showing evidence of acute nonfocal

cerebral abnormalitycerebral abnormality

Criteria that suggest an intrapartum timing Criteria that suggest an intrapartum timing (but are nonspecific to asphyxial insults)(but are nonspecific to asphyxial insults)

(ACOG) and (AAP) Report - January 31, 2003

The majority of newborn The majority of newborn brain injury cases brain injury cases

do not occurdo not occur during labor and deliveryduring labor and delivery

(ACOG) and (AAP) Report - January 31, 2003

Most instances of Most instances of neonatal encephalopathy and neonatal encephalopathy and

cerebral palsy cerebral palsy are attributable toare attributable to

events occurring before labor events occurring before labor begins begins

(ACOG) and (AAP) Report - January 31, 2003

The report Gives evidence that the vast majority of cases originate from :

1. Developmental,2. Metabolic abnormalities, 3. Autoimmune , 4. Coagulation defects, 5. Infection, 6. Trauma, or 7. Combinations of these factors.

(ACOG) and (AAP) Report - January 31, 2003

• The report helps us to understand the causes of neonatal

encephalopathy and cerebral palsy, • The efforts could lead to clinical interventions that will reduce the

rates of these serious cases

Gary D.V. Hankins,MD, chair of the ACOG task force that developed the report.

This report should serve as This report should serve as a valuable resource for:a valuable resource for:

• TThe entire medical community, he entire medical community, • TThe he courtscourts, ,

and forand for• AAll those who care for infants and ll those who care for infants and

children with these disabilitieschildren with these disabilities

ACOG President ,Charles B. Hammond, MD.

It confirms that most brain injuries are It confirms that most brain injuries are not due tonot due to

events occurring during:events occurring during:1.1. LLabor, abor, 2.2. DDelivery,elivery,3.3. RResuscitation, or esuscitation, or 4.4. TTreatment immediately following birthreatment immediately following birth. .

The American Academy of Pediatrics (AAP)welcomes this important report

““We remain concerned about infants We remain concerned about infants with neonatal brain injury,with neonatal brain injury,

and will continue our and will continue our Neonatal Resuscitation ProgramNeonatal Resuscitation Program

that assures pediatricians, receiving that assures pediatricians, receiving the most up-to-date resuscitation skillsthe most up-to-date resuscitation skills" "

AAP President E. Stephen Edwards, MD.

CONCLUSIONCONCLUSION

Labor and delivery are responsible only for

< 10 % of neonatal encephalopathy neonatal encephalopathy

and cerebral palsy and cerebral palsy

The The good newsgood news is that is that: : ““It is not the obstetrician's fault"It is not the obstetrician's fault"

Dr. Ralph Dauterive,

Chairman of the obstetrics and gynecology department at New Orleans.

The The bad newsbad news is that is that:: “ “There is probably not a lot, There is probably not a lot, We can do about it in labor."We can do about it in labor."