ASPHYXIA NEONATORUM

ASPHYXIA NEONATORUM

Defined as impaired respiratory gas exchange

accompanied by the development of acidosis
Definition of perinatal asphyxia
WHO :
A failure to initiate and sustain breathing
at birth.

NNF :
 Moderate asphyxia
 Slow gasping breathing or an apgar score
of 4-6 at 1 minute of age
 Severe asphyxia
 Nobreathing or an apgar score of 0-3 at 1
minute of age
 HOW DOES ASPHYXIA OCCUR?
 Interruption of umbilical cord blood flow, eg: cord
compression during labour

 Failure of exchange across the placenta, eg: abruption

 Inadequate perfusion of maternal side of placenta, eg: maternal

hypotension

 Compromised fetus who cannot tolerate transient

intermittent hypoxia of normal labour

 Failure to inflate lungs

 TO ASSESS THE SEVERITY OF
ASPHYXIA - Apgar Scores
Signs 0 1 2

Colour Blue/pale Blue peripheries Pink

Heart rate 0 <100 >100

Respiration 0 Weak, gasping Regular

Suction response 0 Slight Cries

Tone 0 Fair Active

A -Appearance P- Pulse G- Grimace A-Activity R-Respiration

Quiz:
At birth, a newborn infant is noted to have the following findings: heart
rate – 70/min, respiratory effort – poor and irregular, limp, no reflex
irritability, blue all over the body.

The Apgar score of the baby at this point is?

HR 1, RR 1, Tone 1, reflex 0, color 0

APGAR=3
 PREDISPOSING FACTORS
Maternal Causes

 Medical conditions eg Pulmonary hypertension

Chronic HPT (hyperpatathyroidism)

 Antenatal conditions eg Abnormal uterine contraction

Antepartum haemorrhage
Prolapsed cord
Malpositions etc
 PREDISPOSING FACTORS

Fetal Causes

 Multiple pregnancies

 Big baby with CPD

 Fetal anomalies - Congenital abnormalities
of the lung
 PATHOPHYSIOLOGY
Fetal adaptation to oxygen lack

1. Preferential flow to heart, brain and adrenals

aerobic anaerobic metabolism

glucose pyruvic acid lactic acid Acidosis

Acidosis failure of autoregulation impaired perfusion

increasing acidosis Death unless resuscitated
 PATHOPHYSIOLOGY

2. Primary and Secondary apnoea

Occur as an attempt to minimize metabolic work

 3.Fetal response to asphyxia

Respiratory metabolic acidosis

 4. EEG changes

Loss of faster rhythm iso-electric rhythms

Prolonged voltage suppression with burst of
spike waves indicating risk of significant brain
 CLINICAL FEATURES
 Apnoea, bradycardia
 Altered respiratory pattern
 Cyanosis

 Pallor-shock

 Hypotonia

 Unresponsiveness
 ORGANS INVOLVED IN ASPHYXIA (1)

Asphyxia results in alteration in blood flow to various organs,

hence multiple organ injury

Kidney abnormalities occur in 50% of asphyxiated infants

CNS abnormalities in 30% & CVS & pulmonary abnormalities in
25%

• Renal abnormalities - Oliguria, elevated β2 , microglobulin,

• azotaemina, elevated serum creatinine, acute tubular
necrosis
 ORGANS INVOLVED IN ASPHYXIA (2)

 CNS abnormalities - HIE, PV-IVH

 CVS abnormalities - Ventricular failure (R > L)

Tricuspid regurgitation
Hypotension

 Pulmonary abnormalities - PFC, pulmonary

haemorrhage
 GIT abnormalities - bleeding GIT, NEC
(necrotizing enterocolitis)
 PATHOLOGY OF BRAIN DAMAGE
Extent of damage depends on:

 duration of asphyxia
 severity of asphyxia
 gestational age
 alteration in cerebral blood flow
 changes in glucose/glycogen metabolism
in vulnerable areas of brain.
In hypoxic-ischaemic encephalopathy, as the
cerebral edema develops, the brain function is
affected in descending order.
 Preventing asphyxia
• Perinatal assessment
– Regular antenatal check ups
– High risk approach
– Anticipation of complications during labour
– Timely intervention ( eg. LSCS)
• Perinatal management
– Timely referral
– Management of maternal complications
Prevention,
 PREVENTION
Recognition of at risk pregnancies
Antenatal monitoring
 fetal movements, fetal growth
 CTG for change in baseline, loss of variability, decelerations
 fetal scalp pH
< 7.2 --------------------- immediate delivery
7.2 - 7.25 ------------- repeat in 1 hour
7.25 normal
 Co-ordinated care at delivery by paediatrician
 MANAGEMENT-Investigations
 Hx - of pregnancy and resuscitation

 Metabolic tests - sugar, Ca/P04/Mg, cord BG, ABG,

metabolic screen

 CSF - to exclude infection; assay brain specific creatine

kinase
 EEG - to help with seizure Dx and prognosis
 Tech. scan - for abnormal uptake in damaged area
 MANAGEMENT
 U/S - to exclude PV-IVH

 CT scan - to exclude IVH/trauma, demonstrate severity of edema and for

prognosis

 MRI scan

• Supportive care
 Monitor B/p, To, blood sugar, correct acidosis and electrolyte
 inbalance Care of renal failure - low fluid, dialysis
 Care of cardiac failure - Dopamine, restrict fluid
 Management of inappropriate ADH secretion - prevent overhydration
 MANAGEMENT-1
BASIC CARE :Should be a daily routine in the management of all
these babies -
1. Strict asepsis.
2. Ensure neutral thermal environment.
3. Monitor vital parameters – HR,RR,BP,and Pulse Oximetry.
4. Urine output.
5. Daily weight.
6. Nutrition.
 1. Management of shock
1. Hypovolumic shock needs replacement with fluids, plasma, or
blood.
2. Cardiogenic shock warrants use of pressors like dopamine and /
or dobutamine. In case of refractory shock inspite of use of
pressors of 20 microgram/kg/mt steroids may be tried.
3. Septic shock should be suspected based on intrapartum risk
factors for sepsis, core axillary mismatch and results of sepsis
screen.
 2-MANAGEMENT of Cerebral Oedema
• Minimise cerebral edema
 Ventilation - to prevent apnoea and maintain PC02 of 25 - 30 mmHg
 Ensure adequate oxygenation
 Restrict fluid intake
 Mannitol/frusemide - if urine output is established
 3-MANAGEMENT OF KIDNEY FAILURE
Urine output is by itself not a reliable marker renal
parameters need to be monitored.
2.Fluid restriction is required once renal failure sets in. A
careful evaluation of electrolytes would direct the
fluid management.
3.Daily monitoring of urine output, urine specific gravity,
and body weight are adjuvant to basic care.
4.Rarely peritoneal dialysis is required in case of
persistent oliguria
Whole Body Hypothermia Selective Head Cooling
 DIFFERENTIAL DIAGNOSIS
 Drug depression - maternal drugs, GA
 Prematurity
 Trauma - tentorial tear
 Anaemia
 Neuromuscular disorder
 Infection
 Inborn error of metabolism - Pyridoxine Dependency
 Respiratory tract malformation
That’s a wrap

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