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
DOI:
https://doi.org/10.7196/SAMJ.2023.v113i6.229Keywords:
cerebral palsy, intrapartum hypoxia, low resource settings, neonatal encephalopathy, hypoxic ischaemic encephalopathyAbstract
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.
References
Sartwelle TP, Johnston JC. Cerebral palsy litigation: Change course or abandon ship. J Child Neurol 2015;30(7):828-841. https://doi.org/10.1177/0883073814543306
MacLennan A, Nelson KB, Hankins G, Speer M. Who will deliver our grandchildren? Implications of cerebral palsy litigation. JAMA 2005;294(13):1688-1690. https://doi.org/10.1001/jama.294.13.1688 3. Taylor B, van Waart J, Ranchod S, Taylor A. Medicolegal storm threatening maternal and child
healthcare services. S Afr Med J 2018;108(3):149-150. https://doi.org/10.7196/SAMJ.2018.
v108i3.13139
Ackley BJ, Swan BA, Ladwig G, Tucker S. Evidence-based Nursing Care Guidelines: Medical-surgical Interventions. St Louis, Mo.: Mosby Elsevier, 2008:7.
Jacobsson B, Hagberg G. Antenatal risk factors for cerebral palsy. Best Pract Res Clin Obstet Gynaecol 2004;18(3):425-436. https://doi.org/10.1016/j.bpobgyn.2004.02.011
McIntyre S, Taitz D, Keogh J, Goldsmith S, Badawi N, Blair E. A systematic review of risk factors for cerebral palsy in children born at term in developed countries. Dev Med Child Neurol 2013;55(6):499- 508. https://doi.org/10.1111/dmcn.120177. Badawi N, Kurinczuk JJ, Keogh JM, et al. Intrapartum risk factors for newborn encephalopathy: The Western Australian case-control study. BMJ 1998;317(7172):1554-1558. https://doi.org/10.1136/ bmj.317.7172.1554
Donald K, Samia P, Kakooza-Mwesige A, Bearden D. Pediatric cerebral palsy in Africa: A systematic review. Semin Pediatr Neurol 2014;21(1):30-35. https://doi.org/10.1016/j.spen.2014.01.001
Karumuna JM, Mgone CS. Cerebral palsy in Dar es Salaam. Cent Afr J Med 1990;36(1):8-10.
Van Toorn R, Laughton P, van Zyl N. Aetiology of cerebral palsy presenting at Tygerberg Hospital. S
Afr J Child Health 2007;1(2):74-77.
Singhi P, Saini AG. Changes in the clinical spectrum of cerebral palsy over two decades in North India
– an analysis of 1212 cases. J Trop Pediatr 2013;59(6):434-440. https://doi.org/10.1093/tropej/fmt035
McIntyre S, Taitz D, Keogh J, Goldsmith S, Badawi N, Blair E. A systematic review of risk factors for cerebral palsy in children born at term in developed countries. Dev Med Child Neurol 2013;55(6):499-
https://doi.org/10.1111/dmcn.12017
Wang H, Liddell CA, Coates MM, et al. Global, regional, and national levels of neonatal, infant, and
under-5 mortality during 1990 - 2013: A systematic analysis for the Global Burden of Disease Study
Lancet 2014;384(9947):957-979. https://doi.org/10.1016/S0140-6736(14)60497-9
Kakooza-Mwesige A, Andrews C, Peterson S, Mangen FW, Eliasson AC, Forssberg H. Prevalence of cerebral palsy in Uganda: A population-based study. Lancet Glob Health 2017;5(12):e1275-e1282.
https://doi.org/10.1016/S2214-109X(17)30374-1
Gladstone M. A review of the incidence and prevalence, types and aetiology of childhood cerebral palsy in resource-poor settings. Ann Trop Paediatr 2010;30(3):181-196. https://doi.org/10.1179/146 532810X12786388978481
Ellis M, Manandhar N, Manandhar DS, Costello AM. Risk factors for neonatal encephalopathy in Kathmandu, Nepal, a developing country: Unmatched case-control study. BMJ 2000;320(7244):1229- 1236. https://doi.org/10.1136/bmj.320.7244.1229
Bruckmann EK, Velaphi S. Intrapartum asphyxia and hypoxic ischaemic encephalopathy in a public hospital: Incidence and predictors of poor outcome. S Afr Med J 2015;105(4):298-303. https://doi. org/10.7196/SAMJ.9140
Lally PJ, Price DL, Pauliah SS, et al. Neonatal encephalopathic cerebral injury in South India assessed by perinatal magnetic resonance biomarkers and early childhood neurodevelopmental outcome. PLoS ONE 2014;9(2):e87874. https://doi.org/10.1371/journal.pone.0087874
Wu YW, Escobar GJ, Grether JK, et al. Chorioamnionitis and cerebral palsy in term and near-term infants. JAMA 2003;290(20):2677-2684. https://doi.org/10.1001/jama.290.20.2677
Grether JK, Nelson KB. Maternal infection and cerebral palsy in infants of normal birth weight. JAMA 1997;278(3):207-211.
Figueras F, Gratacos E. Update on the diagnosis and classification of fetal growth restriction and proposal of a stage-based management protocol. Fetal Diagn Ther 2014;36(2):86-98. https://doi. org/10.1159/000357592
Brosens I, Pijnenborg R, Vercruysse L, Romero R. The ‘great obstetrical syndromes’ are associated with disorders of deep placentation. Am J Obstet Gynecol 2011;204(3):193-201. https://doi.org/10.1016/j. ajog.2010.08.009
Figueras F, Caradeux J, Crispi F, Eixarch E, Peguero A, Gratacos E. Diagnosis and surveillance of late-onset fetal growth restriction. Am J Obstet Gynecol 2018;218(2S):S790-S802.e1. https://doi. org/10.1016/j.ajog.2017.12.003
Volpe JJ. Placental assessment provides insight into mechanisms and timing of neonatal hypoxic-ischemic encephalopathy. J Neonatal Perinatal Med 2019;12(2):113-116. https://doi.org/10.3233/NPM-190270
Redline RW. Classification of placental lesions. Am J Obstet Gynecol 2015;213(4 Suppl):S21-S28.
https://doi.org/10.1016/j.ajog.2015.05.056
Redline RW. Placental pathology: A systematic approach with clinical correlations. Placenta 2008;29(Suppl A);S86-S91. https://doi.org/10.1016/j.placenta.2007.09.003
Bhorat IE, Bagratee JS, Pillay M, Reddy T. Use of the myocardial performance index as a prognostic indicator of adverse fetal outcome in poorly controlled gestational diabetic pregnancies. Prenat Diagn 2014;34(13):1301-1306. https://doi.org/10.1002/pd.4471
Nelson KB. Causative factors in cerebral palsy. Clin Obstet Gynecol 2008;51(4):749-762. https://doi. org/10.1097/GRF.0b013e318187087c
MacLennan AH, Thompson SC, Gecz J. Cerebral palsy: Causes, pathways, and the role of genetic variants. Am J Obstet Gynecol 2015;213(6):779-788. https://doi.org/10.1016/j.ajog.2015.05.034
Thayyil S, Pant S, Montaldo P, et al. Hypothermia for moderate or severe neonatal encephalopathy in low-income and middle-income countries (HELIX): A randomised controlled trial in India, Sri Lanka, and Bangladesh. Lancet Glob Health 2021;9(9):e1273-e1285. https://doi.org/10.1016/S2214- 109X(21)00264-3
Ballot DE, Ramdin TD, Bandini RM. Therapeutic hypothermia for neonatal hypoxic ischaemic encephalopathy should not be discontinued in low- and middle-income countries. S Afr Med J 2021;111(12):1168-1169. https://doi.org/10.7196/SAMJ.2021.v111i12.16180
Bhorat I, Buchmann E, Soma-Pillay P, Nicolaou E, Pistorius L, Smuts I. Cerebral palsy and criteria implicating intrapartum hypoxia in neonatal encephalopathy – an obstetric perspective for the South African setting. S Afr Med J 2021;111(3b):280-288. https://doi.org/10.7196/SAMJ.2021.v111i4b.15399
Bhorat IE, Pistorius L, Soma-Pillay P, Smuts I. The case for the routine use of umbilical cord pH in all deliveries. O&G Forum 2017;27(3):33-33.
Nelson KB, Sartwelle TP, Rouse DJ. Electronic fetal monitoring, cerebral palsy, and caesarean section: Assumption versus evidence. BMJ 2016;355:i6405. https://doi.org/10.1136/bmj.i6405
Houseinne N, Punt MC, Brown JL, et al. Strategies for intrapartum foetal surveillance in low- and middle-income countries: A systematic review. PLoS ONE 2018;13(10):e0206295. https://doi. org/10.1371/journal.pone.0206295
Elsingergy MM, Worede F, Venkatakrishna S, Curic J, Andronikou S. Magnetic resonance imaging diagnosis of causes of cerebral palsy in a developing country: A database of South African children. S Afr Med J 2021;111(9):910-916. https://doi.org/10.7196/SAMJ.2021.v111i9.15666
Nakao M, Nanba Y, Okumura A, et al. Correlation between heart rate evolution patterns and MRI findings in severe cerebral palsy: A longitudinal study. BJOG 2022;129(9):1542-1582. https://doi. org/10.1111/1471-0528.17089
Neonatal encephalopathy and neurologic outcome, second edition: Report of the American College of Obstetricians and Gynecologists’ Task Force on Neonatal Encephalopathy. Obstet Gynecol 2014;123(4):896-901. https://doi.org/10.1097/01.AOG.0000445580.65983.d2
Mirmiran M, Barnes PD, Keller K, et al. Neonatal brain MRI before discharge is better than serial cranial ultrasound predicting cerebral palsy in very low birthweight infants. Pediatrics 2004;114(4):992-998. https://doi.org/10.1542/peds.2003-0772-L
Pasternak JF, Gorey MT. The syndrome of acute near-total intrauterine asphyxia in the term infant. Pediatr Neurol 1998;18(5):391-398. https://doi.org/10.1016/s0887-8994(98)00002-2
Medina-Alva P, Duque KR, Zea-Vera A, et al. Combined predictors of neurodevelopment in very low birthweight preterm infants. Early Hum Dev 2019;130:109-115. https://doi.org/10.1016/j. earlhumdev.2019.01.019
Omo-Aghoja L. Maternal and fetal acid-base chemistry: A major determinant of perinatal outcome. Ann Med Health Sci Res 2014;4(1):8-17. https://doi.org/10.4103/2141-9248.126602
Miltenburg AS, Kiritta RF, Meguid T, Sundby J. Quality of care during childbirth in Tanzania: Identification of areas that need improvement. Reprod Health 2018;15(1):14. https://doi.org/10.1186/ s12978-018-0463-1
Wall SN, Lee ACC, Carlo W, et al. Reducing intrapartum-related neonatal deaths in low-and middle- income countries – what works? Semin Perinatol 2010;34(6):395-407. https://doi.org/10.1053/j. semperi.2010.09.009
Brodie M. Why TAC wants a say in landmark medical negligence case. Spotlight, 10 December 2019.
https://www.spotlightnsp.co.za/2019/12/10/why-tac-wants-a-say-in-major-medical-negligence-case/
(accessed 27 July 2020).
Nelson KB, Ellenberg JH. Antecedents of cerebral palsy: Multivariate analysis of risk. N Engl J Med
;315(2):81-86. https://doi.org/10.1056/NEJM198607103150202.
Badawi N, Kurinczuk JJ, Keogh JM, et al. Antepartum risk factors for newborn encephalopathy: The
Western Australian case-control study. BMJ 1998;317(7172):1549-1553. https://doi.org/10.1136/ bmj.317.7172.1549
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