NEW ORLEANS, LA -- At a news conference today, experts from the American College of Obstetricians and Gynecologists (ACOG) convened at its Annual Clinical Meeting to address the implications and aftermath of a major report on the possible causes of infant brain damage. The report, Neonatal Encephalopathy and Cerebral Palsy: Defining the Pathogenesis and Pathophysiology, concluded that the majority of newborn brain-injury cases do not occur during labor and delivery. Rather, most instances of neonatal encephalopathy and cerebral palsy are attributable to events occurring before labor begins.

The report gives evidence that the vast majority of neonatal encephalopathy and cerebral palsy cases originate from developmental or metabolic abnormalities, autoimmune and coagulation defects, infection, trauma, or combinations of these factors. The report, a joint publication of ACOG and the American Academy of Pediatrics (AAP), has received the endorsement of six organizations, including the National Institute of Child Health and Human Development of the National Institutes of Health and the Centers for Disease Control and Prevention.

"Based on this report, we now know that less than 10% of cases of neurologic impairment in newborns are the result of events occurring in labor and, of these, the majority are not preventable. The reality is that very rarely can anything be done during labor or delivery that will prevent this devastating outcome from occurring," commented Gary D.V. Hankins, MD, chair of the ACOG task force that developed the document. "However, this raises the question, 'What do we need to know about what might be occurring during pregnancy itself or even before a woman gets pregnant that might provide answers?'"

Newborn encephalopathy and cerebral palsy are associated with significant mortality rates and long-term illness and have been central in the assignment of blame in obstetric litigation. However, the report confirms that hypoxia (or insufficient supply of oxygen) during labor or delivery is not a significant cause in most of the cases of neonatal encephalopathy or cerebral palsy; less than one-quarter of infants with neonatal encephalopathy show any evidence of having experienced hypoxia during labor. The report also concluded that an underlying event before labor was the primary factor for the adverse outcome in 70% of neonatal encephalopathy cases and contributory in another 25%.

Neonatal encephalopathy is a condition characterized by abnormal consciousness, poor muscle tone and reflexes, difficulty initiating or maintaining breathing, or seizures, and may result in permanent neurologic impairment. In contrast, cerebral palsy is a chronic developmental disability of the central nervous system recognized by uncontrollable movement and posture. According to the report's findings, if there is hypoxia during labor sufficient to cause cerebral palsy in later life, it would also have to be severe enough to cause neonatal encephalopathy in the first few days after birth.

There are numerous risk factors associated with newborn encephalopathy, many of which are complex and are only now being understood. However, the ACOG task force did cite several factors which may increase a woman's risk of having a baby with encephalopathy, including having a family history of seizure or neurologic disorders, or a personal history of infertility treatments, placental or uterine rupture, maternal thyroid disease, severe preeclampsia, intrauterine growth restriction, or delivery of a low-birth-weight baby.

"A helpful aspect of this report is that it lists the criteria used to evaluate the probability that encephalopathy and cerebral palsy were a result of actions during labor. This document is a critical step forward in helping physicians assess the timing of the brain injury and therefore, determining causation. Once we are able to understand and pinpoint when the injury occurred, then we can direct our efforts to clinical interventions that will reduce the rates of these serious pathologies," Dr. Hankins added.

"For years, adverse neurologic outcomes of pregnancy, including cerebral palsy and neonatal encephalopathy, have been assumed to be the effect of events occurring during childbirth. In the face of a bad outcome, many faulted ob-gyns. This report provides a better understanding of the causes of these two conditions and should serve as a valuable resource for the entire medical community, the courts, and for all those who care for infants and children with these disabilities," noted Mary E. D'Alton, MD, a maternal-fetal medicine expert and a member of the ACOG task force. "We're not saying that there are no valid cases for litigation. It's just that the day of delivery is but one day in a 280-day gestation period, during which complications can occur that damage the fetal brain."

"This is a landmark report. It not only provides unique insight into the possible causes of neonatal encephalopathy and cerebral palsy, but also is a scientifically sound and detailed document based on rigorous review of the latest data available on this topic," said Frank C. Miller, MD, past president of ACOG who appointed the task force to analyze the evidence on this issue as one of his presidential initiatives in 1999. "It's important to note that this report presents the results of ongoing work. We hope that our extensive efforts will spur further research on possible prevention and treatment strategies for encephalopathy and cerebral palsy."

The ACOG task force which developed the report was comprised of a multi-specialty panel of medical experts representing the specialties of maternal-fetal medicine, pediatrics, neuroepidemiology, radiology, and pathology. This report complements and updates an International Cerebral Palsy Task Force consensus statement that was published in the British Medical Journal in 1999.

The report was also endorsed by the following professional organizations: the March of Dimes Birth Defects Foundation, the Society for Maternal and Fetal Medicine, the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, and the Society of Obstetricians and Gynaecologists of Canada. The Child Neurology Society recommends this report as a valuable reference tool.

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