Fetal heart rate pattern in term or near-term cerebral palsy: a nationwide cohort study

Nakao, Masahiro; Kondo, Eiji; Hasegawa, Junichi; Toyokawa, Satoshi; Ichizuka, Kiyotake; Kanayama, Naohiro; Shoji, Shuichi; Tamiya, Nanako; Nakai, Asami; Fujimori, Keiya; Maeda, Tsugio; Suzuki, Hideaki; Iwashita, Mitsutoshi; Ikeda, Tomoaki

doi:10.1016/j.ajog.2020.05.059

Cited by 17 publications

(16 citation statements)

References 30 publications

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“…We believe that the research data of Nakao et al 1 are an important contribution, but we suggest that for patients who come into labor, without evidence of existing damage, most CP cases are at least potentially within the control of healthcare providers to maximize the likelihood of good outcomes. What happens after patients arrive and before mothers and babies leave are critical issues amenable to provider influence.…”

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confidence: 91%

Categorization of cerebral palsy cases: a different perspective

Evans

Britt

2021

American Journal of Obstetrics and Gynecology

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Categorization of cerebral palsy cases: a different perspective TO THE EDITORS: Nakao et al 1 rigorously categorized electronic fetal monitoring (EFM) for 1069 cases of severe cerebral palsy (CP). However, our interpretation of their data is somewhat different than the authors. They concluded that, on admission, approximately 30% of cases were already damaged. Accurately identifying such cases would suggest that better strategies for antepartum assessment and action are needed. Some cases of CP certainly have genetic origin and are not preventable, but other cases of CP might have benefited from earlier intervention. We believe that using our multipublished metric, the Fetal Reserve Index (FRI), those cases would likely on admission have been scored as red zone, implying that the fetuses were already in trouble. We consider EFM to be a classic screening test. As such, frequent unanalyzable cases constitute poor screening test metrics. Consequently, more than 20% of their cases were "unclassified" and not included. In addition, they concluded that another 20% of their cases were of postpartum origin.Focusing only on the R-Hon pattern, the authors concluded that only 16% of cases were preventable, which artificially dilutes the importance of labor management. Such method perceptually minimizes the need for adequate evaluation, management, and personnel being available. By removing the damaged cases and 10% of unclassified cases (hypothesizing half of unclassified cases might be identified with a better system), many more cases could actually be amenable to risk reduction with precision evaluation.We have taken an expansive approach to EFM interpretation. With EFM evaluation contextualized by uterine activity and maternal, fetal, and obstetrical risk factors (FRI), our data suggested that screening metrics can be improved. 2e4 In addition, the 20% of cases that Nakoa categorized as having "postpartum" etiologies were consistent with our published observations that fetal and neonatal acid base balances (pH and base excess) typically worsen after birth before they get better, and 85% of neonates have a transient, significant tachycardia (both often beyond risk threshold levels). 4 The -

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confidence: 91%

Categorization of cerebral palsy cases: a different perspective

Evans

Britt

2021

American Journal of Obstetrics and Gynecology

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“…Rapid tocolysis with nitroglycerin could be useful for controlling uterine hypercontraction, which is also included in the FRI. We presumed the 20% R-R class to be because of a prepartum or postpartum etiology, although the etiology was unknown in many cases. 2 Regarding a postnatal etiology, which accounted for 20% of our cerebral palsy cases, almost half the cases were because of neonatal sepsis followed by intracranial hemorrhage, hypoglycemia, and other causes. 2 Infants with cerebral palsy caused by postnatal complications in our data were delivered with a median umbilical arterial pH of 7.32 (interquartile range [IQR], 7.25e7.36), base deficit of 3.4 (IQR, 6.10e2.40), and 1-and 5minute Apgar scores of 9/9 (IQR, 8e9 and 9e10, respectively), followed by the causative events that occurred hours to days after birth (median, 76 hours; IQR, 13.0e306.5).…”

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confidence: 94%

“…We thank Drs Evans and Britt for their Letter to the Editors 1 regarding our original paper in the American Journal of Obstetrics & Gynecology. 2 They expressed concerns about the potential underestimation of the preventability of cerebral palsy. We agree with their opinion that fetal heart rate (FHR) monitoring has limitations from a preventability point of view.…”

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confidence: 99%

Categorization of cerebral palsy cases: a different perspective

Nakao

Iwashita²,

Ikeda

2021

American Journal of Obstetrics and Gynecology

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confidence: 99%

Looking at the data in the right perspective

Nakao¹,

Iwashita²,

Ikeda

2021

American Journal of Obstetrics and Gynecology

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American Journal of Obstetrics and Gynecology. 2 They raised concerns about another potential bias in the fetal heart rate (FHR) analysis and its overestimation of the prevention of the development of cerebral palsy (CP).We agree with their opinion that we should follow the American College of Obstetricians and Gynecologists (ACOG) and American Academy of Pediatrics (AAP) recommendations to define acute peripartum or intrapartum events as a cause of neonatal encephalopathy and CP, which require a low Apgar score, fetal umbilical artery acidemia, neuroimaging evidence, multisystem organ failure, and distinct CP types. 3 What we studied is a specific part of the ACOG and AAP recommendation, that is, "[FHR] monitor patterns consistent with an acute peripartum or intrapartum event" in another section, "type and timing of contributing factors that are consistent with an acute peripartum or intrapartum event." 3 Although we concluded that intrapartum hypoxic brain injury accounted for approximately 30% of severe CP cases, we should investigate in a future study the other factors such as multisystem organ failure and distinct CP types and how they relate to FHR evolution types. Further assessment of the associations between the FHR patterns and magnetic resonance imaging findings of the infantile brain is ongoing. One point we want to emphasize is preventability. The ACOG or AAP does not address possible preventability of acute stress in the peripartum or intrapartum periods. Assuming that it would be feasible to prevent irreversible brain damage in the subacute Hon's pattern (R-Hon) cases, but not in the acute reassuring-prolonged deceleration (R-PD) cases, we concluded that "up to 16% of cases may be prevented if more focus is placed on the earlier changes seen with Hon's FHR progression."Regarding the clinical factors underlying CP, we only included single-causeeidentified cases to simplify the comparison. In addition to these 473 cases, 83 cases were multifactorial, and 513 cases were undetermined or of unknown cause. Of the multifactorial cases, most were attributed to the combined association of umbilical cord abnormality and other factors, such as intrauterine infection (41 cases [49%]), placental abruption (12 cases [14%]), and intrauterine growth restriction (8 cases [9.5%]). FHR evolutional types were bradycardia (2.4%),

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Fetal heart rate pattern in term or near-term cerebral palsy: a nationwide cohort study

Cited by 17 publications

References 30 publications

Categorization of cerebral palsy cases: a different perspective

Categorization of cerebral palsy cases: a different perspective

Categorization of cerebral palsy cases: a different perspective

Looking at the data in the right perspective

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