PERINATAL ASPHYXIA

Fred N Were Department of Paediatrics University of Nairobi

DEFINITION
A range of disorders that occur subsequent to oxygen deprivation of a fetus/newborn during the two weeks surrounding delivery The main syndrome usually involves the brain but many other organs can be involved

Pathophysiology-Gross
Reduction of oxygen supply to the body organs (HYPOXIA) Progressive reduction of systemic blood flow (ISCHEMIA) Eventual decrease of cerebral & coronary blood flow (LOSS OF AUTOREGULATION) Hypoxic/Ischaemic cell death

Pathophysiology-Molecular

Accumulation of intracellular calcium

Increase of excitatory amino acids in the damaged cells Elaboration and increased liberation of reactive oxygen species (free radicals)

Etiology

Prenatal
Placental insufficiency syndromes

Labor/Delivery
prolonged/obstructed labor cord accidents/ Ante partum hemorrhage

Post Natal
ineffective resuscitation at birth severe respiratory diseases

Clinical Diagnosis

APGAR SCORING This signifies presence of Central Nervous system depression

PRESENCE OF ENCEPHALOPATHY Suggesting actual neuronal damage

APGAR SCORING
0 1
peripheral cyanosis
<100 Weak Weak Shallow 0 None None None

2
pink
>100 Strong Strong Lusty

Appearance
PULSE

Pale/blue

Grimace Activity Respiration

Performed at 1&5 minutes. If abnormal repeated at 10 & 20 minutes

APGAR Interpretation
1 minute score identifies those needing resuscitation 5 minute score defines asphyxia as:

Mild Moderate Severe 6&7 4&5 0-3

Extended scores estimate or predict later outcomes

Hypoxic Ischaemic Encephalopathy

Grade 1; MILD
Hyperactive and jittery, no convulsions

Grade 2; MODERATE
dull and lethargic but awake or arousable convulsions frequent

Grade 3; SEVERE
Stuporous/comatose with intractable fits Other organ involvement, decorticate or decerebrate

Laboratory Evaluation

Cerebral Ultrasound
Electro Encephalography CT Scans MRI

Principals of Management

Effective resuscitation at birth

Active maintenance of normal homeostasis during the acute phase Appropriate management of convulsions and other complications Some experimental methods

Principals of Management

Effective resuscitation at birth

Active maintenance of normal homeostasis during the acute phase Appropriate management of convulsions and other complications Some experimental methods

Objectives Of Resuscitation

To correctly identify the need for

resuscitation at birth

To understand the ABC sequence of

resuscitation as applied to the newborn

Evaluation of the Newborn

Dry and warm the newborn

The need for life support interventions will

be indicated by the simultaneous

evaluation of:
Respiration Colour Heart

rate

Respiration
Good spontaneous respiratory activity may manifest as
vigorous crying or adequate breaths

Dry warm and leave infant alone

If apnoea or gasping persist after a few seconds of tactile

stimulation:

ABC of resuscitation must commence

Heart Rate

Observe HR at praecodium or base of umbilicus

If HR <100 bpm even if the newborn is breathing: Deliver positive pressure ventilation with 21-100% oxygen If HR < 60bpm and newborn is breathing: Commence ECC then Adrenaline if necessary

Colour

Central cyanosis/palor with adequate breathing: Deliver free flow oxygen No breathing: ABC of resusc

AIRWAY: Clearing

Position infant and remove secretions Neutral / slightly extended position by towel placement Secretions cleared first from the mouth, then from the nose

BREATHING and Stimulation

Routine drying and suctioning Rubbing the back Flicking the soles of the feet If no response to tactile stimulation occurs within few seconds:
Then bag, valve and mask ventilation with 21-100% oxygen

Positive Pressure Ventilation

Adequate expansion of the lung is the most important
measure needed for successful resuscitation

Indications for IPPV:

Apnoea / gasping
breath HR < 100 bpm Persistent central cyanosis

Positive Pressure Ventilation

Most newborns who require positive pressure ventilation can be adequately ventilated with a bag valve and mask

Key Point:
The most important and effective action in neonatal resuscitation is: Ventilation with Air or Oxygen

Tracheal Intubation
Indications for tracheal intubation during neonatal Resuscitation include:

Tracheal suctioning Ineffective / prolonged BVM Chest compression required Tracheal drugs Congenital diaphragmatic hernia Extreme prematurity Transport

Chest Compressions
If the heart rate is < 60 bpm despite effective positive pressure ventilation with 100% oxygen then give CC at ratio of 3 to 1
i e 90 cc for 30 breaths

Emergency Drugs

Very rarely required If HR < 60 bpm after 30 seconds of adequate ventilation and chest compressions:

Adrenaline (10-30mcg/kg)
IV (peripheral/umbilical), Tracheal, Osseous

Newborn Life Support

Dry &
cover
A
RC (UK)

Airway &

Breathing

C
D

CC
D

Principals of Management

Effective resuscitation at birth

Active maintenance of normal homeostasis during the acute phase Appropriate management of convulsions and other complications Some experimental methods

Maintenance of Homeostasis

Monitor and maintain oxygenation Monitor and correct serum electrolytes;

Sodium, Calcium, Magnesium

Monitor and correct Blood glucose (especially

avoiding hypoglycemia)

Monitor and maintain acid base balance within the normal range Monitor and maintain normal blood circulation

Principals of Management

Effective resuscitation at birth Active maintenance of normal homeostasis during the acute phase

Appropriate management of convulsions and other complications Some experimental methods

Treatment of Convulsions
Ensure normal homeostasis Phenobarbitone at 20mg/kg bolus is the 1st line drug; if 2 doses 1 hr apart fail then Phenytoin at 20mg/kg bolus is used. This

can also be used as 1st line especially when respiratory depression is an important consideration

Refractory convulsions; Phenytoin and

Phenobarb at maintenance dose plus either clonazepam or paraldehyde.

Major Complications

Pulmonary (PPH, Mec Asp Synd)

Hyperventilation, pulmonary vasodilators

Renal (Acute Tubular Necrosis; ARF)

Fluid restriction, peritoneal dialysis, ultrafiltration

Cardiac (Myocardial Ischemia; Pump Failure)

Ionotropic drugs

Gastrointestinal (Necrotizing Enterocolitis)

Antibiotics, GUT resting, surgery

Haematological (DIC, Jaundice)

Blood platelate and clotting factor replacement

Principals of Management

Effective resuscitation at birth

Active maintenance of normal homeostasis during the acute phase Appropriate management of convulsions and other complications Some experimental methods

Experimental Methods

Oxygen free radical scavengers

Calcium channel blockers Inhibitors of glutamic activity

These are presumed to work reducing the secondary cell damage following the initial hypoxic injury. None in clinical use yet

Clinical Prognostic Indicators

Low extended APGAR score

Severity of neurological syndrome Additional organ complications
especially cardiac and renal

Poor socioeconomic status

particularly predicts later neuro developmental delays

Summary

Perinatal asphyxia is an important cause of both neonatal morbidity and mortality It accounts for probably one quarter of all neonatal deaths in many countries The mainstay of care is anticipation and effective resuscitation at birth (BVM). Supportive care seldom useful in severe cases