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In utero exposure to maternal injury and the associated risk of cerebral palsy


Importance — Although maternal unintentional injury during pregnancy has shown negative impacts on the mother and fetus, the evidence on its long-term associations with children’s neurodevelopment is limited.

Objective — To examine the association between maternal unintentional injury and cerebral palsy (CP) in offspring.

Design, Setting, and Participants — Thiswas a population-based, longitudinal, cohort study of all in-hospital live births born between April 1, 2002, and March 31, 2017, in a publicly funded healthcare system setting of Ontario, Canada. Infants born more than 20 weeks’ gestation were included and followed up until March 31, 2018. Excluded from the analysis were stillbirths, infants with missing or invalid records, and births with missing or invalid birth characteristics. Data were analyzed from March 1 to June 30, 2021.

Exposures — Maternal unintentional injury during pregnancy ascertained based on inpatient or emergency department diagnoses.

Main Outcomes and Measures — CP diagnosis between birth and the end of follow-up in 2018 with the CP case definition of a single inpatient or 2 or more outpatient diagnoses at least 2 weeks apart between birth and age 16 years.

Results — Of 2 110 177 children included in this study (mean [SD] gestational age, 38.8 [1.9] weeks; 1 082 520 male [51.3%]), 81 281 (3.9%) were exposed in utero to maternal unintentional injury. During a median (IQR) follow-up time of 8 (4-12) years, 5317 children (0.3%) were diagnosed with CP (292 CP cases [5.5%] were exposed to maternal unintentional injury). The mean incidence rates of CP were 4.36 and 2.93 per 10 000 child-years in the exposed and the unexposed group, respectively. Children exposed to maternal unintentional injury had a modest increase in the risk of CP, compared with those unexposed (hazard ratio [HR], 1.33; 95%CI, 1.18-1.50) after adjusting for maternal sociodemographic and clinical characteristics. Severe injuries that resulted in hospitalization and delivery within 1 week from the injury conferred higher risks of CP (adjusted HR, 2.18; 95%CI, 1.29-3.68 and adjusted HR, 3.40; 95%CI, 1.93-6.00, respectively). Results were robust in multiple bias analyses.

Conclusions and Relevance — In this Canadian population-based birth cohort study, in utero exposure to maternal unintentional injury was associated with an increased risk of CP, with a higher risk with more severe injuries. These findings fill an important gap in knowledge on the potential role of maternal injury on children’s neurodevelopment outcomes. Public health professionals and stakeholders should be aware of these potential long-term consequences on offspring when designing programs and providing recommendations about safety during pregnancy. Early monitoring and developmental assessment of children exposed to maternal
injury might be warranted.



Ahmed A, Rosella LC, Oskoui M, Watson T, Yang S. JAMA Pediatr. 2023; 177(1):53-61. Epub 2022 Nov 28.

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