Perinatal risk factors for adverse neurodevelopmental outcome after spontaneous preterm birth

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Abstract

Objective: The aim of this study was to investigate to what extend perinatal factors contribute to the neurodevelopmental outcome in a group neonates born after spontaneous preterm labour with or without prolonged rupture of the membranes (PROM). Methods: In a cohort of neonates born after the spontaneous onset of labour with or without PROM before 34 weeks of gestation a stepwise forward logistic regression was performed to analyse the influence of antenatal and postnatal variables on adverse outcome. Adverse neurodevelopmental outcome was defined as a Griffith’s developmental score <85, cerebral palsy, a major disability or perinatal death associated with severe cerebral damage. Results: The study group consisted of 185 neonates. Seven neonates died with severe cerebral damage. After a forward logistic regression analysis three factors appeared to have an independent influence: gestational age protected against an adverse outcome (odds ratio (OR) per day increase 0.95, 95% confidence interval (CI) 0.90–0.97) while abnormal cranial ultrasound (intraventricular haemorrhage and periventricular leucomalacia) (OR 6.33, 95% CI 2.16–18.52) and the need for a second course of antibiotics (OR 1.85, 95% CI 1.02–3.33) increased the risk for adverse outcome. Comparing the group with a normal neurodevelopmental outcome with those with cerebral palsy, cranial ultrasound abnormalities were independently associated with cerebral palsy (OR 48.75, 95% CI 11.78–201.76). Conclusion: The most important way of preventing neurological damage in infants is to increase gestational age at birth and to avoid the development of intraventricular haemorrhage and periventricular leucomalacia.

Introduction

Prematurity is the major contributor to neonatal mortality and morbidity [1], [2], [3]. Long-term neonatal morbidity is a result of the sequelae of obstetrical and neonatal events and of neurological damage, such as intraventricular haemorrhage and periventricular leucomalacia [4], [5], [6]. Several studies have demonstrated that neonates born after spontaneous premature labour with or without prolonged rupture of the membranes (PROM) have an increased risk of developing cerebral palsy or neurological impairment compared to preterm neonates born after an elective delivery due to fetal growth restriction or maternal diseases [7], [8], [9], [10], [11].

Cytokines, leucotrins and prostaglandins originating from an inflammatory process in utero probably play an important role in the onset of spontaneous preterm labour and are also causally associated with neonatal neurological damage [12], [13], [14], [15], [16], [17].

In a previous study perinatal risk factors for the development of severe cranial ultrasound abnormalities were analysed in a group of neonates born between 24 and 34 weeks after spontaneous onset of labour with or without PROM [18]. The aim of this cohort study was to investigate to what extend perinatal factors contribute to the neurodevelopmental outcome in this group of preterm neonates.

Section snippets

Materials and methods

All medical records of women who delivered in the period from 1 January 1990 to 31 December 1995 at the University Medical Centre, Utrecht, a tertiary obstetrical referral hospital in the Centre of The Netherlands were reviewed for preterm birth after spontaneous onset of labour with or without PROM between 24 and 34 weeks of gestation. Gestational age was calculated from the first day of the last menstrual cycle and if necessary, adjusted by early ultrasound estimates of gestational age.

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Results

8958 women delivered in the obstetrical department of the University Medical Center Utrecht from 1 January 1990 to 31 December 1995. Of these women 229 fulfilled the entry criteria (3.9%). There were 43 twin pregnancies resulting in 272 neonates born between 24 and 34 weeks after spontaneous onset of labour with or without PROM. For various reasons 87 neonates were excluded from the study; 60 admitted to another NICU than the neonatal department of the University Medical Center Utrecht

Discussion

The incidence of adverse neurodevelopmental outcome in this study was 32.9%. This coincides with other studies in which the incidence varied between 17% [22] and 40% [2], [6]. The main findings of our study are that three perinatal events (gestational age, cranial ultrasound abnormalities and the need for a second course of antibiotics) are significantly associated with an adverse neurodevelopmental outcome in this cohort of neonates (Table 3). This is partly in accordance with other studies in

References (29)

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