It is crucial to interpret fetal heart rate patterns with a focus on the pattern evolution during labor to estimate the relationship between cerebral palsy and delivery. However, nationwide data are ...not available.
The aim of our study was to demonstrate the features of fetal heart rate pattern evolution and estimate the timing of fetal brain injury during labor in cerebral palsy cases.
In this longitudinal study, 1069 consecutive intrapartum fetal heart rate strips from infants with severe cerebral palsy at or beyond 34 weeks of gestation, were analyzed. They were categorized as follows: (1) continuous bradycardia (Bradycardia), (2) persistently nonreassuring, (3) reassuring-prolonged deceleration, (4) Hon’s pattern, and (5) persistently reassuring. The clinical factors underlying cerebral palsy in each group were assessed.
Hypoxic brain injury during labor (those in the reassuring-prolonged deceleration and Hon’s pattern groups) accounted for 31.5% of severe cerebral palsy cases and at least 30% of those developed during the antenatal period. Of the 1069 cases, 7.86% were classified as continuous bradycardia (n=84), 21.7% as persistently nonreassuring (n=232), 15.6% as reassuring-prolonged deceleration (n=167), 15.9% as Hon’s pattern (n=170), 19.8% as persistently reassuring (n=212), and 19.1% were unclassified (n=204). The overall interobserver agreement was moderate (kappa 0.59). Placental abruption was the most common cause (31.9%) of cerebral palsy, accounting for almost 90% of cases in the continuous bradycardia group (64 of 73). Among the cases in the Hon’s pattern group (n=67), umbilical cord abnormalities were the most common clinical factor for cerebral palsy development (29.9%), followed by placental abruption (20.9%), and inappropriate operative vaginal delivery (13.4%).
Intrapartum hypoxic brain injury accounted for approximately 30% of severe cerebral palsy cases, whereas a substantial proportion of the cases were suspected to have either a prenatal or postnatal onset. Up to 16% of cerebral palsy cases may be preventable by placing a greater focus on the earlier changes seen in the Hon’s fetal heart rate progression.
Objective
To investigate the association between hypoxic‐ischaemic insult timing and brain injury type in infants with severe cerebral palsy (CP).
Design
Longitudinal study.
Setting
Database of the ...Recurrence Prevention Committee, Japan Obstetric Compensation System for Cerebral Palsy.
Sample
Infants with severe CP born at ≥34 weeks of gestation.
Methods
The intrapartum fetal heart rate (FHR) strips were categorised as continuous bradycardia; persistently non‐reassuring (NR‐NR); reassuring‐prolonged deceleration (R‐PD); Hon's pattern (R‐Hon); persistently reassuring (R‐R); and unclassified. The brain magnetic resonance imaging (MRI) scans were categorised based on the predominant site involved: basal ganglia‐thalamus (BGT); white matter (WM); watershed (WS); stroke; normal; and unclassified.
Main outcome measures
Manifestations of the brain MRI types and the association between FHR evolution pattern and MRI type were analysed.
Results
Among 672 eligible infants, 76% had BGT‐dominant injury, 5.4% WM, 1.2% WS, 1.6% stroke, 1.9% normal, and 14% unclassified. Placental abruption and small‐for‐gestational age were associated with an increased (adjusted odds ratio aOR 8.02) and decreased (aOR 0.38) risk of BGT injury, respectively. The majority of infants had BGT injury in most FHR groups (bradycardia, 97%; NR‐NR, 75%; R‐PD, 90%; R‐Hon, 76%; and R‐R, 45%). The risk profiles in case of BGT in the NR‐NR group were similar to those in the R‐PD and R‐Hon groups.
Conclusion
BGT‐dominant brain damage accounted for three‐fourths of the cases of CP in term or near‐term infants, even in prenatal onset cases. Hypoxic‐ischaemic insult has a major impact on CP development during the antenatal period.
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Basal ganglia‐thalamus injury constitutes 76% of severe cerebral palsy cases, predominant even in antenatal‐onset cases.
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Basal ganglia‐thalamus injury constitutes 76% of severe cerebral palsy cases, predominant even in antenatal‐onset cases.
This article includes Author Insights, a video available at https://vimeo.com/bjogs/authorinsights17089.
Our goal was to compare the treatment outcomes of open-abdominal radical hysterectomy (O-RH) and total laparoscopic hysterectomy (TLRH) with vaginal cuff creation and without using a uterine ...manipulator in stage IB1-B2 (tumor size < 4 cm) cervical cancer cases. In this retrospective multicenter analysis, 94 cervical cancer stage IB1-B2 patients who underwent O-RH or TLRH in six hospitals in Japan between September 2016 and July 2020 were included; 36 patients underwent TLRH. Propensity score matching was performed because the tumor diameter was large, and positive cases of lymph node metastases were included in the O-RH group due to selection bias. The primary endpoint was progression-free survival (PFS) and recurrence sites of TLRH and O-RH. PFS and OS (overall survival) were not significant in both the TLRH (n = 27) and O-RH (n = 27) groups; none required conversion to laparotomy. The maximum tumor size was <2 and ≥2 cm in 12 (44.4%) and 15 (55.6%) patients, respectively, in both groups. Reportedly, the TLRH group had lesser bleeding than the O-RH group (p < 0.001). Median follow-up was 33.5 (2−65) and 41.5 (6−75) months in the TLRH and O-RH groups, respectively. PFS and OS were not significantly different between the two groups (TLRH: 92.6%, O-RH: 92.6%; log-rank p = 0.985 and 97.2%, 100%; p = 0.317, respectively). The prognosis of early cervical cancer was not significantly different between TLRH and O-RH. Tumor spillage was prevented by creating a vaginal cuff and avoiding the use of a uterine manipulator. Therefore, TLRH might be considered efficient.
Sirenomelia is a very rare congenital anomaly. Type I is the mildest type, and the long bone structures are all normally present with only soft tissue fusion. We experienced a case of type I ...sirenomelia complicated by severe oligohydramnios. Because of severe oligohydramnios, ultrasonographic images were not very clear. The associated findings with sirenomelia (single umbilical artery and bilateral renal agenesis) were helpful for the prenatal diagnosis of this disease. Detailed sonographic examination of the fetus was thought to be necessary for the accurate prenatal diagnosis of sirenomelia.
To assess the impact visceral adipose tissue percentage (VAT%) on surgical outcomes during minimally invasive surgery in obese women with endometrial cancer.
Retrospective observational cohort study.
...Mie University Hospital, Japan.
Of the 73 women (body mass index BMI >30 kg/m
) with obesity and primary endometrial cancer, 52 underwent robotic surgery, while 21 underwent laparoscopic surgery between April 2014 and December 2022.
We investigated the correlation between surgical outcomes (operative time and blood loss) and obesity (BMI and visceral adipose tissue percentage VAT%).
Abdominal fat-related parameters were measured at the level of the umbilicus using preoperative computed tomography. A weak negative correlation was found between BMI and VAT% (CC = -0.313, p = .001). Multivariate analysis showed that VAT% had a stronger correlation to total and practical operative time than BMI (β = 0.338 vs 0.267, β = 0.311 vs 0.209, respectively) and was an independent predictor of blood loss. VAT% was an independent predictive marker prolonged for operative time and increased blood loss during lymphadenectomy.
VAT% could be an indicator of surgical outcomes for patients with obesity and endometrial cancer.
Cerebral palsy is more common among preterm infants than among full-term infants. Although there is still no clear evidence that fetal heart rate monitoring effectively reduces cerebral palsy ...incidence, it is helpful to estimate the timing of brain injury leading to cerebral palsy and the causal relationship with delivery based on the fetal heart rate evolution patterns. Understanding the relationship between the timing and the type of brain injury can help to identify preventive measures in obstetrical care.
This study aimed to examine the relationship between the timing of insults and the type of brain injury in preterm infants with severe cerebral palsy.
This longitudinal study was based on a nationwide database for cerebral palsy. The data of infants with severe cerebral palsy (equivalent to levels 3–5 of the Gross Motor Function Classification System-Expanded and Revised), born between 2009 and 2014 at 28 to 33 weeks of gestation, were included. The intrapartum fetal heart rate evolution patterns were evaluated by 3 obstetricians blinded to clinical information other than gestational age at birth, and these were categorized after agreement by at least 2 of the 3 reviewers into (1) continuous bradycardia, (2) persistently nonreassuring (prenatal onset), (3) reassuring–prolonged deceleration, (4) Hon’s pattern (intrapartum onset), (5) persistently reassuring (pre- or postnatal onset), and (6) unclassified. Infant brain magnetic resonance imaging findings at term-equivalent age were assessed by a pediatric neurologist blinded to the background details, except for gestational age at birth and corrected age at image acquisition, and these were categorized as (1) basal ganglia–thalamus, (2) white matter, (3) watershed cortex or subcortex, (4) stroke, (5) normal, and (6) unclassified based on the predominant site involved. The risk factors for the basal ganglia–thalamus group were compared with those of the combined white matter and watershed injuries group.
Among 1593 infants with severe cerebral palsy, 231 were born at 28 to 33 weeks of gestation, and 140 met the eligibility criteria. Fetal heart rate evolution patterns were categorized as bradycardia (17% 24); persistently nonreassuring (40% 56); reassuring–prolonged deceleration (7% 10); reassuring–Hon (6% 8); persistently reassuring (7% 10); and unclassified (23% 32). Cerebral palsy was presumed to have an antenatal onset in 57% of infants and to have been caused by intrapartum insult in 13% of infants. Magnetic resonance imaging showed that 34% (n=48) of infants developed basal ganglia–thalamus-dominant brain injury. Of the remaining 92 infants, 43% (60) showed white matter injuries, 1% (1) showed watershed injuries, 4% (5) showed stroke, 1% (1) had normal findings, and 18% (25) had unclassified findings. Infants with continuous bradycardia (adjusted odds ratio, 1033.06; 95% confidence interval, 15.49–68,879.92) and persistently nonreassuring fetal heart rate patterns (61.20; 2.09–1793.12) had a significantly increased risk for basal ganglia–thalamus injury.
Severe cerebral palsy was presumed to have an antenatal onset in 57% of infants and to have been caused by intrapartum insult in only 13% of infants born at 28 to 33 weeks of gestation. Although the white matter–watershed injury was predominant in the study populations, severe acute hypoxia-ischemia may be an important prenatal etiology of severe cerebral palsy in preterm infants.
We compared the surgical outcomes of robot-assisted laparoscopic hysterectomy (RAH) and total laparoscopic hysterectomy (TLH). This single-center cohort study compared 139 RAH cases from January, ...2017 to September, 2021 and 291 TLH cases between January, 2015 and December, 2020. We retrospectively evaluated surgical outcomes, including total operative time (defined as the time from port wound incision to port wound closure), net operative time (defined as the time from the start of pneumoperitoneum to the end of pneumoperitoneum), estimated blood loss, weight of excised uterus (±adnexa), and overall complications, and the relationship between surgeon experience and operative time, net operative time, and blood loss in RAH and TLH. There was no significant difference in the total operative time between the two groups. Regardless of surgeon experience, the net operative time was significantly shorter in the RAH group than in the TLH group (p <0.001) and the estimated blood loss was significantly lower in RAH cases than in TLH cases (p = 0.01). The net operative time per uterine weight was shorter in the TLH group than that in the RAH group; however, there was no significant difference. RAH resulted in statistically better surgical outcomes in terms of net operative time and blood loss, regardless of surgeon experience. However, net operative time and blood loss also seem to be significantly affected by uterus weight. Large trials are imperative to determine the more effective surgical approach between RAH and TLH for different patient subsets.
Background: We aimed to retrospectively review data of pregnant women with the α-fibrinogen Thr331Ala polymorphism; evaluate the relationship between this polymorphism and spontaneous abortion (SA), ...fetal growth restriction (FGR), and intrauterine fetal death (IUFD); and assess the effects of aspirin and/or heparin.
Materials and methods: We examined the outcomes of 29 pregnancies (nine women) in women with the α-fibrinogen Thr331Ala polymorphism. Of these, 16 were untreated, whereas 13 were treated with heparin and/or aspirin.
Results: The live birth rate was significantly higher in the treated group than in the nontreated group (69.2 versus 6.2%; p = .0004). In addition, the prophylactic use of a low dose of aspirin and/or heparin during early pregnancy in women with Thr331Ala may be an effective method for reducing fetal loss in these patients.
Conclusions: This polymorphism interacts with pregnancy to result in poor obstetrical outcomes, but these effects can be mitigated with medical intervention. This study is the first to report outcomes of pregnancies complicated by the Thr331Ala polymorphism, which we believe may cause thrombophilia, SA, and IUFD. This study highlights the need for further research on this polymorphism in pregnancy.
ABSTRACT
The study of fetal heart rate (FHR) pattern evolution during labor is useful for evaluating the timing of perinatal brain injury that can lead to cerebral palsy (CP). Magnetic resonance ...imaging (MRI) is also useful for prospectively predicting neurological outcomes and retrospectively evaluating the pathophysiological types and patterns that affect brain injury. Using both FHR evolution studies and MRI findings of infants may help to evaluate the insult severity and pattern, as well as insult timing, of CP. Currently, studies on the association between these 2 tools are lacking. The aim of this study was to investigate the association between FHR patterns and MRI findings.
This was a longitudinal cohort study using the nationwide database of the Recurrence Prevention Committee, Japan Obstetric Compensation System for Cerebral Palsy. Included were infants with severe CP at ≥34 weeks of gestation between 2009 and 2014. Severe CP was defined as equivalent to levels 3 to 5 of the Gross Motor Function Classification System. Excluded were infants with missing or uninterpretable cardiotocograph tracings or unavailable brain MRI findings after birth. Cardiotocograph strips were analyzed, and FHR patterns were categorized into 6 groups: bradycardia, persistently nonreassuring (NR-NR) pattern, reassuring-prolonged deceleration (R-PD), initially reassuring that progressed over time to a nonreassuring, or Hon pattern (R-Hon), persistent reassuring (R-R) pattern, and unclassified. Brain MRI patterns were classified based on the predominant site—basal ganglia–thalamus (BGT), white matter, watershed, stroke, normal, and unclassified—then described as mild, moderate, or severe.
A total of 672 were included in the analysis. In the analysis of FHR patterns, 9% had bradycardia, 25% had NR-NR, 17% had R-PD, 17% had R-Hon, 13% had R-R, and 20% were unclassified. The majority had BGT injury (76%), indicating the cause as acute, profound hypoxia-ischemia. In infants in which the BGT region was spared, 5.4% had white matter injury, 1.2% had watershed injury, 1.6% had stroke, 1.9% had normal findings, and 14% were unclassified. In infants with BGT injury, common perinatal risk factors for CP included umbilical cord abnormality (>40%), placental abruption (23%), intrauterine infection (18%), and small for gestational age (13%). There was a significant increased risk of BGT injury in infants with placental abruption (adjusted odds ratio aOR, 8.02; 95% confidence interval CI, 1.53–41.95), but a decreased risk in small for gestational age infants (aOR, 0.38; 95% CI, 0.17–0.86). Basal ganglia–thalamus injury impacted a substantial proportion of infants across all FHR patterns, including bradycardia (97%), NR-NR (75%), R-PD (90%), R-Hon (76%), R-R (45%), and unclassified cases (45%). Most infants with BGT injury showed severe damage, with significant differences observed in the bradycardia group (aOR, 6.71; 95% CI, 1.26–35.75), NR-NR group (aOR, 2.51; 95% CI, 1.10–5.73), and R-PD group (aOR, 7.04; 95% CI, 2.24–22.10) compared with the R-R group after adjusting for clinical background. Cortical damage in the BGT accompanied most cases—with significantly more severe involvement in the bradycardia group (aOR, 5.61; 95% CI, 1.20–26.33), NR-NR group (aOR, 4.57; 95% CI, 1.33–15.68), and R-Hon group (aOR, 4.69; 95% CI, 1.22–18.00). Brainstem injuries were less frequent, with no difference in prevalence between groups.
In summary, 76% of infants with severe CP developed BGT injury based on the analysis of brain MRI findings. Basal ganglia–thalamus injuries were more frequently characterized by severe neonatal asphyxia versus non-BGT injuries.
(Abstracted from
Am J Obstet Gynecol
2020;223:907.e1–907.e13)
Among the major causes of cerebral palsy (CP) are hypoxic events that occur during labor. Therefore, fetal heart rate (FHR) monitoring to ...prevent brain injury associated with these events is an integral part of intrapartum management.
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