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Brachial Palsy: Prediction Prevention.

Outline. HistoryNatural historyRisk FactorsPrevention strategiesConclusions. History. Smellie 1764Erb 1874 delivery paralysis" related to moderately energetic manipulation by the obstetrician". Significance of Brachial Palsy. Complication of birth traumaMajor cause of neonatal morbidityFe

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Brachial Palsy: Prediction Prevention.

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    1. Brachial Palsy: Prediction & Prevention. Raphi Pollack, MDCM, FRCSC. Bikur Cholim Hospital, Jerusalem.

    2. Outline History Natural history Risk Factors Prevention strategies Conclusions

    3. History Smellie 1764 Erb 1874 “delivery paralysis” related to “moderately energetic manipulation by the obstetrician”

    4. Significance of Brachial Palsy Complication of birth trauma Major cause of neonatal morbidity “Fetal-physician” risk Accounts for 4.2% of OBS litigation

    6. Clinical Syndromes Erb Palsy C5, C6 root avulsion Upper trunk plexopathy Arm Adduction & internal rotation Elbow extended & forearm pronated “Waiters tip” position +/- Horner syndrome

    7. Clinical Syndromes Flail arm Injury to entire plexus Klumpke palsy Lower trunk (C8, T1) injury Poor grasp, proximal function preserved

    8. Electrodiagnosis Nerve conduction studies Changes in amplitude of motor & sensory response Electromyography Study of motor unit potential Technically difficult in the neonate Insights into pathogenesis

    9. Electrodiagnosis: Timing of Injury Fibrillations Onset = 12-21 days Peak = 35 days Conduction abnormalities : Sensory Onset = 5-6 days Peak = 10 days Conduction abnormalities : Motor Onset = 2-4 days Peak = 7 days

    10. Incidence of Brachial Palsy 0.5-3 per 1000 births Gilbert et al (1995) 1.5/1000 births 5420 cases annually in USA 180 cases annually in Israel

    11. Natural History Important to understand burden of disease Contrast with clavicular # Resolution – how often ? Michelow HSC (1994) 92% resolved Bager (1997) 49% resolved 22% severely impaired Eng (1996) 22% resolved 78% long term disabilities

    12. Pathogenesis Excessive downward traction. Vs. In-utero insult.

    13. In- utero insult Koenigsberger (1980) EMG evidence of prenatal injury Dunn & Engle (1985) Bicornuate uterus Bb skeletal deformities, muscle atrophy, brachial palsy EMG findings

    14. In-utero insult : The Evidence 1,611 cases of OBP 47% of all OBP do not involve shoulder dystocia 60/1,611 cases of OBP Cesarean delivery Ascertainment bias ?? Excessive traction at time of CS ?? Gilbert (1999)

    15. In-utero insult : Natural History Gherman (1998) 40 cases of OBP. OBP in absence of SD : high persistence. OBP in presence of SD : low persistence. Suggests pathogenetic heterogeneity.

    16. Brachial Palsy: Risk Factors Shoulder dystocia (OR=76.1) Neonatal birthweight Instrumental vaginal delivery Breech presentation (OR=5.6) Gestational DM (OR=1.9) Prior infant with brachial palsy

    17. Brachial Palsy & Neonatal BW

    18. Brachial Palsy & Instrumental Delivery

    19. Highest Risk of Brachial Palsy Maternal Diabetes Mellitus & BW > 4500 Gms. & Instrumental Vaginal Delivery OR = 52

    20. Pts. At Highest Risk for OBP

    21. Birth Trauma: Recurrence Risk Baskett (1995) Shoulder dystocia over 10 yrs. (N=254) Recurrent shoulder dystocia = 1/93 (1.1%) 0/8 cases of OBP in setting of prior OBP Al-Qattan (1996) 16/49 (33%) cases of recurrent OBP

    22. OBP: Negative associations Prematurity (OR = 0.8) IUGR (OR = 0.9) Cesarean delivery (OR = 0.2) No factors were entirely protective

    23. Prevention Strategies Manipulation of BW Tight control in DM Risk stratification Identification of the macrosomic fetus Elective induction Elective Cesarean delivery

    24. Murphy’s Law: First Corollary “Nothing is as simple as it first seems”

    25. Prevention Strategies Must be broad based. Most OBP cases are not predictable. BW < 4000 Gms. Not associated with DM. Perlow (1996) 19% of OBP predictable. Skillful management of shoulder dystocia.

    26. Fetal Macrosomia: Diagnosis MacDonald measurement (SFH) Maternal estimation Sonographic EFW All techniques limited

    31. Fetal Macrosomia: Induction of Labor Inclusion EFW > 4000 Gms. @ 38 wks. RCT. Induction (N=134). Expectancy (N=139). Power to detect 15% change in CS rate. Gonen 1997.

    32. Fetal Macrosomia: Induction of Labor

    33. Fetal Macrosomia: Elective Cesarean Delivery Decision analysis model. Three policies compared. No sonographic EFW. C/S for EFW > 4000 Gms. C/S for EFW > 4500 Gms. Rouse 1996.

    34. Fetal Macrosomia: Elective Cesarean Delivery

    35. Fetal Macrosomia: Elective Cesarean Delivery 4000 Gms. Threshold Would increase C/S rate by 50% Reduces OBP by 31% Costs $4,900,00 per OBP prevented Leads to 1 maternal death per 3.2 OBP cases prevented Cannot be justified medically or economically Rouse, 1996

    36. Conclusions Beware of macrosomic infants Avoid midpelvic deliveries in macrosomics & GDMs Manage Shoulder Dystocia Don’t rush Avoid excessive traction

    37. Practical Advice Avoid poor judgment… Judgment comes from experience… Experience comes from poor judgment. Jeanty

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