Your SlideShare is downloading. ×
0
Download
Download
Download
Download
Download
Download
Download
Download
Download
Download
Download
Download
Download
Download
Download
Download
Download
Download
Download
Download
Download
Download
Download
Download
Download
Download
Download
Download
Download
Download
Download
Download
Download
Download
Download
Download
Download
Download
Download
Download
Download
Download
Upcoming SlideShare
Loading in...5
×

Thanks for flagging this SlideShare!

Oops! An error has occurred.

×
Saving this for later? Get the SlideShare app to save on your phone or tablet. Read anywhere, anytime – even offline.
Text the download link to your phone
Standard text messaging rates apply

Download

951

Published on

0 Comments
1 Like
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total Views
951
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
50
Comments
0
Likes
1
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
No notes for slide

Transcript

  • 1. Are Neonatal Encephalopathy & Cerebral Palsy Obstetric malpractice? Dr. Ashraf Fouda Demiatte General Hospital
  • 2. Neonatal encephalopathy <ul><li>C linical syndrome of: </li></ul><ul><li>Disturbed neurological function </li></ul><ul><li>during the first week after birth . </li></ul><ul><li>T ype of brain damage associated with inflammation , or swelling of the brain. </li></ul><ul><li>M ay or may not result in permanent neurological problems. </li></ul>
  • 3. Neonatal Encephalopathy <ul><li>Is manifested by : </li></ul><ul><li>D ifficulty breathing , </li></ul><ul><li>P oor muscle tone and reflexes , </li></ul><ul><li>A bnormal consciousness , and often: </li></ul><ul><li>S eizures </li></ul>
  • 4. Cerebral palsy <ul><li>Permanent non pregressive neurological disorder </li></ul><ul><li>“ Palsy ” – means weakness or paralysis or lack of muscle control. </li></ul><ul><li>T he most common physical disability in childhood. </li></ul>
  • 5. Symptoms of Cerebral Palsy <ul><li>D ifficulty with balance or walking </li></ul><ul><li>I nvoluntary movements </li></ul><ul><li>S ensory problems </li></ul><ul><li>M ay have seizures ( Epilepsy ) </li></ul><ul><li>M ental Retardation </li></ul><ul><ul><li>50-70% of cerebral palsy cases have mental retardation </li></ul></ul>
  • 6. Timing of diagnosis of cerebral palsy <ul><li>T ypically not at birth. </li></ul><ul><li>T he more mild the case ( like Slurred speech )... the older the child at diagnosis. </li></ul><ul><li>T he more severe the case ( like Quadreplegia ....the earlier the diagnosis. </li></ul>
  • 7. Cerebral palsy
  • 8. Cerebral palsy
  • 9. <ul><li>Newborn encephalopathy and cerebral palsy </li></ul><ul><li>are associated with significant mortality rates and </li></ul><ul><li>long-term morbidity </li></ul>
  • 10. <ul><li>For much too long </li></ul><ul><li>all neonatal encephalopathy has been assumed to be </li></ul><ul><li>hypoxic </li></ul><ul><li>and unfortunately , </li></ul><ul><li>documented and coded in that way in medical records </li></ul>
  • 11. The assumption that labor and delivery caused these conditions has been a huge medicolegal problem for obstetricians
  • 12. <ul><li>It was also stated that </li></ul><ul><li>cerebral palsy and mental retardation </li></ul><ul><li>could be </li></ul><ul><li>reduced by 50% </li></ul><ul><li>with the use of </li></ul><ul><li>electronic FHR monitoring </li></ul>
  • 13. <ul><li>This assumption lead to </li></ul><ul><li>rapid acceptance of </li></ul><ul><li>electronic FHR monitoring </li></ul><ul><li>with subsequent </li></ul><ul><li>increases in cesarean deliveries </li></ul><ul><li>for fetal distress </li></ul>
  • 14. <ul><li>But does the use of these precautions decrease the incidence of </li></ul><ul><li>Newborn encephalopathy and cerebral palsy ? </li></ul>
  • 15. <ul><li>Unfortunately the incidence </li></ul><ul><li>of cerebral palsy </li></ul><ul><li>remains unchanged , </li></ul><ul><li>even with </li></ul><ul><li>the tremendous improvements in obstetric, neonatal and surgical care </li></ul><ul><li>in the last 30 years </li></ul>
  • 16. <ul><li>Developed and underdeveloped countries have </li></ul><ul><li>identical </li></ul><ul><li>cerebral palsy rates </li></ul>
  • 17. <ul><li>Studies of cerebral palsy prevalence in </li></ul><ul><li>China, Malta, Slovenia, and India </li></ul><ul><li>demonstrate </li></ul><ul><li>rates identical to those of developed countries </li></ul>The availability of electronic fetal monitoring and the capability of emergent cesarean within 30 minutes is generally lacking in these countries
  • 18. <ul><li>This suggest that cerebral palsy is primarily </li></ul><ul><li>a developmental event , </li></ul><ul><li>not influenced by </li></ul><ul><li>current obstetric technologies available in </li></ul><ul><li>developed countries </li></ul>
  • 19. <ul><li>ACOG task force </li></ul><ul><li>from leaders of </li></ul><ul><li>obstetrics, pediatrics, neurology, pathology, </li></ul><ul><li>started at 1999 </li></ul><ul><li>and </li></ul><ul><li>reviewed this debatable issue </li></ul>
  • 20. <ul><li>They worked </li></ul><ul><li>many hundreds of hours </li></ul><ul><li>to study & review </li></ul><ul><li>the mechanisms and timing </li></ul><ul><li>of etiologic events that lead to </li></ul><ul><li>neonatal encephalopathy </li></ul><ul><li>and cerebral palsy </li></ul>
  • 21. <ul><li>They developed a report issued on </li></ul><ul><li>January 31, 2003 </li></ul><ul><li>by the American College of Obstetricians and Gynecologists (ACOG) </li></ul><ul><li>and the American Academy of Pediatrics (AAP) </li></ul>
  • 22. <ul><li>Over 75 % of cases </li></ul><ul><li>of neonatal encephalopathy </li></ul><ul><li>have </li></ul><ul><li>no clinical signs </li></ul><ul><li>of intrapartum hypoxia </li></ul>(ACOG) and (AAP) Report - January 31, 2003
  • 23. <ul><li>It is now well known that </li></ul><ul><li>hypoxic-ischemic encephalopathy </li></ul><ul><li>(HIE) </li></ul><ul><li>is only one type of neonatal encephalopathy </li></ul>(ACOG) and (AAP) Report - January 31, 2003
  • 24. <ul><li>P renatal strokes (like trauma), </li></ul><ul><li>I ntrauterine infections (like rubella), </li></ul><ul><li>C erebral malformations, </li></ul><ul><li>G enetic, </li></ul><ul><li>A nd many other conditions </li></ul>Other types of encephalopathy arise from :
  • 25. <ul><li>The best available evidence suggests </li></ul><ul><li>an incidence rate of </li></ul><ul><li>Pure HIE </li></ul><ul><li>(Hypoxic Ischemic Encephalopathy) </li></ul><ul><li>(i.e., with intrapartum hypoxia in the absence of any other preconceptional or antepartum abnormalities) </li></ul><ul><li>is approximately </li></ul><ul><li>1-2 per 10,000 births </li></ul>(ACOG) and (AAP) Report - January 31, 2003
  • 26. <ul><li>When HIE is combined </li></ul><ul><li>with neonatal encephalopathy from </li></ul><ul><li>all other causes </li></ul><ul><li>the incidence is </li></ul><ul><li>2 - 3 per 1,000 births </li></ul>(ACOG) and (AAP) Report - January 31, 2003
  • 27. Neonatal encephalopathy (ACOG) and (AAP) Report - January 31, 2003 incidence Pure HIE All types < 3 per 1,000 births < 2 per 10,000 births
  • 28. <ul><li>Therefore </li></ul><ul><li>only about </li></ul><ul><li>10% </li></ul><ul><li>of neonatal encephalopathy </li></ul><ul><li>is due to </li></ul><ul><li>hypoxia / ischemia </li></ul>(ACOG) and (AAP) Report - January 31, 2003
  • 29. <ul><li>Any cerebral palsy resulting from </li></ul><ul><li>acute intrapartum asphyxia </li></ul><ul><li>is even less frequent </li></ul><ul><li>(less than 10%) </li></ul><ul><li>because </li></ul><ul><li>Not all HIE , result in cerebral palsy </li></ul>(ACOG) and (AAP) Report - January 31, 2003
  • 30. Essential intrapartum criteria sufficient to cause cerebral palsy are (must meet all four) <ul><li>E vidence of a metabolic acidosis in fetal umbilical cord, </li></ul><ul><li>E arly onset of severe or moderate neonatal encephalopathy in infants born at 34 or more weeks of gestation, </li></ul><ul><li>C erebral palsy of the spastic quadriplegia, </li></ul><ul><li>E xclusion of other identifiable etiologies such as trauma, coagulation disorders, infectious conditions, or genetic disorders. </li></ul>(ACOG) and (AAP) Report - January 31, 2003
  • 31. <ul><li>A hypoxic event occurring immediately before or during labor </li></ul><ul><li>A sudden and sustained fetal bradycardia or the absence of fetal heart rate variability in the presence of persistent, late, or variable decelerations </li></ul><ul><li>A pgar scores of 0-3 beyond 5 minutes </li></ul><ul><li>O nset of multisystem involvement within 72 hours of birth </li></ul><ul><li>E arly imaging study showing evidence of acute nonfocal cerebral abnormality </li></ul>Criteria that suggest an intrapartum timing (but are nonspecific to asphyxial insults) (ACOG) and (AAP) Report - January 31, 2003
  • 32. The majority of newborn brain injury cases do not occur during labor and delivery (ACOG) and (AAP) Report - January 31, 2003
  • 33. <ul><li>Most instances of </li></ul><ul><li>neonatal encephalopathy and </li></ul><ul><li>cerebral palsy </li></ul><ul><li>are attributable to </li></ul><ul><li>events occurring before labor begins </li></ul>(ACOG) and (AAP) Report - January 31, 2003
  • 34. The report Gives evidence that the vast majority of cases originate from: <ul><li>D evelopmental, </li></ul><ul><li>M etabolic abnormalities, </li></ul><ul><li>A utoimmune , </li></ul><ul><li>C oagulation defects, </li></ul><ul><li>I nfection, </li></ul><ul><li>T rauma, or </li></ul><ul><li>C ombinations of these factors. </li></ul>(ACOG) and (AAP) Report - January 31, 2003
  • 35. <ul><li>The report helps us to understand the causes of neonatal encephalopathy and cerebral palsy, </li></ul><ul><li>The efforts could lead to clinical interventions that will reduce the rates of these serious cases </li></ul>Gary D.V. Hankins,MD, chair of the ACOG task force that developed the report.
  • 36. <ul><li>This report should serve as </li></ul><ul><li>a valuable resource for: </li></ul><ul><li>T he entire medical community, </li></ul><ul><li>T he courts , </li></ul><ul><li>and for </li></ul><ul><li>A ll those who care for infants and children with these disabilities </li></ul>ACOG President ,Charles B. Hammond, MD.
  • 37. <ul><li>It confirms that most brain injuries are </li></ul><ul><li>not due to </li></ul><ul><li>events occurring during: </li></ul><ul><li>L abor, </li></ul><ul><li>D elivery, </li></ul><ul><li>R esuscitation, or </li></ul><ul><li>T reatment immediately following birth . </li></ul>The American Academy of Pediatrics (AAP) welcomes this important report
  • 38. <ul><li>“ We remain concerned about infants with neonatal brain injury, </li></ul><ul><li>and will continue our </li></ul><ul><li>Neonatal Resuscitation Program </li></ul><ul><li>that assures pediatricians, receiving </li></ul><ul><li>the most up-to-date resuscitation skills &quot; </li></ul>AAP President E. Stephen Edwards, MD.
  • 39. <ul><li>CONCLUSION </li></ul>
  • 40. <ul><li>Labor and delivery are responsible only for </li></ul><ul><li>< 10 % </li></ul><ul><li>of neonatal encephalopathy and cerebral palsy </li></ul>
  • 41. <ul><li>The good news is that : </li></ul><ul><li>“ It is not the obstetrician's fault&quot; </li></ul>Dr. Ralph Dauterive, Chairman of the obstetrics and gynecology department at New Orleans. The bad news is that : “ There is probably not a lot, We can do about it in labor.&quot;
  • 42. Thank you

×