A STUDY OF NEUROLOGICAL ABNORMALITIES OF TERM NEONATES AND ITS RELATIONSHIP TO ADVERSE OBSTETRIC AND NEONATAL FACTORS
Raktima Chakrabarti, PDham, SP Goel
Departments of Pediatrics, LLRM Medical College, Meerut, UP, India,
Address for Correspondence
Dr. Raktima Chakrabarti, Departments of Pediatrics, LLRM Medical College, Meerut, UP- 250004, India.
Email
dr_raktima@yahoo.com
There has been an explosive growth in the developmental neurosciences in recent years. As an increasing number of extremely preterm, seriously ill infants are surviving with better medical care; the burden of neurologically disabled children is increasing. Since the knowledge about various complex interactions during pregnancy, labor and neonatal period can prevent the development of neurological abnormalities it is of utmost importance to find out these factors to decrease this burden.

The present study was carried out in the neonatal unit of the Department of Pediatrics at SVBP Hospital attached to LLRM Medical College, Meerut on 240 term neonates admitted for at least 3 days after delivery. Only term infants (gestational age = 37 weeks) were included in the study. Hospital stay of at least 3 days after delivery was required for inclusion criteria, Infants with gross congenital anomaly were excluded at the outset.

Detailed information about mothers personal history, obstetric history of all three trimesters, labor, and neonatal factors were collected and recorded on a pre structured Performa.

The maternal data included, information about maternal age, weight, height, educational status, socioeconomic status, parity, past adverse pregnancy outcome, antenatal course in present pregnancy, with special emphasis on anemia, pregnancy induced hypertension, ante partum hemorrhage, gestational diabetes mellitus and premature rupture of membrane. Detailed information was also collected about the intra partum course, presence of fetal distress and mode of delivery.

Among neonatal factors emphasis was given on birth weight, Apgar score at 1 and 5 minute, gestational age, hyperbilirubinemia, hypoglycemia, anemia, thrombocytopenia, respiratory distress and septicemia.

A detailed neurological examination, based on the method described by Prachtl was done on all neonates in the behavioral state 3 - eyes open, some isolated spontaneous movements, no crying in addition to routine examination. The neurological examination was done only after 48 hours of delivery, as the behavioral state and many responses are not stable until after the first two days of life. Neonatal neurological examination included behavioral state, muscle tone, posture, movement, deep tendon reflexes, neonatal reflexes, presence of abnormal twitching, convulsions and tremors. These newborns were also examined in prone position, ventral suspension, upright position, pulled-to-sit position depending on general condition. Cry of the infants, anterior fontanel, size of the pupil, reaction to light, doll's eye phenomena, habituation to auditory and visual stimulus were also observed. Abnormal examination findings were supported by hematological, biochemical and radiological investigations and were followed up for at least one month for further neurological evaluation.

Obtained data were compiled and statistically analyzed by Chi Square test.

Results: The overall incidence of neonatal neurological abnormalities in the present study was 16.67% (40/240). It was found that maternal education has statistically significant correlation with the neonatal neurological abnormality (p< 0.05). (Table 1).

Table 1: Relationship between maternal education and neonatal neurological abnormalities
Educational statusNumber with CNS abnormality (n=40) (%)Number Without CNS abnormality (n=200) (%)P Value
Illiterate19 (47.5)59 (29.5)< 0.05
Up to 5th class6 (15)23 (11.5)
More than 5 th but less than high school7 (17.5)26 (13)
26 (13)7 (17.5)58 (29)
Intermediate1 (2.5)21 (10.5)
Graduate0 (0)13 (6.5)


Among the maternal anthropometric factors: maternal weight, quetlet index (weight/height2) were found to be significantly correlated with neonatal neurological status (p< 0.05). Relationship with maternal age, height and parity was not statistically significant (Table 2).

Table2. Relationship between maternal parameters and neonatal neurological abnormalities
MaternalWith CNS abnormality (Mean)Without CNS abnormalitiesP value
anthropometry (Mean) 
Age (years )25.2125.68> 0.05
Weight (kg )48.3450.13< 0.05
Height (cm)152.58153..19> 0.05
Quetlet index2.1072.154< 0.05
Parity2.462.18> 0.05


A significant correlation was also found between antenatal care and neonate's neurological status (p < 0.05). 52.5% mother with abnormal neonates had no antenatal check up, 12.5% had < 3 and 35% had 3 or more antenatal check up. Among normal neonates, 53% mothers had 3 or more number of check ups, 17% had <3 and 30 % had no check up.

The presence of pregnancy induced hypertension (PIH), ante partum hemorrhage (APH), premature rupture of membrane (PROM), gestational diabetes mellitus (GDM) had a highly significant correlation with neurological abnormalities (p<0.001) (Table 3).

Table 3. Association of pregnancy complications and neurological abnormalities
Pregnancy complicationsWith CNS abnormalitiesWithout CNS abnormalitiesP value
PIH20%7%<0.001
PROM32.5%9.5%<0.001
APH15%5%<0.001
GDM2.5%1.5%<0.001
Fetal distress   
Heart rate irregularities60%24.5%<0.001
Meconium stained liquor45%5.5%<0.001


Out of 17 neonates delivered at home by trained birth attendants 10 (58.82%) had neurological morbidities. Neonatal factors associated with neurological abnormalities are depicted in Table 4.

Table 4. Association between neonatal factors and neurological abnormalities
ParametersWith CNS morbiditiesWithout CNS morbiditiesP value

Gestational age 
Small for gestational age 
Appropriate for gestation 
Large for gestation

25%
72.5%
2.5%
18.5%
79%
2.5%
<0.05

Gender 
Male baby
Female baby

70%
30%
51%
49%
<0.05

Apgar score 
At 1minute (mean )
At 5 minute (mean)

3.65 
5.30
6.78
8.49
<0.001
Respiratory distress70%4.5%<0.001
Early onset sepsis30%4.5%<0.001
Metabolic problems2.5%1.5%>0.05
Hematological problems30%6.5%<0.001
Hyperbilirubinemia7.5%7.5%>0.05
Acute renal failure17.5%0%<0.001


Among the 40 neonates with neurological abnormalities, cranial ultrasonography was done in 34 cases within 7 days of birth. 22 (64.71%) neonates had no abnormality on USG, increased echogenicity was present in 5 (14.71%) cases, 5 (14.71%) had ventricular dilatation and intra ventricular hemorrhage was present in 2 (5.88%) cases. Of these 40 neonates with neurological abnormalities, 7 expired, 11 left untreated and 22 improved. On follow up among these 22 patients, 12 (54.55%) were normal, 4 (18.18%) had suspected neurological abnormalities, 6 (27.27%) were abnormal. On the other hand, 59 normal neonates were followed up and none of them had neurological abnormalities.
Discussion
This hospital based study revealed that neonatal neurological abnormality is significantly influenced by various maternal and neonatal factors. The adverse maternal factors observed here were illiteracy and low maternal weight. A strong association was found between the number of antenatal visits and neonatal neurological abnormality. This points towards the need to improve the availability of proper antenatal care so that high risk cases would be identified and proper management could be done in time.

The presence of one or more of the pregnancy complications was found to be significantly associated with neonatal neurological abnormality. Of these complications pregnancy induced hypertension and premature rupture of membrane had more significant correlation. We found a highly significant correlation between fetal distress, in the form of fetal heart rate irregularity and meconium stained amniotic fluid and neurological abnormality. Poor Apgar score at 1 and 5 minute also had impact on the same. Small for gestational age neonates were found to be at greater risk for neurological abnormality in the present study. A positive correlation also found between male gender and neurological abnormality. In the present study, we found a significant correlation between neonatal neurological abnormality and neonatal problems like respiratory distress, early onset sepsis, anemia, thrombocytopenia, acute renal failure. Respiratory problems may be attributed to meconium aspiration, sepsis, asphyxia and may overlap other predictors of neurological abnormality. Sepsis may cause hypoxemia, acidosis and can mimic many features of neonatal encephalopathy or may be a cause for it. Acute renal failure may be attributed to the neonatal encephalopathy.

Thus, the present study has shown a better prediction of neurological morbidity among neonates who are clinically at risk. Many of the risk factors are preventable and universal availability of proper antenatal and perinatal services would go a long way in reducing the neurological morbidity.
Acknowledgement
We acknowledge Department of Pediatrics & Neonatology along with Department of Gynecology & Obstetrics for valuable support and also the cooperation of the study subjects.
References :
  1. Levene MI, Kornberg J, William THC. The incidence and severity of post asphyxial encephalopathy in full term infants. Early Hum. Dev. 1985; 11: 21 -26.
  2. Levene MI. Cerebral ultrasound and neurological impairment: telling the future. Arch Dis Child 1990; 65: 469-471.
  3. Misra PK, Shrivastava N, Malih GK, Kapoor RK, Shrivastava KL, Rastogi S. Apgar in relation to apgar score in term neonates. Indian Pediatr. 1994;31(10): 1215-1218.
  4. Nelson KB, Bromah SH. Perinatal risk factors in children with serious motor and mental handicaps. Ann Neurol 1977 ; 2: 371-377.
  5. Nelson KB, Ellenberg JH. Apgar score as predictors of chronic neurologic disability. Pediatrics 1981;68:36-44.
  6. Nelson KB. Relationship of intrapartum and delivery room events to long term neurologic outcome. Clinics in Perinatology .1989; 16:995-1007.
  7. Peiper A. Cerebral function in infancy and childhood New York consultants bureau 1963.
  8. Prechtl HFR .Prognostic value of neurological signs in newborn infant Proc.Roy SocMed 1965;58;3.
  9. Prechtl HFR. The neurological examination of full-term newborn infant in : Second revised and enlarged version , Clinics in Developmental Medicine 63.London :Heinmann , 1977.
  10. Prechtl HFR .Qualitative changes of spontaneous movements in fetus and preterm infants are a marker of neurological dysfunction . Early Hum Dev 1990 ;23: 151-159.
  11. Prechtl HFR State of the art of a new functional assessment of the young nervous system .An early predictor of cerebral palsy. Early Hum Dev 1997 ;50:1-11.
  12. Rubin RA , Barlow B (1977) Perinatal influences on the behaviour and learning problems of children . Advances in child clinical psychology , Vol. 1 New York : Plenum Press.
  13. Sarnat HB, Sarnat MS . Neonatal encephalopathy following fetal distress .A clinical and electroencephalographic study .Arch Neurol 1976 ; 33: 696-705.
  14. Sinha SK, Sims DG, Davies JM , Chiswick ML. Relation between periventricular hemorrhage and ischemic brain lesion diagnosed by ultrasound in very preterm infants .Lancet 1985; 2: 1154-1155.
  15. Volpe JJ .neurology of the new born . Third edition . WB Saunders Company. 1995.
Last Updated : Wednesday, October 01, 2008 Vol 5 Issue 10 Art #42
How to Cite URL :
Chakrabarti R, Chakrabarti R, PDham, Goel S. A STUDY OF NEUROLOGICAL ABNORMALITIES OF TERM NEONATES AND ITS RELATIONSHIP TO ADVERSE OBSTETRIC AND NEONATAL FACTORS. Pediatric Oncall [serial online] 2008[cited 2008 January 1];5. Art #42. Available From : http://www.pediatriconcall.com/Journal/Article/FullText.aspx?artid=127&type=J&tid=&imgid=&reportid=303&tbltype=
Disclaimer: The information given by www.pediatriconcall.com is provided by medical and paramedical & Health providers voluntarily for display & is meant only for informational purpose. The site does not guarantee the accuracy or authenticity of the information. Use of any information is solely at the user's own risk. The appearance of advertisement or product information in the various section in the website does not constitute an endorsement or approval by Pediatric Oncall of the quality or value of the said product or of claims made by its manufacturer.