Brachial Palsy: Prediction & Prevention. Raphi Pollack, MDCM, FRCSC. Bikur Cholim Hospital, Jerusalem.
Outline <ul><li>History </li></ul><ul><li>Natural history </li></ul><ul><li>Risk Factors </li></ul><ul><li>Prevention stra...
History <ul><li>Smellie 1764 </li></ul><ul><li>Erb 1874 “delivery paralysis” related to “moderately energetic manipulation...
Significance of Brachial Palsy <ul><li>Complication of birth trauma </li></ul><ul><li>Major cause of neonatal morbidity </...
 
Clinical Syndromes <ul><li>Erb Palsy </li></ul><ul><ul><li>C5, C6 root avulsion </li></ul></ul><ul><ul><li>Upper trunk ple...
Clinical Syndromes <ul><li>Flail arm </li></ul><ul><ul><li>Injury to entire plexus </li></ul></ul><ul><li>Klumpke palsy </...
Electrodiagnosis <ul><li>Nerve conduction studies </li></ul><ul><ul><li>Changes in amplitude of motor & sensory response <...
Electrodiagnosis: Timing of Injury <ul><li>Fibrillations </li></ul><ul><ul><ul><li>Onset  = 12-21 days </li></ul></ul></ul...
Incidence of Brachial Palsy <ul><li>0.5-3 per 1000 births </li></ul><ul><li>Gilbert et al (1995) 1.5/1000 births </li></ul...
Natural History <ul><li>Important to understand burden of disease </li></ul><ul><ul><li>Contrast with clavicular # </li></...
Pathogenesis <ul><li>Excessive downward traction. </li></ul><ul><li>Vs. </li></ul><ul><li>In-utero insult. </li></ul>
In- utero insult <ul><li>Koenigsberger (1980) </li></ul><ul><ul><li>EMG evidence of prenatal injury </li></ul></ul><ul><li...
In-utero insult : The Evidence <ul><li>1,611 cases of OBP </li></ul><ul><li>47% of all OBP do not involve  shoulder dystoc...
In-utero insult : Natural History <ul><li>Gherman (1998) 40 cases of OBP. </li></ul><ul><li>OBP in absence of SD : high pe...
Brachial Palsy: Risk Factors <ul><li>Shoulder dystocia (OR=76.1) </li></ul><ul><li>Neonatal birthweight </li></ul><ul><li>...
Brachial Palsy & Neonatal BW
Brachial Palsy & Instrumental Delivery
Highest Risk of Brachial Palsy <ul><li>Maternal Diabetes Mellitus </li></ul><ul><li>& </li></ul><ul><li>BW > 4500 Gms. </l...
Pts. At Highest Risk for OBP 100 pts 92   pts normal 8   pts   OBP
Birth Trauma: Recurrence Risk <ul><li>Baskett (1995) </li></ul><ul><li>Shoulder dystocia  over 10 yrs.  (N=254) </li></ul>...
OBP: Negative associations <ul><li>Prematurity (OR = 0.8) </li></ul><ul><li>IUGR (OR = 0.9) </li></ul><ul><li>Cesarean del...
Prevention Strategies <ul><li>Manipulation of BW </li></ul><ul><ul><li>Tight control in DM </li></ul></ul><ul><li>Risk str...
Murphy’s Law: First Corollary <ul><li>“ Nothing is as simple as it first seems” </li></ul>
Prevention Strategies <ul><li>Must be broad based. </li></ul><ul><li>Most OBP cases are not predictable. </li></ul><ul><ul...
Fetal Macrosomia: Diagnosis <ul><li>MacDonald measurement (SFH) </li></ul><ul><li>Maternal estimation  </li></ul><ul><li>S...
 
 
 
 
Fetal Macrosomia:  Induction of Labor <ul><li>Inclusion EFW > 4000 Gms. @ 38 wks. </li></ul><ul><li>RCT. </li></ul><ul><li...
Fetal Macrosomia:  Induction of Labor 2 0 Brachial Palsy 6 5 Shoulder Dystocia 18 19 C/S for CPD 4132  * 4062 BW (Gms.) 3....
Fetal Macrosomia: Elective Cesarean Delivery <ul><li>Decision analysis model. </li></ul><ul><li>Three policies compared. <...
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  > 400...
Fetal Macrosomia: Elective Cesarean Delivery <ul><li>4000 Gms. Threshold </li></ul><ul><ul><li>Would increase C/S rate by ...
Conclusions <ul><li>Beware of macrosomic infants </li></ul><ul><li>Avoid midpelvic deliveries in macrosomics & GDMs </li><...
Practical Advice <ul><li>Avoid poor judgment… </li></ul><ul><li>Judgment comes from experience… </li></ul><ul><li>Experien...
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Brachial Palsy Prediction Prevention

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Brachial Palsy Prediction Prevention

  1. 1. Brachial Palsy: Prediction & Prevention. Raphi Pollack, MDCM, FRCSC. Bikur Cholim Hospital, Jerusalem.
  2. 2. Outline <ul><li>History </li></ul><ul><li>Natural history </li></ul><ul><li>Risk Factors </li></ul><ul><li>Prevention strategies </li></ul><ul><li>Conclusions </li></ul>
  3. 3. History <ul><li>Smellie 1764 </li></ul><ul><li>Erb 1874 “delivery paralysis” related to “moderately energetic manipulation by the obstetrician” </li></ul>
  4. 4. Significance of Brachial Palsy <ul><li>Complication of birth trauma </li></ul><ul><li>Major cause of neonatal morbidity </li></ul><ul><li>“ Fetal-physician” risk </li></ul><ul><li>Accounts for 4.2% of OBS litigation </li></ul>
  5. 6. Clinical Syndromes <ul><li>Erb Palsy </li></ul><ul><ul><li>C5, C6 root avulsion </li></ul></ul><ul><ul><li>Upper trunk plexopathy </li></ul></ul><ul><ul><li>Arm Adduction & internal rotation </li></ul></ul><ul><ul><li>Elbow extended & forearm pronated </li></ul></ul><ul><ul><li>“ Waiters tip” position </li></ul></ul><ul><ul><li>+/- Horner syndrome </li></ul></ul>
  6. 7. Clinical Syndromes <ul><li>Flail arm </li></ul><ul><ul><li>Injury to entire plexus </li></ul></ul><ul><li>Klumpke palsy </li></ul><ul><ul><li>Lower trunk (C8, T1) injury </li></ul></ul><ul><ul><li>Poor grasp, proximal function preserved </li></ul></ul>
  7. 8. Electrodiagnosis <ul><li>Nerve conduction studies </li></ul><ul><ul><li>Changes in amplitude of motor & sensory response </li></ul></ul><ul><li>Electromyography </li></ul><ul><ul><li>Study of motor unit potential </li></ul></ul><ul><li>Technically difficult in the neonate </li></ul><ul><li>Insights into pathogenesis </li></ul>
  8. 9. Electrodiagnosis: Timing of Injury <ul><li>Fibrillations </li></ul><ul><ul><ul><li>Onset = 12-21 days </li></ul></ul></ul><ul><ul><ul><li>Peak = 35 days </li></ul></ul></ul><ul><li>Conduction abnormalities : Sensory </li></ul><ul><ul><ul><li>Onset = 5-6 days </li></ul></ul></ul><ul><ul><ul><li>Peak = 10 days </li></ul></ul></ul><ul><li>Conduction abnormalities : Motor </li></ul><ul><ul><li>Onset = 2-4 days </li></ul></ul><ul><ul><li>Peak = 7 days </li></ul></ul>
  9. 10. Incidence of Brachial Palsy <ul><li>0.5-3 per 1000 births </li></ul><ul><li>Gilbert et al (1995) 1.5/1000 births </li></ul><ul><li>5420 cases annually in USA </li></ul><ul><li>180 cases annually in Israel </li></ul>
  10. 11. Natural History <ul><li>Important to understand burden of disease </li></ul><ul><ul><li>Contrast with clavicular # </li></ul></ul><ul><li>Resolution – how often ? </li></ul><ul><ul><li>Michelow HSC (1994) 92% resolved </li></ul></ul><ul><ul><li>Bager (1997) 49% resolved </li></ul></ul><ul><ul><ul><li>22% severely impaired </li></ul></ul></ul><ul><ul><li>Eng (1996) 22% resolved </li></ul></ul><ul><ul><ul><li>78% long term disabilities </li></ul></ul></ul>
  11. 12. Pathogenesis <ul><li>Excessive downward traction. </li></ul><ul><li>Vs. </li></ul><ul><li>In-utero insult. </li></ul>
  12. 13. In- utero insult <ul><li>Koenigsberger (1980) </li></ul><ul><ul><li>EMG evidence of prenatal injury </li></ul></ul><ul><li>Dunn & Engle (1985) </li></ul><ul><ul><li>Bicornuate uterus </li></ul></ul><ul><ul><li>Bb skeletal deformities, muscle atrophy, brachial palsy </li></ul></ul><ul><ul><li>EMG findings </li></ul></ul>
  13. 14. In-utero insult : The Evidence <ul><li>1,611 cases of OBP </li></ul><ul><li>47% of all OBP do not involve shoulder dystocia </li></ul><ul><li>60/1,611 cases of OBP Cesarean delivery </li></ul><ul><li>Ascertainment bias ?? </li></ul><ul><li>Excessive traction at time of CS ?? </li></ul><ul><ul><li>Gilbert (1999) </li></ul></ul>
  14. 15. In-utero insult : Natural History <ul><li>Gherman (1998) 40 cases of OBP. </li></ul><ul><li>OBP in absence of SD : high persistence. </li></ul><ul><li>OBP in presence of SD : low persistence. </li></ul><ul><li>Suggests pathogenetic heterogeneity. </li></ul>
  15. 16. Brachial Palsy: Risk Factors <ul><li>Shoulder dystocia (OR=76.1) </li></ul><ul><li>Neonatal birthweight </li></ul><ul><li>Instrumental vaginal delivery </li></ul><ul><li>Breech presentation (OR=5.6) </li></ul><ul><li>Gestational DM (OR=1.9) </li></ul><ul><li>Prior infant with brachial palsy </li></ul>
  16. 17. Brachial Palsy & Neonatal BW
  17. 18. Brachial Palsy & Instrumental Delivery
  18. 19. Highest Risk of Brachial Palsy <ul><li>Maternal Diabetes Mellitus </li></ul><ul><li>& </li></ul><ul><li>BW > 4500 Gms. </li></ul><ul><li>& </li></ul><ul><li>Instrumental Vaginal Delivery </li></ul><ul><li>OR = 52 </li></ul>
  19. 20. Pts. At Highest Risk for OBP 100 pts 92 pts normal 8 pts OBP
  20. 21. Birth Trauma: Recurrence Risk <ul><li>Baskett (1995) </li></ul><ul><li>Shoulder dystocia over 10 yrs. (N=254) </li></ul><ul><li>Recurrent shoulder dystocia = 1/93 (1.1%) </li></ul><ul><li>0/8 cases of OBP in setting of prior OBP </li></ul><ul><li>Al-Qattan (1996) </li></ul><ul><li>16/49 (33%) cases of recurrent OBP </li></ul>
  21. 22. OBP: Negative associations <ul><li>Prematurity (OR = 0.8) </li></ul><ul><li>IUGR (OR = 0.9) </li></ul><ul><li>Cesarean delivery (OR = 0.2) </li></ul><ul><li>No factors were entirely protective </li></ul>
  22. 23. Prevention Strategies <ul><li>Manipulation of BW </li></ul><ul><ul><li>Tight control in DM </li></ul></ul><ul><li>Risk stratification </li></ul><ul><ul><li>Identification of the macrosomic fetus </li></ul></ul><ul><ul><li>Elective induction </li></ul></ul><ul><ul><li>Elective Cesarean delivery </li></ul></ul>
  23. 24. Murphy’s Law: First Corollary <ul><li>“ Nothing is as simple as it first seems” </li></ul>
  24. 25. Prevention Strategies <ul><li>Must be broad based. </li></ul><ul><li>Most OBP cases are not predictable. </li></ul><ul><ul><li>BW < 4000 Gms. </li></ul></ul><ul><ul><li>Not associated with DM. </li></ul></ul><ul><li>Perlow (1996) 19% of OBP predictable. </li></ul><ul><li>Skillful management of shoulder dystocia. </li></ul>
  25. 26. Fetal Macrosomia: Diagnosis <ul><li>MacDonald measurement (SFH) </li></ul><ul><li>Maternal estimation </li></ul><ul><li>Sonographic EFW </li></ul><ul><li>All techniques limited </li></ul>
  26. 31. Fetal Macrosomia: Induction of Labor <ul><li>Inclusion EFW > 4000 Gms. @ 38 wks. </li></ul><ul><li>RCT. </li></ul><ul><li>Induction (N=134). </li></ul><ul><li>Expectancy (N=139). </li></ul><ul><li>Power to detect 15% change in CS rate. </li></ul><ul><li>Gonen 1997. </li></ul>
  27. 32. 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
  28. 33. Fetal Macrosomia: Elective Cesarean Delivery <ul><li>Decision analysis model. </li></ul><ul><li>Three policies compared. </li></ul><ul><ul><li>No sonographic EFW. </li></ul></ul><ul><ul><li>C/S for EFW > 4000 Gms. </li></ul></ul><ul><ul><li>C/S for EFW > 4500 Gms. </li></ul></ul><ul><ul><li>Rouse 1996. </li></ul></ul>
  29. 34. 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
  30. 35. Fetal Macrosomia: Elective Cesarean Delivery <ul><li>4000 Gms. Threshold </li></ul><ul><ul><li>Would increase C/S rate by 50% </li></ul></ul><ul><ul><li>Reduces OBP by 31% </li></ul></ul><ul><ul><li>Costs $4,900,00 per OBP prevented </li></ul></ul><ul><ul><li>Leads to 1 maternal death per 3.2 OBP cases </li></ul></ul><ul><ul><li>prevented </li></ul></ul><ul><ul><li>Cannot be justified medically or economically </li></ul></ul><ul><ul><li>Rouse, 1996 </li></ul></ul>
  31. 36. Conclusions <ul><li>Beware of macrosomic infants </li></ul><ul><li>Avoid midpelvic deliveries in macrosomics & GDMs </li></ul><ul><li>Manage Shoulder Dystocia </li></ul><ul><ul><li>Don’t rush </li></ul></ul><ul><ul><li>Avoid excessive traction </li></ul></ul>
  32. 37. Practical Advice <ul><li>Avoid poor judgment… </li></ul><ul><li>Judgment comes from experience… </li></ul><ul><li>Experience comes from poor judgment. </li></ul><ul><li>Jeanty </li></ul>

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