Journal of Neonatology & Clinical Pediatrics Category: Clinical Type: Original Article
Intrapartum Asphyxia in Relation with the Risk for Developing of Cerebral Palsy
- Mihaela-Adela Vintan1*, Smaranda Avramescu2
- 1 Department Of Pediatric Neurology, Children’s Emergency Hospital Cluj-Napoca, Romania
- 2 Iuliu Hatieganu University Of Medicine And Pharmacy Cluj Napoca, Romania
*Corresponding Author:Mihaela-Adela Vintan
Department Of Pediatric Neurology, Children’s Emergency Hospital Cluj-Napoca, Romania
Tel: +40 745617441,
Received Date: May 14, 2019 Accepted Date: May 29, 2019 Published Date: Jun 05, 2019
Background and goals
Neonatal hypoxic-ischemic injury defined as: “Asphyxia of the umbilical blood supply to the human fetus occurring at 36 gestational weeks or later”, represents still a stable cause of mortality and disability despite the progress in assisted respiratory and intensive care technology. It is thought to be the major cause for developing of Cerebral Palsy (CP). We performed an observational study that included children with cerebral palsy, in order to asses the relation of intrapartum asphyxia and CP.
Our group included children with diagnosis of CP, age under 5 years with same characteristics regardind sex, families social and educational level. There were excluded children with malformations, braintumors, neurometabolic and neurodegenerative disorders. We evaluated the relation between the presence of intrapartum asphyxia and type of CP, type of neurological involvement: Spastic, extrapiramidal or mixt and the relation with CP comorbidities as motor and mental retardation and epilepsy.
We evaluated 110 children with CP - 63 females (57 %) and 47 males (43 %); 43 of them (39 %) presented documented intrapartum asphyxia. The type of CP was dominating spastic type (79 %), associated with motor retardation in 102 (92 %), cognitive disability in 81 (73,63 %) and epilepsy in 53 of them (48 %). We found possible relationship for developing distonic and mixt type of neurological involvement, no relation regarding the type of CP - tetraparesis, diparesis or hemiparesis. In our group, no relationship was found regarding motor and mental retardation and history of intrapartum asphyxia, instead there was a correlation with epilepsy in this group of children.
CP is a multifactorial disorder. Intrapartum asphyxia could be a factor that determines the type of CP and associated disabilities, but it is not specific. Probably studies on larger groups could better clarify the relation between CP and intrapartum asphyxia.
HI - Hypoxic-Ischemic
HIE - Hypoxic-Ischemic Encephalopathy
EEG - Electroencephalography
CP - Cerebral Palsy
The watershed zone is susceptible to injury in brain hypoperfusion. There are differences between term and preterm neonates regarding brain reaction to hypoxia, due to anatomical particularities. Preterm have imagerie cerebrale blood flow, the periventricular white matter is the most vulnerable to ischemic insult; autoregulation of cerebral blood flow is limited in preterm infants due to immature vasoregulatory mechanisms and underdevelopment of arteriolar smooth muscles. Hypoxic-ischemic insult results in germinal matrix hemorrhage from rupture of the periventricular capillaries and increased venous pressure dueto ischemic tissue reperfusion, cysts formation in periventricular area and finally, periventricular leukomalacia associated with ventriculomegali and thinning of corpus callosum .
In term infants, circulation and autoregulation of cerebral blood flow are similar to that of an adult. Ischemic and hemorrhagic injuries tend to follow similar patterns of those in adults. Infarcts in the parasagital watershed areas are the most common lesions and they involve territories between anterior cerebral artery and middle cerebral artery, or between middle cerebral artery and posterior cerebral artery; both cortex and subcortical white matter being involved. Severe and diffuse hypoxia results in cerebral edema followed by cortical atrophy, ulegyria or multicystic encephalomalacia .
Hypoxic-ischemic cerebral imjury during the perinatal period is one of the most commonly recognized causes of severe, long-term neurologic deficits in children; it is often related to Cerebral Palsy (CP) . Neonatal HIE occurs in 1.5 / 1000 of the live births . After neonatal HIE, 5-10 % of surviving babies present persistent motor deficits, while 20 - 50 % have sensory or cognitive deficits that persist to adolescence [2,3,5,9,10].
A meta-analysis of seven studies, that included 386 infants, analysed the average incidence of mortality and morbidity: 5.9 % of patients across all studies died, 16.3 % presented neonatal seizures, while 17.2 % associated neurological deficits, 14.2 % of them later developed cerebral palsy [5,11].
Cerebral Palsy (CP) describes a group of permanent disorders of the development of movement and posture, causing activity limitation, that are attributed to non-progressive disturbances that occurred in the developing fetal or infant brain. The motor disorders of CP are often accompanied by disturbances of sensation, perception, cognition, communication, behaviour, by epilepsy and by secondary musculoskeletal problems” .
CP affects approximately 2-2.5 / 1000 live births in the Western world, and more children in the developing world. The sex ratio is 1.4:1 males to females. Perinatal HIE in term infants was evaluated to be respondable for 25 - 30 % of causes of CP in the 80’s . In our days, birth asphyxia and complicated labour and delivery are responsable for 10 % of causes of CP .
SUBJECTS AND METHOD
Statistical analysis was performed using Microsoft Office Excel & Epi Info. We evaluated and quantified the relationship between risk factor and CP. Chi-square test was used: Any statistical hypothesis test wherein the sampling distribution of the test statistic is a chi-squared distribution when the null hypothesis is true. p-value ≤ 0.05 - indicates strong evidence against the null hypothesis, so you reject the null hypothesis.p-value > 0.05 - indicates weak evidence against the null hypothesis, so you fail to reject the null hypothesis. p-values very close to the cutoff (0.05) are considered to be marginal (could go either way). We used Risk Ratio (Relative Risk) = RR, with confidence intervals of 95 % (upper an lower limit); RR > 1.2 - meaning there’s a higher risk for children exposed to develop CP; RR < 0.8 - significantly lowers the risk of children exposed to develop CP.
RESULTS AND DISCUSSIONS
SPASTIC TYPE OF CP
DISTONIK - DYSKINETIC TYPE OF CP
p = 0,13; meaning it could be a possible clinical relevance, but larger sample is needed.
MIXED TYPE OF CP
RELATION WITH TOPOGRAPHICAL DISTRIBUTION OF THE CP
In the group of paraplegia
We further analyzed the relation of intrapartum asphyxia in our CP group and associated impairments
Analyzing statistical corelation between intrapartum aspyxia and association of cognitive imparment in our group of CP children, we found that cognitive imparment was 1,07 times more frequent in children with CP and intrapartum asphyxia comparing with non-exposed; RR = 1,07 (95 % CI 0,85 - 1,33), but no clinical relevance was found (p = 0,55).
According to DSM 5, intelectual disability (term that replace the old term of ”mental retardation”) is classified as: Mild (IQ = 50-55 to 70), moderate (IQ = 35-40 to 50-55), severe (IQ = 20-25 to 35-40) and profound (IQ below 20-25) .
Intelectual disability was present in 84 (76 %) of our CP children; 17 of them (15 %) presented mild intelectual disability, 18 (16 %) presented moderate intelectual disability, while the others 46 presented severe and profound intelectual disability. In the group of mild intelectual disability, statistical data showed that mild cognitive impairment was 1,38 times more frequent in children with CP and intrapartum asphyxia comparing with non-exposed, RR = 1,38 (95 % CI 0,57 - 3,31), it could be posible clinical relevance but, larger sample is needed (p = 0,46). As about moderate intelectual impairment, statistical analysis revealed that it was 1,24 times more frequent in children with CP and intrapartum asphyxia comparing with non-exposed; RR = 1,24 (95 % CI 0,53 - 2,9), there is posible clinical relevance, but larger sample is needed (p = 0,61).
Regarding the group of profound intelectual disability, it was 0,91 times more frequent in children with CP and intrapartum asphyxia comparing with non-exposed; RR = 0,91 (95 % CI 0,57 - 1,44), no clinical relevance was found (p = 0,69).
Also, 12 children (11 %) presented hyperanxiety documented by psychological evaluation. Statistical analysis showed that anxiety is 0,14 times more frequent in children with CP and intrapartum asphyxia comparing to non-exposed; RR = 0,14 (95 % CI 0,01 - 1,05), there was definite clinical relevance (p = 0,01).
Limitations of the study: As statistical analysis showed, larger samples are needed to identify relationship between intrapartum asphyxia and CP type and associated imparments. The observation was conducted when intrapartum and perinatal monitoring was still under development, observational studies in more recent years could show if the parameters remain the same or if they have improved.
We identified an obvious relationship between intrapartum asphyxia and paraplegia (‘mild’) form of CP.
Our results showed that intrapartum asphyxia could be involved in the development of associated impairments such as: Epilepsy, behavior disorders and cognitive impairment in children with CP, but larger groups and more recent observations are needed.
CONFLICT OF INTEREST
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Citation: Vin?an MA, Avramescu S (2019) Intrapartum Asphyxia in Relation with the Risk for Developing of Cerebral Palsy. J Neonatol Clin Pediatr 6: 030.
Copyright: © 2019 Mihaela-Adela Vintan, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.