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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.

The American College of Obstetricians and Gynecologists and the American Academy of Pediatrics published a report in 2003 entitled “Neonatal Encephalopathy and Cerebral Palsy,” listing criteria for relating neonatal signs of encephalopathy to acute peripartum and intrapartum events. A follow up report in 2014, entitled “Neonatal Encephalopathy and Neurologic Outcomes” emphasized that neonatal encephalopathy can lead to a range of developmental outcomes that are not limited to cerebral palsy. Only limited new epidemiologic data on neonatal encephalopathy has become available since the 2003 report. Reliable tools that can accurately correlate intrapartum events with long-term neurologic outcome are still lacking. As such, the current report moves away from the structured 2003 criteria and states that there are no definitive diagnostic tests or criteria that dependably identify an infant in whom acute intrapartum events have directly caused neonatal encephalopathy. The task force advocates adopting a broad perspective in the approach to evaluation of infants with neurologic dysfunction and outlines 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:

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. 

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

Initial Approval July 2015; Updated January 2017

 

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