The basal ganglia (or basal nuclei) is a group of subcortical nuclei, of varied origin, in the

brains of vertebrates including humans, which are situated at the base of the forebrain.
Another nucleus of the basal ganglia is the substantia nigra ("black substance"). Located in the
upper portions of the midbrain, below the thalamus, it gets its color from neuromelanin, a close
relative of the skin pigment. One part (the pars compacta) uses dopamine neurons to send
signals up to the striatum.

Germinal matrix haemorrhages, also know as periventricular-intraventricular haemorrhages

(PVIH), correspond to the most common type of intracranial haemorrhage in neonates and are related to a
perinatal stress affecting the highly vascularised subependymal germinal matrix. The majority of cases occur in
premature births within the first week of life. They are a cause of significant morbidity and mortality in this
population.

Epidemiology
Germinal matrix haemorrhage can only occur when germinal matrix is present and is therefore only seen in
premature infants. Haemorrhages can be identified in 67% of infants born prematurely at 28-32 weeks 1 and
80% of infants born between 23 and 24 weeks of gestation 2. The majority of haemorrhages (90%) are
identified within 4 days of birth, and 40% within the first 5 hours 4.

Clinical presentation
Clinical presentation for grade I and II bleeds is vague. These are usually found on routine ultrasound
performed on premature neonates. With grade III and IV bleeds respiratory depression or apnoea, abnormal
posturing, seizures and bulging fontanelles may be seen 2.

Pathology
The germinal matrix is formed early during embryogenesis and is the site of glial and neuronal differentiation.
From here cells migrate peripherally to form the brain. It is densely cellular and, not surprisingly, also densely
vascular 2.

The blood vessels of the germinal matrix are weak walled and predisposed to haemorrhage. A significant
stress experienced by a premature infant after birth may cause these vessels to rupture. The bleeding occurs
initially in the periventricular areas causing a periventricular haemorrhage (PVH). If this bleeding persists, the
expanding volume of blood dissects into the adjacent lateral ventricles leading to an intraventricular
haemorrhage (IVH).

There are a direct relation between prematurity, germinal matrix and thus the number of capillaries in this
region: at 32 weeks germinal matrix is only present at the caudothalamic groove. By 35-36 weeks gestation the
germinal matrix has essentially disappeared and thus the risk of haemorrhage is markedly reduced.

Risk factors
 low birthweight
 cyanotic congenital heart disease
 prolonged labour
 multifetal pregnancy
Classification
See: grading of neonatal intracranial haemorrhage.

Radiographic features
Ultrasound
This is the investigation of choice since it is portable and does not require sedation. Germinal matrix
haemorrhages appear as echogenic regions close to the caudothalamic groove extending along the floor of the
frontal horn of the lateral ventricle.

It is important to distinguish haemorrhage from the normal choroid plexus which is also echogenic. The
caudothalamic groove acts as a convenient landmark: echogenicity anterior to the groove represents blood as
the choroid finishes at the groove 4.

CT
CT may demonstrate high attenuating regions in keeping with haemorrhage which may or may not also be
seen dependently within the ventricles.

With grade IV bleeds, large confluent regions of low density (venous infarction) and patchy regions of
hyperdensity (haemorrhage) are seen in the periventricular regions. They are typically flame-shaped 4.

MRI
The appearance of the haemorrhage will vary according to the age of the bleed (see ageing blood on MRI).

Treatment and prognosis

Ideal treatment is prevention of premature delivery. Antenatal dexamethasone administered to the mother, or
indomethacin administered to the infant also decrease the incidence, although the exact mechanism by which
this occurs is uncertain 2.

If hydrocephalus is present, CSF drainage may be necessary.

Prognosis depends on the extent of haemorrhage and presence of hydrocephalus (see germinal matrix
haemorrhage grading). Grade I and II haemorrhages have good prognosis, whereas grades III and IV have
poor prognosis, with a 90% mortality for grade IV bleeds 1.

In grade IV bleeds significant areas of cerebral tissue may be lost, forming porencephalic cysts.

Complications
 post haemorrhagic hydrocephalus
 blockage of villi
 obliterative fibrosing arachnoiditis
 periventricular leukomalacia
 cyst formation
 o cavitation of haemorrhage
o subependymal cyst
o unilocular porencephalic cyst

Differential diagnosis
Differential considerations on antenatal ultrasound includes:

 normal choroid plexus: does not extend anterior to the caudothalamic groove/foramen of Monro
 Intraventricular haemorrhage of the newborn: within the subependymal region, rather than the germinal
matrix
 early periventricular leukomalacia: when echogenicity is increased, common in preterm
 hypoxic ischemic brain injury: involves subcortical cerebral or basal ganglia injury; common in term babies
 TORCH CNS infection: commonly seen with periventricular calcifications

 In anatomy, the germinal matrix is a highly cellular and highly vascularized region in
the brain from which cells migrate out during brain development. The germinal matrix is the
source of both neurons and glial cells and is most active between 8 and 28 weeks gestation.
It is a fragile portion of the brain that may be damaged leading to an intracranial
hemorrhage known as a germinal matrix hemorrhage.
 Location/Anatomy: The germinal matrix is next to the lateral ventricles (the "inside" of the
brain).
 Function/Physiology: Neurons and glia migrate radially outward from the germinal matrix
towards the cerebral cortex. For more information, see the associated articles on neuronal
migration and corticogenesis.
 Dysfunction/Pathophysiology: in prenatology/neonatology, intraventricular hemorrhages
occur starting in the germinal matrix due to the lack of structural integrity there.
Intraventricular hemorrhages are a common and harmful issue in children born prematurely.
Anke Equinus Contracture

- Discussion:
- see: role of ankle and subtalar joint in gait
- normally, during the transition from foot flat to heel off, the foot dorsiflexes as the body
moves forward;
- gait consequences of equinus contracture:
- patient may adopt a toe to toe gait pattern or a toe to heel gait pattern (premature
forefoot loading)
- reduced propulsion
- excessive knee hyperextension
- excessive foot pronation which allows more dorsiflexion to occur at the subtalar joint;
- reduced stride length of the opposite limb
- reduced gait velocity
- external rotation
 - diff dx:
- anterior ankle impingement
- leg length descrepancy
- hyperpronation of the foot
- clubfoot
- ankle equinus in CP
- immobilization after trauma
Auditory aphasia: Impairment in the understanding of auditory language and communication.
Sounds are heard but they convey no meaning.

Differential diagnosis

Condition Differentiating signs/symptoms

Spinal muscular atrophy  Several subtypes. Patient is floppy at birth and exhibits progressive
weakness. There is no spasticity, but patients may develop contractures.

Muscular  No spasticity, but patients can develop contractures. There are various
dystrophy/myopathy subtypes, including Duchenne's, Becker's, and limb girdle.
 Child may be weak at birth or may have apparent normal development until
approximately 3 years of age followed by a progressive loss of function and
muscle weakness. There may be a positive family history.
 Examination reveals a positive Gowers' sign with regression of walking
ability.
 Becker's type is less debilitating and manifests later in childhood. Limb
girdle type may not present until late teens or 20s.
In biology and human medicine, gravidity and parity are the number of times a female is or has
been pregnant (gravidity) and carried the pregnancies to a viable gestational age (parity).[1] These
terms are usually coupled, sometimes with additional terms, to indicate more details of the woman's
obstetric history.[2] When using these terms:

 Gravida indicates the number of times a woman is or has been pregnant, regardless of the
pregnancy outcome.[3] A current pregnancy, if any, is included in this count. Twin pregnancy is
counted as 1.
 Parity, or "para" indicates the number of pregnancies reaching viable gestational age (including
live births and stillbirths). The number of fetuses does not determine the parity.[4] Twin pregnancy
carried to viable gestational age is counted as 1.
 Abortus is the number of pregnancies that were lost for any reason, including induced abortions
or miscarriages. The abortus term is sometimes dropped when no pregnancies have been lost.
Stillbirths are not included

Gravidity[edit]
In human medicine, "gravidity" refers to the number of times a woman has
been pregnant,[1] regardless of whether the pregnancies were interrupted or resulted in a live birth.

 The term "gravida" can be used to refer to a pregnant woman.

 A "nulligravida" is a woman who has never been pregnant.
 A "primigravida" is a woman who is pregnant for the first time or has been pregnant one time.
 A "multigravida" or "secundigravida" is a woman who has been pregnant more than one time.
Terms such as "gravida 0", referring to a nulligravida, "gravida 1" for a primigravida, and so on, can
also be used. The term "elderly primigravida" has also been used to refer to a woman in her first
pregnancy, who is at least 35 years old.[5]
In biology, the term "gravid" (Latin: gravidus "burdened, heavy"[6]) is used to describe the condition of
an animal (most commonly fish or reptiles) when carrying eggs internally. For example, Astatotilapia
burtoni females can transform between reproductive states, one of which is gravid, and the other
non-gravid. In entomology it describes a mated female insect.

Parity[edit]
Parity is the number of pregnancies carried to viable gestational age.
A woman who has never carried a pregnancy beyond 20 weeks is nulliparous, and is called
a nullipara or para 0.[7] A woman who has given birth once before is primiparous, and is referred to
as a primipara or primip; moreover, a woman who has given birth two or more times
is multiparous and is called a multip. Finally, grand multipara describes the condition of having given
birth three or more times.
Like gravidity, parity may also be counted. A woman who has given birth one or more times can also
be referred to as para 1, para 2, para 3 and so on.
Viable gestational age varies from region to region.
In agriculture, parity is a factor in productivity in domestic animals kept for milk production. Animals
that have given birth once are described as "primiparous"; those that have given birth more than
once are described as "pluriparous".[8][9] Those that have given birth twice may also be described as
"secondiparous", in which case "pluriparous" is applied to those that have given birth three times or
more.

Nulliparity[edit]
A nulliparous (/nʌlˈɪpərəs/) woman (a nullipara or para 0) has never given birth.
Prolonged nulliparity (/ˌnʌlᵻˈpærᵻti/) is a risk factor for breast cancer. For instance, a meta-analysis of
8 population-based studies in the Nordic countries found that nulliparity was associated with a 30%
increase in risk of breast cancer compared with parous women, and for every 2 births, the risk was
reduced by about 16%. Women having their first birth after the age of 35 years had a 40% increased
risk compared to those with a first birth before the age of 20 years.[10]

Recording systems[edit]
A number of systems are incorporated into a woman's obstetric history to record the number of past
pregnancies and pregnancies carried to viable age. These include:

 The gravida/para/abortus (GPA) system, or sometimes just gravida/para (GP), is one such
shorthand.[citation needed] For example, when recording the history of a woman who has had two
pregnancies (both of which resulted in live births), it would be noted as G2P2. The obstetric
history of a woman who has had four pregnancies, one of which was a miscarriage before 20
weeks, would be noted as G4P3A1 (in the UK this is written as G4P3+1). That of a woman who has
had one pregnancy of twins with successful outcomes would be noted as G1P1.[11]
 TPAL is one of the methods to provide a quick overview of a female's obstetric history.[12] In
TPAL, the T refers to term births (after 37 weeks gestation), the P refers to premature births,
the A refers to abortions, and the L refers to living children.[13] When reported, the "abortions"
number refers to the total number of induced abortions and miscarriages except ectopic
pregnancies prior to 20 weeks. If a fetus is aborted after 20 weeks, spontaneously or electively,
then it is counted as a premature birth and P will increase but L will not.[citation needed] The TPAL is
described by numbers separated by hyphens. Multiple births (twins, triplets and higher multiples)
count as one birth, but each living child is counted separately. For example, a pregnant woman
who carried one pregnancy to term with a surviving infant; carried one pregnancy to 35 weeks
with surviving twins; carried one pregnancy to 9 weeks as an ectopic (tubal) pregnancy; and has
three living children would have a TPAL annotation of T1, P1, A1, L3. This could also be written
as 1-1-1-3.
 The term GTPAL is used when the TPAL is prefixed with gravidity, and GTPALM when GTPAL
is followed by number of multiple pregnancies.[13] For example, gravidity and parity of a woman
who has given birth at term once and has had one miscarriage at 12 weeks would be recorded
as G2 T1 P0 A1 L1. This notation is not standardized and can lead to misinterpretations.[7]
Though similar, GPA should not be confused with the TPAL system, the latter of which may be used
to provide information about the number of miscarriages, pretermbirths, and live births by dropping
the "A" from "GPA" and including four separate numbers after the "P", as in G5P3114. This TPAL form
indicates five pregnancies, with three term births, one preterm birth, one induced abortion or
miscarriage, and four living children.[14]
Criticism[edit]
In humans, it can lead to some ambiguity for events occurring between 20 and 24 weeks,[15] and for
multiple pregnancies.[16]

LMP = Last Menstrual Period.

Use the first day of the last menstrual period to calculate the due date. The quick way to do it in your head
is to count backwards 3 months from the first day of the LMP, then add 7 days. So if the LMP was 8/15,
the 3 months backwards is 5 (May) plus 7 days added to the 15th=22, so the due date is May 22.
EDC or EDD = the due date.
EDC stands for the old-fashioned “estimated date of confinement.” EDD is the more modern “Estimated
Day of Delivery.” The key word here is “estimated.” Babies take different lengths of time to get “done,”
and anywhere from 3 weeks before to 2 weeks after the due date the delivery is “at term.”
Trimester = the pregnancy is divided into 3 “trimesters.”
The first one is from LMP up until 12 or 13 weeks.
The second trimester is from 12-13 weeks until 28 weeks.
The third trimester is from 28 weeks until delivery.
NSVD = normal spontaneous vaginal delivery
SVD = spontaneous vaginal delivery – same as NSVD
VAD = vacuum assisted delivery.
The doctor (not us midwives) applies a suction cup (like a plumber’s helper) to the baby’s head and gently
draws it out, when the mother is too tired to push effectively any more but the baby is very low in the
pelvis.
Primary Cesarean Section = first time a mother has delivered by Cesarean. (*1E)
Secondary Cesarean Section = mother has already had a previous Cesarean delivery, and this is a
repeat Cesarean birth. (*2E)
VBAC = Vaginal Birth After Cesarean.
The mother has had a previous Cesarean delivery but has now delivered vaginally. There is a small
amount of risk (less than 1%) that the old surgical scar on the uterus will rupture when a VBAC is
attempted, so mothers who wish to attempt a VBAC must understand the risks and sign an “informed
consent” that shows they are aware of the risks/benefits.
TOL = Trial of Labor.
If a woman has had a previous Cesarean birth and wants to have a VBAC, she is said to be undergoing a
“trial of labor” when her contractions start.
ME = median or midline episiotomy.
A cut made with surgical scissors from the opening of the vagina straight back toward the rectum just
before the birth. We would do one of these if it seemed the woman was going to tear in an area where it
is hard to do a repair, like up by the clitoris, or if the baby’s heartbeat is low and we cannot wait for the
tissue to stretch naturally, to get the baby out sooner.
MLE = mediolateral episiotomy.
The cut is made from the vaginal opening at an angle more toward the leg than straight back. Elizabeth
and I don’t do these.
Perineal laceration = a natural tearing of the tissue between the vaginal opening and the rectum.
It used to be taught that it was better to cut an episiotomy than allow a tear, but in the last 25 years all the
research in OB literature has shown that lacerations are usually not as large as episiotomies, heal faster
than episiotomies, and are less painful than episiotomies.
There are 4 “degrees” of lacerations:
A first degree laceration 1E is minor and does not involve muscle.
A second degree laceration 2E is equivalent to a median episiotomy, and does involve some muscle.
A third degree laceration 3E involves some of the muscle of the rectal sphincter, and a fourth degree
laceration goes all the way through the rectal sphincter.
G = gravida.
The number of times the woman has been pregnant. Usually seen in association with:
P = the outcome of those pregnancies.
Examples:
G1P0 = the woman is pregnant for the first time and has not yet delivered
G1P1 = the woman has had one pregnancy and has delivered once
There can be 4 numbers after the “P” for “para.”
The first number is how many term pregnancies.
The second number is how many premature babies.
The third number is how many abortions or miscarriages
The fourth number is how many living children survive.
Examples:
G4P1111 = the woman is currently pregnant with her fourth pregnancy. She had one full-term delivery,
one premature delivery which did not survive, one abortion or miscarriage, and has one living child.
G3P2002 = the woman is pregnant with her third child and has two living full-term kids
G6P2124 = the woman is pregnant with her sixth pregnancy. She had 2 abortions or miscarriages, and
surviving children include 2 full-term pregnancies and one premie which survived. Since the last number
indicates she has 4 living kids, then you have to figure that one of the pregnancies was a twin pregnancy
and both the babies survived.
VTOP = Voluntary termination of pregnancy
SAB = spontaneous abortion
IVF = in vitro fertilization.
Egg(s) harvested from the mother are fertilized in the lab with the father’s or a donor’s sperm, when
couples have been unable to conceive naturally. If a couple has had IVF, then we can calculate the due
date from the date of conception rather than the date of LMP.
Sono, sonogram, ultrasound, scan = different terms for the same thing: looking at something inside the
body by bouncing high-frequency sound waves off the internal structures to get a picture of what’s inside.
Dating scan = Most accurate in first trimester. Used to get an EDC when the LMP is unknown or the
midwife finds that the uterus is smaller or larger than it should be, given the number of weeks from the
LMP.
Nuchal translucency = sonogram at 11 – 13 weeks of gestation which measures the thickness of the
fold of the neck on the back of the fetus. This can be quite difficult since the fetus is still very small at this
point, and may be moving around a lot. However, if the neck fold is abnormally thickened it is very
suspicious for a finding of Down Syndrome or another fetal abnormality. This sonogram is most often
paired with a blood test called the Ultrascreen, First Screen, or etc. to calculate a “risk score” for Down
Syndrome/associated anomalies. Remember, this is a SCREENING TEST ONLY. It cannot diagnose a
problem, only point out that a problem MAY BE there. The mother must have a definitive test ( amnio or
CVS) which actually examines the chromosomes of the fetus before anyone can say for sure that there is
truly a problem with the baby.
Anatomy scan = done at about 20 weeks gestation (as measured from LMP).
A very comprehensive sonogram to look for any fetal anomalies. Can usually detect abnormalities in the
brain, heart, bones (including spine) , facial features, kidneys, stomach, liver, genitals. Could not see an
internal problem, like cleft palate. Cannot by itself rule out Down Syndrome, as the thickness of the neck
fold which is apparent at 11 – 13 weeks has disappeared by this point in the pregnancy.
CVS = Chorionic villus sampling.
The “villi” (plural of villus) are parts of the placenta. Since the baby and the placenta form from the joining
of the egg and the sperm, the genetics of the placenta is usually the same as the genetics of the
placenta. So if a very small portion of the placenta is taken for analysis at 11 weeks or so from the LMP, it
should be possible to be sure whether the placenta/baby are affected by Down Syndrome (or another
problem). This procedure has a risk of miscarriage of 1 -2%. The most experienced center for CVS in
Manhattan in Mt. Sinai Hospital, where we would refer any patients who are interested in this procedure.
Amno = amniocentesis.
Another procedure, which, like CVS, is 100% accurate in diagnosing genetic problems because it can
obtain fetal tissue for analysis, but because it is an “invasive” procedure also incurs a risk of a 1-2% loss
of the pregnancy. It is done around the 16 week from LMP, and involves a needle penetrating the uterine
wall to obtain amniotic fluid. That amniotic fluid contains sloughed-off skin cells of the fetus, which can be
examined under the electron microscope to look at the number of chromosomes. 3 copies of the 21st
chromosome indicate Down Syndrome. Other trisomies exist but are much rarer.
GST = glucose screening test.
This is a SCREENING test only for diabetes of pregnancy, done at 26-28 weeks from LMP. If over 135, it
indicates the patient needs a full 3 hour GTT (glucose tolerance test) for diabetes of pregancy, which is
the definitive test.
GBS = Group B Strep.
This is an organism which is not a sexually-transmitted disorder, and which causes no problems for any
woman who carries it or any man who might have intecourse with her. It is only a potential problem for a
woman who is a carrier (as are about 20% of normal women) who is going to have a baby. If a woman is
a carrier of this organism, she could potentially pass it on to her child during delivery, and the child could
POSSIBILY become very sick. The Centers for Disease Control in the US has advised that all
practitioners test every pregnant woman under their care for GBS at 34 – 37 weeks gestation, and treat
all positive results with antibiotics in labor to prevent transmission to the infant. If the mother is positive for
GBS, she can still deliver in the Birthing Center if she meets all other criteria, but she must have
antibiotics before delivery or the pediatricians will insist on a longer hospital stay so they can make sure
the baby is not affected adversely.
NST = Non-stress test.
Done to make sure the baby is healthy, usually in the third trimester of pregnancy; most often when the
mother is a week or more overdue but also done if the mother reports decreased fetal movement.
 Involves putting an external fetal monitor on the mother’s abdomen to record fetal movements and to see
that the baby’s heartbeat increases when the baby moves.
BPP= biophysical profile.
A type of sonogram done in the third trimester to assess the baby’s health.Doctor looks for baby’s
movements, heart rate, etc. and especially the amount of amniotic fluid. If the amount of amniotic fluid is
markedly decreased, they will often recommend we induce the patient.

op·is·thot·o·nos

ˌäpəsˈTHädənəs/
noun
MEDICINE
noun: opisthotonus
1. spasm of the muscles causing backward arching of the head, neck, and spine, as in
severe tetanus, some kinds of meningitis, and strychnine poisoning.

People with spasticity describe their muscles as feeling stiff, heavy and difficult to move. ...
A spasm is a sudden involuntary tightening or contraction of a muscle. Any muscle can be
affected but leg spasms and spasticity affecting the arms, legs or the trunk and back are most
common.

CORTICAL-
relating to the outer layer of the cerebrum
Severity of drooling was quantified using a modified Thomas-Stonell and Greenberg visual scale
simplified into three grades: 1 = dry; 2 = mild/moderate; 3 = severe/fulsome