Conception - pregnancy - deliveryConception - pregnancy - delivery 11stst week week

(Early) neonatal period :(Early) neonatal period : birth birth 11stst week week

late neonatal period :late neonatal period : birthbirth 44thth week week

Survive from deathSurvive from death

Survive from sequallaeSurvive from sequallae

Cause ofCause of DeathDeathdeathdeath proportion (%)proportion (%)

Birth AsphyxiaBirth Asphyxia 21.121.1Birth Trauma Birth Trauma 10.610.6Tetanus neonatorumTetanus neonatorum 14.114.1Sepsis,meningitisSepsis,meningitis 7.2 7.2PneumoniaPneumonia 19.019.0DiarrhaeDiarrhae 1.5 1.5PrematurityPrematurity 10.310.3Congenital malformationCongenital malformation 11.111.1OthersOthers 5.1 5.1

Injuries of newborn associated to the deliveryInjuries of newborn associated to the delivery

Excluded to :Excluded to :

Amniocenthesis injuryAmniocenthesis injury

Intra uterine transfusionIntra uterine transfusion

Fetal venous punctureFetal venous puncture

Injuries related to resuscitationInjuries related to resuscitation

The fatal type The fatal type significantly significantly due to due to obstetric practice obstetric practice

and technology and technology 3,7 per 100,000 3,7 per 100,000

live birth.live birth.

The non fatal type The non fatal type variesvaries

the injury typethe injury type

2-7 per 1000 live births2-7 per 1000 live births

Necessitates careful physicalNecessitates careful physical

++ neurologic examination neurologic examination

1. Primiparity1. Primiparity

2. Small maternal stature2. Small maternal stature

3. Maternal pelvic anomalies3. Maternal pelvic anomalies

4. Prolonged or extremely rapid labor4. Prolonged or extremely rapid labor

5. Deep transverses arrest5. Deep transverses arrest

6. Oligohydramnion6. Oligohydramnion

7. Abnormal presentation7. Abnormal presentation

8. Use of mid forceps or vacuum extraction8. Use of mid forceps or vacuum extraction

9. Version and extraction9. Version and extraction

10. VLBW infant or extreme prematurity10. VLBW infant or extreme prematurity

11. Fetal macrosomia11. Fetal macrosomia

12. Large fetal head12. Large fetal head

13. Fetal anomalies13. Fetal anomalies

1. Soft tissue injuries1. Soft tissue injuries

2. Head surface2. Head surface

3. Neck and shoulder3. Neck and shoulder

4. Extremity4. Extremity

5. External genital5. External genital

6. Intra abnominal injuries6. Intra abnominal injuries

7. Intra cranial injuries7. Intra cranial injuries

A. Head and neck injuryA. Head and neck injury

B. Cranial nerve, spinal card and peripheralB. Cranial nerve, spinal card and peripheral nerve injuriesnerve injuries

C. Bone injuriesC. Bone injuries

D. Intra abdominal injuriesD. Intra abdominal injuries

E. Soft-tissue injuriesE. Soft-tissue injuries

ErythemaErythema

PetechiaePetechiae

Ecchymosis and hematomaEcchymosis and hematoma

Aberration and lacerationAberration and laceration

Subcutaneus fat necrosisSubcutaneus fat necrosis

Caput succedaneumCaput succedaneum

Vacuum caputVacuum caput

Subconjunctival bleedingSubconjunctival bleeding

Facial bone fractureFacial bone fracture

PetechiaePetechiae

HematomaHematoma

EcchymosisEcchymosis

LacerationLaceration

Pheripheral facialis nerve paresePheripheral facialis nerve parese

Brachial plexusBrachial plexus

Paralysis/Parese Duchene-ERBParalysis/Parese Duchene-ERB

Paralysis/Parese KlumppkeParalysis/Parese Klumppke

Paralysis/Parese nerve phreniceesParalysis/Parese nerve phrenicees

Clavicula fractureClavicula fracture

1. Associated with fetal monitoring1. Associated with fetal monitoring

2. Extracranial hemorrhage2. Extracranial hemorrhage

a) Classification :a) Classification :

1. Cephalhematoma1. Cephalhematoma

2. Subgaleal hematoma2. Subgaleal hematoma

3. Caput succedaneum3. Caput succedaneum

4. Vacuum caput4. Vacuum caput

b) Management :b) Management :

3. Intracranial hemorhage3. Intracranial hemorhage

1. Cranial nerve injury1. Cranial nerve injury

facial nerve injuryfacial nerve injury

2. Cervical nerve root injuries2. Cervical nerve root injuries

a. Phrenic nerve palsy (C3,4 or 5)a. Phrenic nerve palsy (C3,4 or 5)

b. Brachial plexus injuriesb. Brachial plexus injuries

C5-6 roots injuriesC5-6 roots injuries

80% of plexus brachialis injury80% of plexus brachialis injury

Biceps reflex (-)Biceps reflex (-)

Radial reflex (-)Radial reflex (-)

Moro (-)Moro (-)

Grasp reflex (+)Grasp reflex (+)

Pathognomonis : Porter signPathognomonis : Porter sign

Radiology : DD/bone fractureRadiology : DD/bone fracture

Physiotherapy :Physiotherapy : Fixation : arm abduction 90º, shoulder exorotation wrist 90º,Fixation : arm abduction 90º, shoulder exorotation wrist 90º, lower arm suppination extention of hand.lower arm suppination extention of hand.

C7 th1 roots injuriesC7 th1 roots injuries

2,5% of brachial plexus injuries2,5% of brachial plexus injuries

Internal arm muscle disturbancesInternal arm muscle disturbances

Biceps reflex (+)Biceps reflex (+)

Radial reflex (+)Radial reflex (+)

Moro reflexs (-) / assymetryMoro reflexs (-) / assymetry

Grasp replex (-)Grasp replex (-)

Incase of sympathic nerve included :Incase of sympathic nerve included : Horner Syndrome (ptosis,myosis,Horner Syndrome (ptosis,myosis, ecophthalmos,head/facial anhydrosisecophthalmos,head/facial anhydrosis homolateralhomolateral

Physiotherapy : netral positionPhysiotherapy : netral position

C3,4,5 root injuriesC3,4,5 root injuries

Respiratory distress, cyanosis, tachypneaRespiratory distress, cyanosis, tachypnea

Radiology :Radiology :

* diaphragma elevation* diaphragma elevation

* shift of mediastinum & heart* shift of mediastinum & heart

FluoroscopyFluoroscopy

* seesaw movement* seesaw movement

* Shiftened of mediastinum* Shiftened of mediastinum

Therapy : NICU Therapy : NICU ventilator, surgery ventilator, surgery

Breech deliveryBreech delivery Male : scrotalMale : scrotal

capsula testiscapsula testis Female : labia majora injuryFemale : labia majora injury EdemaEdema aberrationaberration hematomahematoma hematocelehematocele Conservative therapyConservative therapy

RareRare

MalpresentationMalpresentation

Soft tissuesSoft tissues Humerus fractureHumerus fracture Femur fractureFemur fracture Coxsae dislocationCoxsae dislocation Radial articulation dislocationRadial articulation dislocation

Extremely rareExtremely rare

Uncovered by bone tissueUncovered by bone tissue

LiverLiver

SpleenSpleen

Adrenal glandAdrenal gland

Intracranial haemorrhageIntracranial haemorrhage

Cause : * mechanicalCause : * mechanical * hypoxic* hypoxic * combined* combined

Hypoxic trauma more difficent Hypoxic trauma more difficent to be avoidedto be avoided

CNS immaturityCNS immaturity Cerebral circulationCerebral circulation autoregulationautoregulation

ClassificationClassification 1. Subdural1. Subdural 2. Primary subarachnord2. Primary subarachnord 3. Intracerebral3. Intracerebral 4. Periventricular - intraventricular4. Periventricular - intraventricular

Hypoxic birth trauma :Hypoxic birth trauma :

HIE necrosisHIE necrosis

cerebral cortex atrophycerebral cortex atrophy

periventricular leucomalaciaperiventricular leucomalacia

basal ganglia degenerationbasal ganglia degeneration

Prognosis : Severity of encephalopathyPrognosis : Severity of encephalopathy

ServeServe 40% death, 40% death,

10% neurological disturbance,10% neurological disturbance,

mental retardation, vision disturbance,mental retardation, vision disturbance,

hearing impairment, celebral paresishearing impairment, celebral paresis

Anomalies occured since the gestation Anomalies occured since the gestation periodperiod

Classification :Classification :

MajorMajorMinorMinor

GeneticGeneticNon geneticNon genetic

Chromosome aberrationChromosome aberration

Single mutant geneSingle mutant gene

Multifactorial inheritanceMultifactorial inheritance

~ Numerical ~ Numerical TrisomyTrisomy TetrasomyTetrasomy MonosomyMonosomy

~ Structural ~ Structural DeletionDeletion InversionInversion TranslocationTranslocation

~ Autosome dominant~ Autosome dominant

~ Autosome Recessive~ Autosome Recessive

~ X-linked inheritance~ X-linked inheritance

~ Thalassemia~ Thalassemia

~ Sickle cell anemia~ Sickle cell anemia

~ Haemophilia~ Haemophilia

~ Cystic fibrosis~ Cystic fibrosis

~ G6PD deficiency~ G6PD deficiency

1. Infection 1. Infection : TORCH : TORCH

2. Environment : Mercury2. Environment : Mercury

3. Drug-poison : ~ Thalidomide3. Drug-poison : ~ Thalidomide ~ Warfarin~ Warfarin

4. Habit 4. Habit : ~ Alcohol : ~ Alcohol ~ Retinoic acid~ Retinoic acid

5. Nutrient 5. Nutrient : ~ Folic Acid : ~ Folic Acid

6. Mechanical : ~ Deformity due to amniotic band6. Mechanical : ~ Deformity due to amniotic band

CauseCause Inc :Inc :

Genetic abnormalitiesGenetic abnormalities - Multifactorial inheritance - Multifactorial inheritance 0.6 CHD, anencephaly0.6 CHD, anencephaly- Single mutant genes- Single mutant genes 0.1 Polycystic Kidney0.1 Polycystic Kidney- Chromosomal abnormalities - Chromosomal abnormalities 0.1 Down syndrome0.1 Down syndrome- Uncertain inheritance- Uncertain inheritance 0.3 Polydactyly0.3 Polydactyly

Uterus FactorsUterus Factors 0.1 Breech presentation0.1 Breech presentation amniotic bandsamniotic bands

Drugs taken by motherDrugs taken by mother 0.01 Warfarin0.01 Warfarin

Maternal conditionsMaternal conditions 0.1 D.M0.1 D.M

Unknown etiologyUnknown etiology 1.1 Omphe1.1 Omphelocelelocele

TotalTotal 2.41% 2.41%

Figure 3. An initiating malformation may give rise to secondaryFigure 3. An initiating malformation may give rise to secondarydeformation or disruption , and vice versa. The terminology, deformation or disruption , and vice versa. The terminology, such as malformation sequence, refers to the initiating defect and such as malformation sequence, refers to the initiating defect and its consequences. When the nature of the initiating defect isits consequences. When the nature of the initiating defect isunresolved between the three types, the term malformation is unresolved between the three types, the term malformation is generally utilized.generally utilized.

MalformationMalformation

DisruptionDisruptionDeformationDeformation

Nature of ProblemNature of Problem

DeformationDeformation(mechanical)(mechanical)

MalformationMalformation(poor formation(poor formation))

DisruptionDisruption(destructive)(destructive)

MultipleMultiplelocalizedlocalizeddefectdefect

SingleSingleLocalizedLocalizeddefecdefec

MalformationMalformationsyndomesyndome

Malformation,Malformation,malformationmalformationsequencesequence

Deformation,Deformation,deformationdeformationsequencesequence

Disruption,Disruption,disruptiondisruptionsequencesequence

MalformationMalformationassociationassociation

Figure 4. Most patient with multiple structural defect will fall into oneFigure 4. Most patient with multiple structural defect will fall into oneof there five categories. The prognosis management, and recurrence riskof there five categories. The prognosis management, and recurrence riskcounseling may vary considerably among these vategories.counseling may vary considerably among these vategories.

SINGLE LOCALIZED ANOMALY in early morphogenesis

SECONDARY ANOMALIES

PATTERN OF MULTIPLE ANOMALIES in later morphogenesis

Figure 1. Sequence designates a single localized anomaly plus itssubsequently derived structural consequences, as depicted above.

Non genetic type : Optimal perinatal services Rehabilitation Operative surgery Supportive treatment Pra-conseptional conselling

Genetic type : Optimal perinatal service Rehabilitation Operative surgery Supportive treatment Genetic councelling Pra-conceptional councelling