Cerebral palsy among term and postterm births

Abstract

Context: Although preterm delivery is a well-established risk factor for cerebral palsy (CP), preterm deliveries contribute only a minority of affected infants. There is little information on the relation of CP risk to gestational age in the term range, where most CP occurs.

Objective: To determine whether timing of birth in the term and postterm period is associated with risk of CP.

Design, setting, and participants: Population-based follow-up study using the Medical Birth Registry of Norway to identify 1,682,441 singleton children born in the years 1967-2001 with a gestational age of 37 through 44 weeks and no congenital anomalies. The cohort was followed up through 2005 by linkage to other national registries.

Main outcome measures: Absolute and relative risk of CP for children surviving to at least 4 years of age.

Results: Of the cohort of term and postterm children, 1938 were registered with CP in the National Insurance Scheme. Infants born at 40 weeks had the lowest risk of CP, with a prevalence of 0.99/1000 (95% confidence interval [CI], 0.90-1.08). Risk for CP was higher with earlier or later delivery, with a prevalence at 37 weeks of 1.91/1000 (95% CI, 1.58-2.25) and a relative risk (RR) of 1.9 (95% CI, 1.6-2.4), a prevalence at 38 weeks of 1.25/1000 (95% CI, 1.07-1.42) and an RR of 1.3 (95% CI, 1.1-1.6), a prevalence at 42 weeks of 1.36/1000 (95% CI, 1.19-1.53) and an RR of 1.4 (95% CI, 1.2-1.6), and a prevalence after 42 weeks of 1.44 (95% CI, 1.15-1.72) and an RR of 1.4 (95% CI, 1.1-1.8). These associations were even stronger in a subset with gestational age based on ultrasound measurements: at 37 weeks the prevalence was 1.17/1000 (95% CI, 0.30-2.04) and the relative risk was 3.7 (95% CI, 1.5-9.1). At 42 weeks the prevalence was 0.85/1000 (95% CI, 0.33-1.38) and the relative risk was 2.4 (95% CI, 1.1-5.3). Adjustment for infant sex, maternal age, and various socioeconomic measures had little effect.

Conclusion: Compared with delivery at 40 weeks' gestation, delivery at 37 or 38 weeks or at 42 weeks or later was associated with an increased risk of CP.

Figure 1

Daily prevalence of cerebral palsy per 1000 (top panel) and daily number of births (lower panel) according to gestational age at birth from 37 weeks to 44 weeks among the 1,682,441 members of the study cohort. The smoothed curve (top panel) was fitted using the LOESS method.

Figure 2

Information on CP and digestive diseases (ICD-9: 520-579, ICD-10: K00-K93) is from the study cohort of 1,682,441 members, whereas information on congenital anomalies is based on 1,720,443 persons (original study cohort, without exclusion of congenital anomalies). Error bars indicate 95% confidence intervals.