Asphyxia Neonatorum by Shagufta Nisar

Asphyxia neonatorum, also called birth or newborn asphyxia, is defined as a failure to start regular respiration within a minute of birth. Asphyxia neonatorum is a neonatal emergency as it may lead to hypoxia (lowering of oxygen supply to the brain and tissues) and possible brain damage or death if not correctly managed. Newborn infants normally start to breathe without assistance and usually cry after delivery. By one minute after birth most infants are breathing well. If an infant fails to establish sustained respiration after birth, the infant is diagnosed with asphyxia neonatorum.
According to the World Health Organization, asphyxia neonatorum is one of the leading causes of newborn deaths in developing countries, in which 4 to 9 million cases of newborn asphyxia occur each year, accounting for about 20 percent of the infant mortality rate.

1. ASPHYXIA NEONATORUM BY SHAGUFTA NISAR

2. Asphyxia  —Lack of oxygen Asphyxia neonatorum , also called birth or newborn asphyxia Asphyxia neonatorum is respiratory failure in the newborn, a condition caused by the inadequate intake of oxygen before, during, or just after birth. A sphyxia neonatorum infants are completely limp and do not move at all P rofound metabolic or mixed acidemia (pH< 7.00) in umbilical cord blood. Persistence of low Apgar scores less than 3 for more than 5 minutes. Evidence of multiple organ involvement (such as that of kidneys, lungs, liver, heart and intestine). ASPHYXIA NEONATORUM

3. Categorised into 2 grades

4. CAUSES RESPIRATORY FACTORS Failure of the respiratory center Prematurity Intrauterine hypoxia Umbilical cord anomalies and accidents Hypovolemia secondary to antepartum hemorrhage Maternal conditions (cardiovascular problems, pulmonary disease, toxemia, other systemic illness) Obstetrical factors Uterine and cervical malformation Multiple gestation Abnormal presentation Difficult delivery

5. CAUSES CONT.

6. CLINICAL MENIFESTATIONS Altered Respiratory Patteren : grunting, grasping Cynosis Pallor – shock Hypotonia Irresponsiveness

7. SYMPTOMS

8. EARLY COMPLICATIONS

9. Risk F actors Prolonged rupture of membranes Meconium-stained fluid Multiple births Lack of antenatal care Low birth weight infants Malpresentation Augmentation of labour with oxytocin Antepartum hemorrhage

10. Prognosis Depends on how long the new born is unable to breathe. For example, clinical studies show that the outcome of babies with low five-minute Apgar scores is significantly better than those with the same scores at 10 minutes. With prolonged asphyxia, brain, heart, kidney, and lung damage can result and also death, if the asphyxiation lasts longer than 10 minutes

11. Perinatal asphyxia is closely associated with hypoxic-ischemic encephalopathy (HIE) which is one of the leading causes of neonatal mortality and long-term neurological disabilities.

12. HYPOXIC ISCHEMIC ENCEPHALOPATHY Hypoxia Ishemia Clinical Neurological Syndrome Sarnat and Sarnat classified HIE into 3 Grades Grade I (MILD) Grade II (MODERTE) Grade III (SEVERE)

13. GRADE I Hyper-alert , jittery and dilated pupils. Strong Moro reflex . Resolves within 24 hours without long term sequelae GRADE II Lethargic with seizures . Weak suck and Moro reflex. Mild hypotonia . 15-30 % chance of severe sequelae . Duration 2-14 day GRADE III Flaccid, stuporous , co- matose No suck, no Moro and pro-longed seizures. • Raised intra-cranial pres -sure. Lasts for weeks.

14. HYPOXIA- ISCHEMIA LEADS TO BRAIN INJURY

15. DIAGNOSIS

16. Diagnosis Normally, the Apgar score is of 7 to 10. Infants with a score between 4 and 6 have moderate depression of their vital signs while infants with a score of 0 to 3 have severely depressed vital signs and are at great risk of dying unless actively resuscitated.

17. DIFFERENTIAL DIAGNOSIS Drug depression Prematurity Trauma Anemia Neuromuscular Disorder Infection Inborn Error of metabolism- Pyridoxin dependency Respiratory track malformation

18. Treatment

19. Selective cerebral or whole bodytherapeutic Hyothermia ( C ool Therapy) Control Seizures : Phenobarbitone , Phenytoin, Midazolam. Mechanical Ventilaion , or (ECMO) Volume expansion Pressue Amines TREATMENT

20. TREATMENT A= Establish open airway: Suctioning, if necessary  endotracheal intubation B= Breathing: Through tactile stimulation, PPV, bag and mask, or through  endotracheal tube C= Circulation: Through chest compressions and medications if needed D= Drugs: Adrenaline .01 of .1 solution Hypothermia treatment  to reduce the extent of brain injury Epinephrine 1:10000 (0.1-0.3ml/kg) IV Saline solution for hypovolemia

21. MANAGMENT Newborn with birth asphyxia Baby requiring bag and mask ventilation (BMV) OR Intubation with or without medications at birth MILD ASPHYXIA Requiring BMV for less than 60 seconds No intubation or medications at birth based on the severity of asphyxia Assess at 5 minutes after birth: Assess sensorium and tone Look for abnormal movements IF Normal tone and sensorium; No abnormal movements; No other complications Then Shift to mother’s side; Initiate breastfeeding; If not able to breastfeed, start alternative methods of feeding IF Abnormal sensorium/tone OR Abnormal movements

22. Moderate or severe asphyxia Requiring BMV for 60 seconds or more Required bag and mask ventilation (BMV) for 60 seconds or more at birth , OR Needed intubation or medications at birth Check vitals : Temperature , heart rate, capillary refill time (CRT), colour , oxygen saturation (SpO2), respiratory rate , lower chest retractions, abnormal movements

23. Prevention Anticipation is the key to preventing asphyxia neonatorum . During labor, the medical team must be ready to intervene appropriately and to be adequately prepared for resuscitation. Use partograph for vigilant labor monitoring PERINATAL ASSESMENT: Regular perinatal checkups Timely interventions PERINATAL MANAGEMENT: Timely refferal Management of maternal complication prevention

24. INVESTIGATIONS Serum biochemistry electrolyes ureacreainine , ca + phosphate URINALYSIS AND MICROSCOPY Heamaturia , Heamoglobinuria , Myoglobinuria , Proteinuria BLOOD Heamoglobin , platelet count, pH, Base deficit or Bicarbonate URINE BIOCHEMISTRY Creatinine , sodium, osmolatily ULTRASOUND (SELECTED CASES) Abnormality of Renal structural or parenchyma Rena tracts including bladder size Doppler assesment of renal vasculature

25. REFERENCES www.healthline.com   http:// www.healthofchildren.com/A/Asphyxia-Neonatorum.html#ixzz6ce6eQfEc :  http://www.healthofchildren.com/A/Asphyxia-Neonatorum.html#ixzz6ce6HpKPZ https://www.newbornwhocc.org/STPs/STP_Asphyxia-management_Pre-Final.pdf https://www.researchgate.net/publication/270340840_Birth_Asphyxia https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5261744/ CAUSES Raul C. Banagale , MD, and Steven M. Donn , MD Ann Arbor, Michigan http://www.healthofchildren.com/A/Asphyxia-Neonatorum.html#ixzz6ce6xHWFr ASPHYXIA NEONATORUM BY IAN DONALD Department of Midwifery, University of Glasgow, Scotland Brit. J. Anaesth . (1960), 32, 106 https:// www.ucsfbenioffchildrens.org/conditions/birth_asphyxia/treatment.html