Cerebral Palsy and Criteria Implicating Intrapartum Hypoxia in Neonatal Encephalopathy – An Obstetric Perspective for the South African Setting

Bhorat, Ismail; Buchmann, Eckhart; Soma-Pillay, Priya; Nicolaou, E; Pistorius, L. R.; Smuts, Izelle

doi:10.7196/samj.2021.v111i3b.15399

Cited by 3 publications

(7 citation statements)

References 63 publications

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“…FIRS increases the risk of neonatal encephalopathy (NE) in term infants by a factor of twelve [10,43].…”

Section: Postnatal Consequences Infant Neurological Damagementioning

confidence: 99%

“…The fetal and neonatal brain is highly susceptible to inflammation and oxidative stress as it continues developing during the third trimester, early postnatal period, and the first few years of life [10]. The severity of inflammation highly correlates with cerebral damage, and the most severe cases are related to necrotizing funisitis and severe chorionic vasculopathy [43][44][45][46].…”

Section: Postnatal Consequences Infant Neurological Damagementioning

confidence: 99%

“…Finally, cerebral inflammation increases the risk of neurodevelopmental impairment during childhood and adulthood [43][44][45][46].…”

Section: Postnatal Consequences Infant Neurological Damagementioning

confidence: 99%

“…In cases of FIRS, the injuries of a newborn baby must be assessed to quantify a possible compensation [50,51]. FIRS can determine consequences to several systems (respiratory, cardiovascular, gastrointestinal and endocrinological), but the most relevant is brain damage with neurological impairments and a wide spectrum of possible disabilities [10,43,47,50,52,63]. Medical records of the child's status at birth should be integrated with a detailed medicolegal examination.…”

Section: Medico-legal Implications Of Firsmentioning

confidence: 99%

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Infection Induced Fetal Inflammatory Response Syndrome (FIRS): State-of- the-Art and Medico-Legal Implications—A Narrative Review

et al. 2023

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Fetal inflammatory response syndrome (FIRS) represents the fetal inflammatory reaction to intrauterine infection or injury, potentially leading to multiorgan impairment, neonatal mortality, and morbidity. Infections induce FIRS after chorioamnionitis (CA), defined as acute maternal inflammatory response to amniotic fluid infection, acute funisitis and chorionic vasculitis. FIRS involves many molecules, i.e., cytokines and/or chemokines, able to directly or indirectly damage fetal organs. Therefore, due to FIRS being a condition with a complex etiopathogenesis and multiple organ dysfunction, especially brain injury, medical liability is frequently claimed. In medical malpractice, reconstruction of the pathological pathways is paramount. However, in cases of FIRS, ideal medical conduct is hard to delineate, due to uncertainty in diagnosis, treatment, and prognosis of this highly complex condition. This narrative review revises the current knowledge of FIRS caused by infections, maternal and neonatal diagnosis and treatments, the main consequences of the disease and their prognoses, and discusses the medico-legal implications.

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“…FIRS increases the risk of neonatal encephalopathy (NE) in term infants by a factor of twelve [10,43].…”

Section: Postnatal Consequences Infant Neurological Damagementioning

confidence: 99%

Section: Postnatal Consequences Infant Neurological Damagementioning

confidence: 99%

“…Finally, cerebral inflammation increases the risk of neurodevelopmental impairment during childhood and adulthood [43][44][45][46].…”

Section: Postnatal Consequences Infant Neurological Damagementioning

confidence: 99%

Section: Medico-legal Implications Of Firsmentioning

confidence: 99%

See 2 more Smart Citations

Infection Induced Fetal Inflammatory Response Syndrome (FIRS): State-of- the-Art and Medico-Legal Implications—A Narrative Review

et al. 2023

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“…<7 and/or base deficit ≥12 mmol/L, [32] and a recommendation for universal cord pH to be performed in all deliveries [33] has been made by the BetterObs programme of the South African Society of Obstetricians and Gynaecologists. Sepsis, for example, which is an important antenatal priming factor, limits the benefit of cooling (data for chorioamnionitis in the HELIX trial were absent), but funisitis was noted in 16% of neonates, which implies that antenatal infection could explain the predominant white-matter damage that was detected by magnetic resonance imaging (MRI)).…”

Section: Intrapartum V Antenatal Factors In Cp Causation In Low-resou...mentioning

confidence: 99%

Cerebral palsy and its medicolegal implications in low- resource settings – the need to establish causality and revise criteria to implicate intrapartum hypoxia: A narrative review

Bhorat,

Buchmann,

Soma-Pillay

et al. 2023

S Afr Med J

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The objective of this study was to establish scientific causality and to devise criteria to implicate intrapartum hypoxia in cerebral palsy (CP) in low-resource settings, where there is potential for an increase in damaging medicolegal claims against obstetric caregivers, as is currently the situation in South Africa. For the purposes of this narrative review, an extensive literature search was performed, including any research articles, randomised controlled trials, observational studies, case reports or expert or consensus statements pertaining to CP in low-resource settings, medicolegal implications, causality, and criteria implicating intrapartum hypoxia. In terms of causation, there are differences between high-income countries (HICs) and low-resource settings. While intrapartum hypoxia accounts for 10 - 14% of CP in HICs, the figure is higher in low-resource settings (20 - 46%), indicating a need for improved intrapartum care. Criteria implicating intrapartum hypoxia presented for HICs may not apply to low-resource settings, as cord blood pH testing, neonatal brain magnetic resonance imaging (MRI) and placental histology are frequently not available, compounded by incomplete clinical notes and missing cardiotocography tracings. Revised criteria in an algorithm for low-resource settings to implicate intrapartum hypoxia in neonatal encephalopathy (NE)/ CP are presented. The algorithm relies first on specialist neurological assessment of the child, determination of the occurrence of neonatal encephalopathy (by documented or verbal accounts) and findings on childhood MRI, and second on evidence of antepartum and intrapartum contributors to the apparent hypoxia-related CP. The review explores differences between low-resource settings and HICs in trying to establish causation in NE/CP and presents a revised scientific approach to causality in the context of low-resource settings for reaching appropriate legal judgments.

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Clinical practice

Bhorat,

Buchmann,

Frank

et al. 2023

S Afr Med J

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Basal ganglia and thalamus (BGT) hypoxic-ischaemic brain injury is currently the most contentious issue in cerebral palsy (CP) litigation in South Africa (SA), and merits a consensus response based on the current available international literature. BGT pattern injury is strongly associated with a preceding perinatal sentinel event (PSE), which has a sudden onset and is typically unforeseen and unpreventable. Antepartum pathologies may result in fetal priming, leading to vulnerability to BGT injury by relatively mild hypoxic insults. BGT injury may uncommonly follow a gradual-onset fetal heart rate deterioration pattern, of duration ≥1 hour. To prevent BGT injury in a clinical setting, the interval from onset of PSE to delivery must be short, as little as 10 - 20 minutes. This is difficult to achieve in any circumstances in SA. Each case needs holistic, multidisciplinary, unbiased review of all available antepartum, intrapartum and postpartum and childhood information, aiming at fair resolution without waste of time and resources.

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Cerebral Palsy and Criteria Implicating Intrapartum Hypoxia in Neonatal Encephalopathy – An Obstetric Perspective for the South African Setting

Cited by 3 publications

References 63 publications

Infection Induced Fetal Inflammatory Response Syndrome (FIRS): State-of- the-Art and Medico-Legal Implications—A Narrative Review

Infection Induced Fetal Inflammatory Response Syndrome (FIRS): State-of- the-Art and Medico-Legal Implications—A Narrative Review

Cerebral palsy and its medicolegal implications in low- resource settings – the need to establish causality and revise criteria to implicate intrapartum hypoxia: A narrative review

Clinical practice

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