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Neonatal Encephalopathy and Cerebral Palsy

7/1/2015 - Moune Jabre, MD

Mentor:  Paul L. Ogburn, MD

Editor:  Martin E. Olsen, MD

Neonatal encephalopathy is a clinical syndrome of neurologic dysfunction noted in the first days of life of a neonate born at or beyond 35 weeks gestation. It is characterized by decreased level of consciousness or seizures, respiratory difficulty and depressed muscle tone. The incidence, 3 per 1,000 live births, has remained unchanged despite the widespread use of intrapartum electronic fetal heart monitoring.

Cerebral palsy is a non-degenerative motor disorder that originates in early development as a result of cerebral abnormality and is noted in the first 5 years of life. Most cases of cerebral palsy occur in infants born at term or near term, although prematurity is the leading risk factor. The incidence is approximately 2 per 1,000 live births. Neonatal encephalopathy and cerebral palsy can be causally linked to each other or to a web of interconnected factors, which may or may not be related to acute intrapartum events.

Neonatal encephalopathy can lead to a range of developmental outcomes that are not limited to cerebral palsy. Reliable tools that can accurately correlate intrapartum events with long-term neurologic outcome are still lacking. As such there are no definitive diagnostic tests or criteria that dependably identify an infant in whom acute intrapartum events have directly caused neonatal encephalopathy. The joint ACOG/AAP task force advocated for adopting a broad perspective in the approach to evaluation of infants with neurologic dysfunction and outlined features that increase or decrease the likelihood of an acute intrapartum causal link.

The critical initial step in evaluating an infant for neonatal encephalopathy is determining if the infant meets the case definition, which has specific criteria. Once neonatal encephalopathy is confirmed, a multidimensional assessment of all potential contributing factors should be undertaken and should include maternal health history, obstetric history, intrapartum factors, cord blood sampling, placental pathology and neuroimaging.

Neonatal signs and contributing factors consistent with acute peripartum/intrapartum events include:

  • Apgar scores < 5 at 5 and 10 minutes
  • Fetal umbilical artery pH < 7.0 and/or base deficit ≥ 12 mmol/L
  • Neuroimaging evidence of acute brain injury consistent with hypoxia-ischemia
  • Multisystem organ failure consistent with hypoxic-ischemic injury
  • Sentinel hypoxic or ischemic event that occurs proximate to labor and delivery (e.g. severe abruption or uterine rupture)
  • Intrapartum fetal heart rate classification that is initially Category I then converts to Category III
  • Absence of other possible etiologies
  • Developmental outcome of spastic quadriplegic or dyskinetic cerebral palsy

The goal of neonatal evaluation is to best define the pathogenesis and timing of the developmental outcome in order to target therapeutic interventions and improve patient counseling.

Further Reading:

American College of Obstetricians and Gynecologists; Executive summary: Neonatal encephalopathy and neurologic outcome, second edition. Report of the American College of Obstetricians and Gynecologists' Task Force on Neonatal Encephalopathy.; Obstet Gynecol. 2014 Apr;123(4):896-901. doi: 10.1097/01.AOG.0000445580.65983.d2. 

Also Available at: http://pediatrics.aappublications.org/content/pediatrics/early/2014/04/22/peds.2014-0724.full.pdf?rss=1

 

Initial Approval July 2015; Reviewed January 2017; Revised May 2018

 

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