Peri/intraventricular haemorrhage: a cranial ultrasound study on 5286 neonates

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Abstract

Objective: We launched a prospective cranial ultrasound study at the Department of Obstetrics and Gynaecology of the University of Giessen. In this study we examined the incidence and severity of brain damage in neonates and related them to various obstetrical risk factors. Study design: More than 90% of all neonates born between 1984 and 1988 were included in the study (n=5286) and were screened by ultrasound for cerebral abnormalities on 5–8 days post-partum. The relation between the incidence of peri/intraventricular haemorrhages (PIVH) and obstetrical risk factors were analyzed by contingency tables. Results: The most frequent abnormality was PIVH (3.6%) of various degrees (grade I–III). Periventricular leucomalacia, porencephalia, subarachnoidal haemorrhages, and hydrocephali were rare (≤0.2%). The incidence of PIVH increased progressively with decreasing gestational age, e.g. from 1.6% at 38–43 weeks up to 50.0% at 24–30 weeks of gestation. A large percentage of babies with PIVH were clinically normal. In immature neonates there was a close inverse relationship between Apgar score at 1, 5 and 10 min and both incidence and severity of PIVH. This was in contrast to findings in mature neonates where a marked increase in the incidence of PIVH was found only with Apgar scores as low as 0–4 points. The relation between the incidence of PIVH and both cardiotocography and arterial cord blood pH was poor, independent of the gestational age. The incidence of PIVH was increased in growth retarded fetuses (pH≤7.29), premature rupture of membranes, fever sub partu and gestosis. It is interesting to note that in mature fetuses there was no difference in the incidence of PIVH between vaginally delivered (0.8%) and sectioned breech presentations (2.1%). In preterms at 35–37 weeks with prolonged labour and secondary cesarean section, the incidence of PIVH was very high (11.2%). Conclusion: From the present study we conclude that the incidence of PIVH especially in immature neonates is highly associated with low Apgar scores at birth. Since the Apgar score reflects the clinical condition and the degree of circulatory centralisation of neonates that is influenced by various ante- and intranatal risk factors, a protective obstetrical management is necessary to reduce the incidence of PIVH in neonates.

Introduction

The successful reduction of perinatal mortality almost to the optimal attainable level has meant that mortality has become less significant as a measure of the quality of obstetric care (Perinatal Statistics-Hessen, 1989). Instead infant morbidity, i.e. degree of asphyxia during birth, clinical condition post-partum, brain damage as well as neurological and mental development throughout childhood and adolescence must be taken into closer consideration when assessing standards of perinatal management.

Even with expert analysis of the cardiotocogram, acid-base status and clinical condition of the infant post-partum, the probability of cerebral damage is still very difficult to estimate 1, 2, 3, 4, 5. This problem, which often becomes the focus of lawsuits and conflicting opinions, essentially arises from a lack of concrete data. For instance, prospective studies with large patient populations are needed to investigate the relation between risk factors arising during pregnancy, birth and post-partum and the occurrence of brain damage, such as peri- or intraventricular haemorrhage in newborns 3, 4, 5, 6.

To examine the incidence and severity of cerebral morbidity in neonates systematically, the Departments of Paediatrics as well as of Obstetrics and Gynaecology at the Justus-Liebig University in Giessen collaborated in launching a prospective cranial ultrasound study of all infants born there between 1984 and 1988. The results of these examinations were related to obstetric data and procedures. Attention was focused on the correlation of these factors to the incidence of peri- and intraventricular haemorrhages (PIVH), since these are by far the most common forms of brain damage.

The present study was limited to neonates born in the Department of Obstetrics and Gynaecology of the University of Giessen so that it can be assumed that the obstetric and paediatric care of the infants was constant over the period mentioned. Some preliminary results have already been published elsewhere [7].

Section snippets

Materials and methods

From 1984 to 1988, a cranial ultrasound study was carried out on all live-born infants on the day of discharge of the mother (5–8 days post-partum) from the Department of Obstetrics and Gynaecology at the University of Giessen. Infants who had to be transferred to the Children's Hospital directly post-partum were screened in the neonate ward there. Some of the infants with abnormal findings were then monitored daily.

Results

Of the 5799 live-born babies delivered between 1984 and 1988, 5286 (91.1%) neonates (51.1% male, 48.9% female) underwent cranial ultrasound screening. In 38 babies gestational age could not be assessed. The basic obstetric data for the neonates and the distribution of the various modes of delivery and of the obstetric risk factors are given in Table 1Table 2, Table 3.

Pathological findings revealed by cerebral ultrasound screening are shown in Table 4. The most common abnormalities (3.6%) were

Discussion

The prospective cranial ultrasound study presented here is an example of successful collaboration between obstetricians and paediatricians to investigate the incidence and severity of PIVH and other pathological findings in neonates in a large, unselected population and to relate these findings to risk factors arising during pregnancy and delivery.

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