Brachial Palsy Prediction  Prevention
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Brachial Palsy Prediction Prevention

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    Brachial Palsy Prediction  Prevention Brachial Palsy Prediction Prevention Presentation Transcript

    • Brachial Palsy: Prediction & Prevention. Raphi Pollack, MDCM, FRCSC. Bikur Cholim Hospital, Jerusalem.
    • Outline
      • History
      • Natural history
      • Risk Factors
      • Prevention strategies
      • Conclusions
    • History
      • Smellie 1764
      • Erb 1874 “delivery paralysis” related to “moderately energetic manipulation by the obstetrician”
    • Significance of Brachial Palsy
      • Complication of birth trauma
      • Major cause of neonatal morbidity
      • “ Fetal-physician” risk
      • Accounts for 4.2% of OBS litigation
    •  
    • Clinical Syndromes
      • Erb Palsy
        • C5, C6 root avulsion
        • Upper trunk plexopathy
        • Arm Adduction & internal rotation
        • Elbow extended & forearm pronated
        • “ Waiters tip” position
        • +/- Horner syndrome
    • Clinical Syndromes
      • Flail arm
        • Injury to entire plexus
      • Klumpke palsy
        • Lower trunk (C8, T1) injury
        • Poor grasp, proximal function preserved
    • Electrodiagnosis
      • Nerve conduction studies
        • Changes in amplitude of motor & sensory response
      • Electromyography
        • Study of motor unit potential
      • Technically difficult in the neonate
      • Insights into pathogenesis
    • Electrodiagnosis: Timing of Injury
      • Fibrillations
          • Onset = 12-21 days
          • Peak = 35 days
      • Conduction abnormalities : Sensory
          • Onset = 5-6 days
          • Peak = 10 days
      • Conduction abnormalities : Motor
        • Onset = 2-4 days
        • Peak = 7 days
    • Incidence of Brachial Palsy
      • 0.5-3 per 1000 births
      • Gilbert et al (1995) 1.5/1000 births
      • 5420 cases annually in USA
      • 180 cases annually in Israel
    • Natural History
      • Important to understand burden of disease
        • Contrast with clavicular #
      • Resolution – how often ?
        • Michelow HSC (1994) 92% resolved
        • Bager (1997) 49% resolved
          • 22% severely impaired
        • Eng (1996) 22% resolved
          • 78% long term disabilities
    • Pathogenesis
      • Excessive downward traction.
      • Vs.
      • In-utero insult.
    • In- utero insult
      • Koenigsberger (1980)
        • EMG evidence of prenatal injury
      • Dunn & Engle (1985)
        • Bicornuate uterus
        • Bb skeletal deformities, muscle atrophy, brachial palsy
        • EMG findings
    • In-utero insult : The Evidence
      • 1,611 cases of OBP
      • 47% of all OBP do not involve shoulder dystocia
      • 60/1,611 cases of OBP Cesarean delivery
      • Ascertainment bias ??
      • Excessive traction at time of CS ??
        • Gilbert (1999)
    • In-utero insult : Natural History
      • Gherman (1998) 40 cases of OBP.
      • OBP in absence of SD : high persistence.
      • OBP in presence of SD : low persistence.
      • Suggests pathogenetic heterogeneity.
    • Brachial Palsy: Risk Factors
      • Shoulder dystocia (OR=76.1)
      • Neonatal birthweight
      • Instrumental vaginal delivery
      • Breech presentation (OR=5.6)
      • Gestational DM (OR=1.9)
      • Prior infant with brachial palsy
    • Brachial Palsy & Neonatal BW
    • Brachial Palsy & Instrumental Delivery
    • Highest Risk of Brachial Palsy
      • Maternal Diabetes Mellitus
      • &
      • BW > 4500 Gms.
      • &
      • Instrumental Vaginal Delivery
      • OR = 52
    • Pts. At Highest Risk for OBP 100 pts 92 pts normal 8 pts OBP
    • Birth Trauma: Recurrence Risk
      • Baskett (1995)
      • Shoulder dystocia over 10 yrs. (N=254)
      • Recurrent shoulder dystocia = 1/93 (1.1%)
      • 0/8 cases of OBP in setting of prior OBP
      • Al-Qattan (1996)
      • 16/49 (33%) cases of recurrent OBP
    • OBP: Negative associations
      • Prematurity (OR = 0.8)
      • IUGR (OR = 0.9)
      • Cesarean delivery (OR = 0.2)
      • No factors were entirely protective
    • Prevention Strategies
      • Manipulation of BW
        • Tight control in DM
      • Risk stratification
        • Identification of the macrosomic fetus
        • Elective induction
        • Elective Cesarean delivery
    • Murphy’s Law: First Corollary
      • “ Nothing is as simple as it first seems”
    • Prevention Strategies
      • Must be broad based.
      • Most OBP cases are not predictable.
        • BW < 4000 Gms.
        • Not associated with DM.
      • Perlow (1996) 19% of OBP predictable.
      • Skillful management of shoulder dystocia.
    • Fetal Macrosomia: Diagnosis
      • MacDonald measurement (SFH)
      • Maternal estimation
      • Sonographic EFW
      • All techniques limited
    •  
    •  
    •  
    •  
    • Fetal Macrosomia: Induction of Labor
      • Inclusion EFW > 4000 Gms. @ 38 wks.
      • RCT.
      • Induction (N=134).
      • Expectancy (N=139).
      • Power to detect 15% change in CS rate.
      • Gonen 1997.
    • Fetal Macrosomia: Induction of Labor 2 0 Brachial Palsy 6 5 Shoulder Dystocia 18 19 C/S for CPD 4132 * 4062 BW (Gms.) 3.2 - Time to delivery (d) Expectancy Induction
    • Fetal Macrosomia: Elective Cesarean Delivery
      • Decision analysis model.
      • Three policies compared.
        • No sonographic EFW.
        • C/S for EFW > 4000 Gms.
        • C/S for EFW > 4500 Gms.
        • Rouse 1996.
    • Fetal Macrosomia: Elective Cesarean Delivery $8,700,000 3,695 C/S for EFW > 4500 Gms. $4,900,000 2,345 C/S for EFW > 4000 Gms. Cost / OBP prevented # C/S performed / OBP prevented Intervention
    • Fetal Macrosomia: Elective Cesarean Delivery
      • 4000 Gms. Threshold
        • Would increase C/S rate by 50%
        • Reduces OBP by 31%
        • Costs $4,900,00 per OBP prevented
        • Leads to 1 maternal death per 3.2 OBP cases
        • prevented
        • Cannot be justified medically or economically
        • Rouse, 1996
    • Conclusions
      • Beware of macrosomic infants
      • Avoid midpelvic deliveries in macrosomics & GDMs
      • Manage Shoulder Dystocia
        • Don’t rush
        • Avoid excessive traction
    • Practical Advice
      • Avoid poor judgment…
      • Judgment comes from experience…
      • Experience comes from poor judgment.
      • Jeanty