Intrapartum Complications Associated With Malformations of Cortical Development

Maria Augusta Montenegro, MD, PhD; Fernando Cendes, MD, PhD; Helena Saito, MD; Jéssica G. Serra, MD; Camila F. Lopes, MD; Ana Maria S. Piovesana, MD, PhD; Helaine Milanez, MD, PhD; Marilisa M. Guerreiro, MD, PhD

Disclosures

J Child Neurol. 2005;20(8):675-678. 

In This Article

Discussion

Cerebral palsy is defined as a group of nonprogressive motor disorders of movement or posture owing to a defect or lesion of the developing brain.[13] There is no consensus as to whether children with congenital developmental anomalies should be included into the category of cerebral palsy. Some authors omitted congenital malformations as an etiology of cerebral palsy[14] and agree that malformations of cortical development should be generally classified under the anomaly itself—for example, lisencephaly/agyria-pachygyria, schizencephaly, polymicrogyria—even if the neurologic findings are compatible with cerebral palsy.[1] However, classic studies on the epidemiology of cerebral palsy did not exclude brain malformations but were careful to exclude progressive disorders.[15]

We found that a high percentage of patients with cortical maldevelopment presented an intrapartum history suggestive of birth asphyxia. However, the true timing of brain damage was prenatal owing to either genetic or environmental factors. The high frequency of intrapartum complications presented by our patients is in keeping with other series in which 23% of patients with Prader-Willi syndrome had birth asphyxia.[16]

Although maternal perception of fetal movements is subjective and sometimes difficult to notice owing to factors such as obesity, it occurs at approximately 20 weeks of gestation. It is the most convenient and widely used method to assess fetal health.[17,18,19,20]

Decreased fetal movements are a pregnancy complication that might occur at the last trimester of pregnancy and can reflect abnormal fetal well-being or neurologic impairment. We found that reduced fetal movements were present in 11% of our patients, suggesting abnormal fetal neurologic behavior already during pregnancy. In this setting, obstetric intervention has little to offer.[21]

It is important to note that three of the patients diagnosed as asphyxiated at birth had neither decreased fetal movements during pregnancy nor intrapartum complications. The ages of these patients ranged from 15 to 18 years; therefore, at the time of their diagnosis, neuroimaging evaluation was not as easily available as it is today. We believe that the misdiagnosis of these patients was due to the widespread belief that birth complications cause most cases of cerebral palsy.

One possible limitation of our study is the fact that the report about the occurrence of intrapartum complication was ascertained retrospectively and precise recollection of events that occurred many years before is difficult. To clarify these reports, the clinical files of all patients were reviewed. Although difficult to perform, a prospective study on intrapartum complications secondary to fetal brain malformations would be the best way to address this issue.

We conclude that patients with cortical malformations frequently present intrapartum complications. Many of these brain malformations can be diagnosed prenatally by ultrasonographic screening at 22 weeks of gestation. The identification of antenatal factors associated with increased vulnerability at birth would allow better parent counseling and preventive medical care during delivery.


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