Book Review

Brain Damage in the Newborn and Its Neurologic Sequels: Pathologic and clinical correlation

N Engl J Med 1999; 340:1602-1603May 20, 1999

Article

Brain Damage in the Newborn and Its Neurologic Sequels: Pathologic and clinical correlation
By Abraham Towbin. 764 pp., illustrated. Danvers, Mass., PRM, 1998. $302. ISBN: 0-9660551-0-1

Childbirth, at least in the developed world, has become very safe over the past several decades, mainly because of advances in the understanding of the effects of maternal disease on the progress of pregnancy and on maternal and fetal outcomes. This understanding has led to earlier diagnosis, through risk-based screening approaches, and appropriate interventions. At the same time, there has been an explosion of knowledge and technology concerning the care of the newborn, particularly the infant born prematurely; as a result, survival rates among the smallest premature infants have reached levels unimaginable even a short time ago.

However, the ability to ascertain the status of the fetus has been slow to develop since the advent of fetal-heart-rate monitoring in the 1960s. Although the additions of ultrasound examination of the fetus and blood-flow studies have assisted in decision making in the case of the growth-restricted fetus, we remain severely limited in our capacity to assess fetal well-being fully. Much of this is due to the limitations of our ability to examine the fetus directly in utero. Moreover, the lack of specificity of the signs of fetal hypoxia, either before or during the birth process, is the reason why the advances in the outcome of pregnancy for the mother have not been mirrored to the same extent in the newborn.

The incidence of cerebral palsy has remained discouragingly constant despite increasing use of electronic monitoring and record rates of cesarean section, at least in North America. Once firmly held convictions that cerebral palsy (Little's disease) was related to events surrounding the time of birth have increasingly been challenged since the 1980s, with the publication of landmark reports from Karin Nelson and Jonas Ellenberg and from Nigel Paneth, who found that in the majority of cases, no evidence of intrapartum asphyxia could be shown on careful review of fetal monitoring during the birth process.

In Brain Damage in the Newborn and Its Neurologic Sequels, one of the foremost perinatal neuropathologists in the world draws on his experience of more than 40 years in correlating the abnormalities found at autopsy in the brain of the newborn infant with the clinical events of pregnancy and the neonatal course. The book has two parts; the first deals with the pathophysiologic correlates of brain damage in the newborn infant, whereas the second contains 238 case studies along with pathological, ultrasound, and computed tomography findings.

The neonatal clinician will take issue with the author's concentration on hypoxia and venous infarction as the most common pathophysiologic insult to the fetal and newborn brain. Most current thinking would be on the side of Joseph Volpe and others, who have made eloquent arguments that ischemia is an important contributor to the pathogenesis of these lesions.

The chief handicapping lesion of the premature brain, periventricular leukomalacia, is given remarkably little attention. However, as a highly experienced neuropathologist, Towbin reinforces the notion that cerebral palsy is rarely the result of immediate perinatal events, and he points out the value of careful attention to the clinical course of the newborn in determining the timing of any insult to the brain. There is an abundance of high-quality illustrations of pathological and imaging findings, which make this an excellent book for any physician involved in the pathological assessment of stillbirths or neonatal deaths. The case studies, although on occasion somewhat repetitive, will be useful for those who care for both mothers and babies — many will find illustrative courses to compare with their own cases. This book should also find its way to those involved in the litigation of obstetrical malpractice, especially because of the clarity with which clinical–pathological correlations are described.

Andrew Shennan, M.B., Ch.B.
Sunnybrook and Women's College Health Sciences Centre, Toronto, ON M5S 1B2, Canada