Epidemiologic aspects of shoulder dystocia-related neurological birth injuries.

PURPOSE: The first part of the study involved data collection for the detection of geographic variations and chronologic fluctuations in the rates of shoulder dystocia. The second part of the research evaluated head-to-body delivery times in cases of arrest of the shoulders at birth that had resulted in fetal damage during the last four decades in the USA. METHODS: The study of geographic and chronologic changes in the rates of shoulder dystocia rested on reported statistics coming from the USA and 11 other countries. These data were obtained by computer search. Evaluation of head-to-body delivery times rested on 104 well-documented cases that resulted in permanent neonatal damage. RESULTS: Literary reports of shoulder dystocia indicate that the incidence of shoulder dystocia has increased in the USA about fourfold since the middle of the twentieth century. No comparable trend has been reported from most other countries. Study of head-to-body delivery times revealed that more than two-thirds of all injured fetuses had been extracted from the birth canal within 2 minutes. CONCLUSIONS: Incidents of shoulder dystocia began to escalate in the USA during the 1980s, shortly after the introduction of "active management" of the birthing process. This new technique replaced a conservative philosophy which had recommended abstinence from intervention on the part of the accoucheur. The authors consider the interventionist approach largely responsible for the exponential increase in the rates of shoulder dystocia in the USA. They recommend adherence to the traditional method of delivery on the part of obstetricians in Europe and elsewhere.

Shoulder dystocia related fetal neurological injuries: the predisposing roles of forceps and ventouse extractions.

On the basis of 333 documented cases of permanent perinatal neurological damage, associated with arrest of the shoulders at birth, the authors conducted a retrospective study in order to evaluate the predisposing role, if any, of the utilization of extraction instruments. The investigation revealed that 35% of all injuries occurred in neonates delivered by forceps, ventouse or sequential ventouse-forceps procedures. This frequency was several-fold higher than the prevailing instrument use in the practices of American obstetricians during the same years. A high rate of forceps and ventouse extractions was demonstrable in all birth weight categories. Average weight and moderately large for gestational age fetuses underwent instrumental extractions more often than grossly macrosomic ones. This circumstance indicates that forceps and ventouse are independent risk factors, unrelated to fetal size. Their use entailed central nervous system injuries significantly more often than did spontaneous deliveries. The findings suggest that extraction procedures may be as important as macrosomia among the factors that lead to neurological damage in the child in connection with shoulder dystocia. Because they augment the intrinsic dangers of excessive fetal size exponentially, the authors consider their use in case of > or =4,000 g estimated fetal weight inadvisable. Sequential forceps-ventouse utilization further doubles the risks and is, therefore, to be avoided in all circumstances.

Prenatally diagnosed fetal brain injuries with known antenatal etiologies.

Periventricular leukomalacia of pre- or postnatal onset is responsible for severe neurological and intellectual impairment and cerebral palsy later in life. The etiology is multifactorial, involving hypoxic-ischemic insults of various origin. The disorder is characterized by multiple necrotic foci of the white matter found most frequently adjacent to the lateral ventricles. In the past, intrapartum factors were thought to be the major cause of neonatal brain damage, but recent investigations highlighted the role of antenatal risk factors. We present 4 cases of antenatally diagnosed brain injury with known and unusual etiology.

The risk of shoulder dystocia related permanent fetal injury in relation to birth weight.

OBJECTIVE: To examine birth weight related risks of fetal injury in connection with shoulder dystocia. STUDY DESIGN: The investigation was based on a retrospective analysis of 316 fetal neurological injuries associated with deliveries complicated by arrest of the shoulders that occurred across the United States. RESULTS: The study revealed that the distribution of birthweights for the high risk shoulder dystocia population differs from the standard birthweight distribution. The relative difference per birthweight interval is used to adjust an assumed 1:1000 baseline risk of injury due to shoulder dystocia following vaginal deliveries. These adjusted risks show a need to consider new thresholds for elective cesarean delivery. CONCLUSIONS: Current North American and British guidelines, that set 5000 g as minimum estimated fetal weight limit for elective cesarean section in non-diabetic and 4500 g for diabetic gravidas, may expose some macrosomic fetuses to a high risk of permanent neurological damage. The authors present the opinion that the mother, having been informed of the risks of vaginal versus abdominal delivery, should be allowed to play an active role in the critical management decisions.

[Fetal ischaemic brain injury in the second trimester of pregnancy]. / Magzati ischaemia okozta agykárosodás a terhesség középso harmadában.

Based on clinical, epidemiologic, and experimental studies, the aetiology of white matter damage, specially periventricular leukomalacia (PVL), is multifactorial and involves pre- and perinatal factors. Each of these factors is supposed to be a major precursor for neurological and intellectual impairment, and cerebral palsy (CP) in later life. Antenatal rather than intrapartum factors are now emerging as the major determinants of cerebral palsy. In this case report maternal trauma, benign tumour, severe anaemia and fetal cerebral vascular malformation are supposed as causative factors in intrauterine periventricular leukomalacia resulting from hypoxic-ischaemic injury.

[25 years' history of Váradi-Papp syndrome (orofaciodigital syndrome VI]. / A Váradi-Papp-szindróma (VI-os típusú orofaciodigitalis szindróma) 25 eves története.

INTRODUCTION: In 1978 the authors studied a male gypsy child with a multiple malformation syndrome. In this gypsy colony further five cases were found with similar features. The characteristic syndrome was published in 1980. Subsequently, the syndrome has been quoted as Váradi-Papp syndrome. AIM: To present the 25-year follow-up of this multiple malformation syndrome. RESULTS: The most common features of 29 affected children with this syndrome consists of orofacial (facial dysmorphism, cleft lip and/or palate abnormality, lingual nodule or tumor of the tongue, buccoalveolar frenula, alveolar and dental abnormalities, strabismus), cerebral/cerebellar (deformation of the skull, semilobar holoprosencephaly and/or absence or dysgenesis of cerebellar vermis or corpus callosum or hypothalamus or pituitary gland), digital (metacarpal abnormalities with central polydactyly, reduplication of the big toes) and genital (cryptorchidism, micropenis) anomalies. The patients are growth-retarded and when survival occurs psychomotor retardation is present. Accumulation of consanguinity and because of the involvement of multiple siblings in these families supports the autosomal recessive inheritance. CONCLUSION: Fetal Váradi-Papp syndrome using ultrasonography in the mid-trimester both in routine screening and detailed scanning can be detected, and termination of pregnancy can be offered to the parents.