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Esterlita Villanueva-Uy
OUTLINE
I. How does a baby receive oxygen after birth? resistance < Systemic
A. Before birth (in utero) Vascular resistance –
B. Transition to neonatal circulation note: There is only functional closing of the foramen ovale
C. At completion of this normal transition
D. What can go wrong during transition?
and ductus arteriosus during delivery. The actual closing of
E. How can you tell if a newborn had in utero or these two shunts takes several days to complete.
perinatal compromise?
F. Risk factors associated with need for resuscitation
II. APGAR Score Pulmonary hypertension in the newborn happens if there is no
III. A Depressed Infant increase in PBF and no decrease in PVR. The lungs remain
constricted and the baby becomes cyanotic.
Table 1.Changes occurring during delivery and their effects. Rapid breathing
Changes Effects
Umbilical cord is clamped Eliminate the placenta Primary apnea
Expansion of the lungs
resulting in a ten-fold Irregular gasping
First breath is taken increase Pulmonary Blood
Flow (PBF) and a ten-fold Secondary apnea
decrease in Pulmonary
vascular resistance (PVR) HYPOXIA
Blood flow increases to the Figure 2. Physiologic changes associated with primary and
Lung fluid gradually
lungs pulmonary vein secondary apnea. Initial oxygen deprivation results in a transient
leaves the alveoli
left atrium period of rapid breathing. If such deprivation persists, breathing
Blood flow to lung Closes foramen ovale movements cease (primary apnea). This is accompanied by a
increases and Left atrial decrease in heart rate and loss of neuromuscular tone. Blood
pressure compensates and increases. If oxygen deprivation and
pressure > Right atrial asphyxia persists, the infant will develop deep gasping
pressure respirations, followed by secondary apnea. This is associated
Pulmonary vascular Closes the ductus arteriosus
with a further decline in heart rate, falling blood pressure and loss pink
of neuromuscular tone. Mnemonic:
The same response can be said about newborns in utero A – appearance (color)
or perinatal compromise. An objective measure that can P – pulse rate (heart rate)
tell you whether the newborn is in perinatal compromise or G – grimace (reflex irritability)
not can be obtained through APGAR Score. A – activity (muscle tone)
Apnea is the best indicator of neonatal compromise R – respiration
because it is the earliest manifestation. Blood
pressure is the last to go. 1 minute APGAR Score
In primary apnea, when hypoxic stimulus is removed, the - more of a measure of state of infant in utero, or
baby will start breathing. In secondary apnea, removing how bad his or her condition in the womb was
hypoxic stimulus will not make the newborn breathe. - use to identify the need for immediate
In the clinics, primary and secondary apnea cannot be resuscitation
differentiated, so when faced with an apneic newborn,
always assume that the baby might already be in 5 minute APGAR Score and particularly the change in
secondary apnea so resuscitate aggressively. the score between 1 and 5 minutes
- useful index of the effectiveness of resuscitation
F. Risk Factors Assoc. with Need for Resuscitation efforts
- be aware of these Risk Factors so you can have all - a score of less than 3 could lead to the
equipment ready in the OR development of cerebral palsy
1. Maternal Most infants at birth are in excellent condition, as indicated by
infection aminionitis APGAR Scores of 7 to 10, and they require no aid other than
pneumonia, asthma, ARDS perhaps simple nasopharyngeal suction. Median score is 9 due
Lungs (Adult respiratory distress to acrocyanosis related to temperature instability
syndrome)
Scoring an infant should be logical. An infant would logically not
arrythmia, structural defects,
heart have good activity if heart sounds are not present.
failure
blood anemia, hemoglobinopathies An infant with a score of 4 to 6 at 1 minute demonstrates
blood vessel SLE, DM, HPN depressed respirations, flaccidity and pale to blue color. Heart
uterus hypertonus, rupture rate and reflex irritability, however, are good.
genetic, drugs, PTL (Preterm
others Infants with scores of 0 to 3 usually have slow and inaudible
labor) , MG (multiple gestation),
abnormal FP (fetal presentation) heart rates and depressed or absent reflex responses.
B. Criteria that Suggest an Intrapartum Timing but 3. Pulmonary blood flow decrease in hypoxemia
Nonspecific to Asphyxial Insults and asphyxia
A sentinel hypoxic event occurring immediately before or during =from this point on, these are the slides in the powerpoint
labor
which were skipped by Dr. Uy, except those in bold. So
A sudden and sustained fetal bradycardia or absent fetal
variability in presence of late decelerations please read these parts. =)
Apgar score of 0-3 beyond 5 minutes
Onset of multi-system involvement within 72 hours of birth D. Injury from Asphyxia
Early imaging study showing evidence of acute non-focal
cerebral abnormality
Inosine
60
50 Hypoxanthine
40
Normal
30
Asphyxia Figure 5. Conversion of ATP into hypoxanthine. When
20 ischemia occurs, ATP is converted into hypoxanthine after
a series of steps.
10
0
Brain
Placenta
Spleen
Lungs
U. Body
Heart
Gut
Adrenals
L. Body
Kidney
Calcium influx
Phospholipase activation
Arachidonic release
Vasodilation Increase
microvascular
permeability Sarnat scoring determines/ predicts how severe
-
Reperfusion the cerebral palsy is/ will be
- Not rare for sarnat score to increase and
ROS release progress
G. Neonatal Encephalopathy and Cerebral Palsy
ROS
The Report of ACOG’s Task Force on Neonatal
DNA strand Neutrophil
Encephalopathy and Cerebral Palsy
Lipid peroxidation
breakage accumulation
1. Neonatal encephalopathy
Membrane Release of proteases, - Defined clinically on the basis of findings to
myeloperoxidase,
damage
prostaglandins
PMN plugging include a combination of abnormal
of capillaries consciousness, tone and reflexes, feeding,
Phagocytosis respiration or seizure and can result from a
Cell death myriad of conditions
- May or may not result in permanent brain
Ischemia
Tissue damage damage
- Term or near term
Figure 6. The release of reactive oxygen species and
its effects. Ischemia leads to the production of 2. Cerebral Palsy
reactive oxygen species, which in turn causes tissue - Chronic disability of the CNS characterized
damage and further cell death. by aberrant control of movement and
posture, appearing early in life and not as a
2. Neurotoxicity is secondary to increase in: result of a progressive neurologic damage
• Increase turnover of NA into MHPG (3- - Spastic diplegia
methoxy-4-hydroxyphenylglycol) - Pathway from intrapartum hypoxic-ischemic
• Excitatory amino acids injury to subsequent CP must progress
- Glutamate and aspartate through neonatal encephalopathy
• Adenosine and gamma aminobutyric acid - Why do we need to predict the development
of cerebral palsy?
This disease is usually detected around
1-2 years of age. Early detection and
intervention like physical therapy and
E. Resuscitation:Immediate Treatment of Asphyxia!
maternal counseling lead to less
1. Airway sequelae
2. Breathing 3. Epidemiology
- room air vs. 100% oxygen Neonatal encephalopathy
- bad effects of excessive oxygen: - Majority (70%) of NE due to events arising
decreased cerebral blood flow and
before labor
increased oxygen radicals
- new studies showing that room air H. Criteria to Define an Acute Intrapartum Event
leads to higher 5th minute APGAR Sufficient to Cause Cerebral Palsy
score, shorter time to first breath,
and less neurologic impairment Essential Criteria
3. Circulation Evidence of a metabolic acidosis in fetal umbilical arterial
4. Drugs cord blood obtained at delivery
Early onset of severe or moderate neonatal
F. Risks of Permanent Sequelae encephalopathy in infants at 34 or more weeks of
gestation
Table 2. Classifying the Degree of Encephalopathy to Cerebral palsy of the spastic quadriplegic or dyskinetic
Establish the “Pretest” Probability of Poor Outcome. type
Exclusion of other identifiable etiologies such as trauma,
coagulation disorders, infectious conditions or genetic
disorders
1. Hypothermia
Decrease of 2-6% below baseline
If preterm:
A. Oxygenation
• O2 blender
• O2 sat goal 90-95%
• Ambu w/o reservoir: 40% (mixed w/ room air)
• Ambu w/ reservoir: roughly 100%
B. Thermoregulation
• Preterms are at risk for hypothermia
• Use radiant warmer, dry baby and replace wet
with dry linen
• If <28 weeks, ziplock is used as a warming back
If meconium stained: