Daily Exam Question - Feb. 17, 2014

By drwall
February 17, 2014

Which of the following is least likely indicative of CP in the neonate?

A. Apgar 1 at 4 minutes

B. Cord Pa02 at 29%

C. Spastic quadriplegia

D. Apgar of 2 at 5 minutes

E. Base Deficit of -16

Answer: B

Criteria to Define an Acute Intrapartum Hypoxic Event as Sufficient to Cause Cerebral Palsy

1.1: Essential criteria (must meet all four)

1.  Evidence of a metabolic acidosis in fetal umbilical cord arterial blood obtained at delivery (pH <7 and base deficit >12 mmol/L)

2.  Early onset of severe or moderate neonatal encephalopathy in infants born at 34 or more weeks of gestation

3.  Cerebral palsy of the spastic quadriplegic or dyskinetic type*

4.  Exclusion of other identifiable etiologies, such as trauma, coagulation disorders, infectious conditions, or genetic disorders

1.2: Criteria that collectively suggest an intra- partum timing (within close proximity to labor and delivery, eg, 0–48 hours) but are nonspecific to asphyxial insults

1.  A sentinel (signal) hypoxic event occurring immediately before or during labor

2.  A sudden and sustained fetal bradycardia or the absence of fetal heart rate variability in the presence of persistent, late, or variable decelerations, usually after a hypoxic sentinel event when the pattern was previously normal

3.  Apgar scores of 0–3 beyond 5 minutes

4.  Onset of multisystem involvement within 72 hours of birth

5.  Early imaging study showing evidence of acute nonfocal cerebral abnormality

*Spastic quadriplegia and, less commonly, dyskinetic cerebral palsy are the only types of cerebral palsy associated with acute hypoxic intrapartum events. Spastic quadriplegia is not specific to intrapartum hypoxia. Hemiparetic cerebral palsy, hemiplegic cerebral palsy, spastic diplegia, and ataxia are unlikely to result from acute intrapartum hypoxia (Nelson KB, Grether JK. Potentially asphyxiating conditions and spastic cerebral palsy in infants of normal birth weight. Am J Obstet Gynecol 1998;179:507–13.).

Modified from MacLennan A. A template for defining a causal relation between acute intrapartum events and cerebral palsy: international consensus statement. BMJ 1999;319:1054–9.

Apgar Score and CNS Outcome

· Apgar score is a quick method of assessing the clinical status of the newborn (52, 53).

· 1- or 5-minute Apgar score is a poor predictor of long-term neurologic outcome in the individual patient (54).

· ¾ of children with cerebral palsy have normal Apgar scores (54).

· Low extended score is prognostically significant!

· Apgar scores of 0–3 beyond 5 minutes

· There is good correlation between an extremely low Apgar score at 15 and 20 minutes and subsequent neurologic dysfunction.

<3 @ >15 min: 53% mortality rate, with CP 36% rate

<3 @ > 20 min: 60% mortality rate, with 57% of survivors had CP

<3 @ 10 min: 17% had CP,rate decreased to approximately 5% if score improved @ 15 & 20 min

· The correlation between low Apgar score (<3) and neurologic disability improves somewhat at 10, 15, and 20 minutes after birth.

Sources: ACOG Neonatal Encephalophathy and CP; and Pearls of Excellence

Daily Exam Question - Written/MOC


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