Asphyxia of the newborn

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Definition
WHO: Asphyxia is incapacity of newborn

to begin or to support of spontaneous respiration after delivery due to breaching of oxygenation during labor and delivery India: Asphyxia is absent or ineffective respiration of newborn of 1 minute old with Apgar score less than 4

Definition
Great Britain: Asphyxia is critical

insufficiency of oxygen in fetus during delivery so severe that leads to development of metabolic acidosis and depression of spontaneous respiration

Definition
Canada: Asphyxia is breach of gas

exchange when hypoxia and hypercapnia, and considerable metabolic acidosis occur

Definition
Australia: Asphyxia is a state with
mother has complications in perinatal

period that decrease provision with oxygen and leads to acidosis functional violation minimum 2 organs due to acts of acute hypoxia

Definition
Ukraine: Asphyxia of newborn as a

nosological form is conditioned by causes when fetus out and find (connect) with severe maternal-placental and (or) umbilical flow leads to increasing of oxygen approach to fetus tissue and hypoxia development

Definition

Asphyxia

Asphyxia: means to be pulse less, but more useful is

a definition of impaired or interrupted gas exchange. These situations can take place: a. Intrauterine: the gas exchange depends on the function of placenta, and the blood-flow in the umbilical vessels. b. Intrapartum c. Postnatal: after delivery the gas exchange takes place in the pulmonary vesicles or alveoli and depends on the function of the heart, lungs and brain.

Causes of Asphyxia
Fetal hypoxia:
Mother: hypoventilation during anesthesia,

cyanotic heart disease, respiratory failure or carbon monoxide poisoning. Low maternal blood pressure as a result of the hypotension that may compression of the vena cava & aorta by the gravid uterus Inadequate relaxation of the uterus to permit placental filling as a result of uterine tetany caused by excessive administration of oxytocin

Fetal hypoxia (cd):

Premature separation of the placenta; placenta previa Impedance to the circulation of blood through the

umbilical cord as a result of compression or knotting of the cord Uterine vessel vasoconstriction by cocaine, smoking Placental insufficiency from numerous causes, including gestosis, eclampcia, toxemia, postmaturity Extremes in maternal age (< 20 years or >35 years) Preterm or postterm gestation.

Causes of Asphyxia
Intrapartus asphyxia: More frequently inadequate obstetric aid Using focerps, vacuum extraction,

cresteller, cesaring cection Trauma: narrow pelvis, presentation Extremely rapid or prolonged labor Multiple gestation Drags depression of CNS: anaesthesia, sedatics & analgetics Meconium stained amniotic fluid

Causes of Asphyxia
Postnatal hypoxia: Anemia severe enough to lower the oxygen

content of the blood to a critical level due to severe hemorrhage or hemolytic disease Shock severe enough to interfere with the transport of oxygen to vital cells from adrenal hemorrhage, intraventricular hemorrhage severe enough to age, overwhelming infection or massive blood loss

Postnatal hypoxia (cd):

A deficit in arterial oxygen saturation

resulting from failure to breathe adequately postnatally due to a cerebral defect, narcosis, or injury Failure of oxygenation of an adequate amount of blood resulting from of cyanotic congenital heart disease of deficient pulmonary function

Gas exchange

Cell pathology

Cell pathology

Cell pathology

Cell pathology

Cell pathology

Cell pathology

Heart rate, breath movements and blood pressure in fetus during primary and secondary apnea

Virginia Apgar

Apgar Score of the Newborn

SIGNSCORE Heart rate

0 1 Absent <100 beats/min

2 >100

Respiratory effort Absent Weak,irregular Strong cry Muscle tone Flaccid Some flexion Well Reflex irritability (response to catheter in nostril) No Grimace Cough or sneeze Skin colour Blue, pale extremities blue pink

CRITERIAS OF SEVERE ASPHYXIA:

Severe metabolic or mix acidosis pH

7.00 in arterial blood of umbilical vessels Assessment by Apgar is 0-3 during more than 5 minutes Neurological symptoms such as general hypotonic, lethargy, coma, seizures Damage of vital organs (lungs, heart and other) in fetus or newborn

Acute complications associated with Asphyxia

hypotension hypoxic encephalopathy seizures persistent pulmonary hypertension hypoxic cardiomyopathy ileum and necrotizing enterocolitis acute tubular necrosis adrenal hemorrhage and necrosis hypoglycemia polycytemia disseminated intravascular coagulation

Brain Edema

Periventricular leukomalacia

Morphologic substrate of Cerebral palsy due to Asphyxia

DIAGNOSIS
Clinical symptoms
Metabolic derangement Renal and/or cardiac failure

Assessment of the brain:

a.. EEG EEG is useful particulary in the

asphyxiated term newborn.

DIAGNOSIS
Serial recordings are almost necessary.
Low voltage. Burst-suppression patterns or electrical

inactivity are associated with bad prognosis. Rapid resolution of EEG abnormalities and/or normal interictal EEG are associated with a good prognosis. b. Ultras onography: Ultrasound can be useful in premature newboms but is of more limited value in the term newborn. c. Computed tomography: CT is of major value both acutely during the neonatal period and later in childhood. The optimal timing of CT scanning is between 2 and 4 days.

DIAGNOSIS
I.

Intrauterine assessment A. Ultrasound and Doppler technique: Ultrasound: to measure the growth of the fetus. For this reason it is important have a reliable gestational age. Early during pregnancy an ultrasound will be done to date the fetus. This method safer than common clinical methods. The growth retarded fetus is in a great risk of developing asphyxia. Doppler techniques: to measure the blood flow in the umbilical vessels or aorta. A low flow or decreasing flow indicates a fetus in risk of asphyxia.

DIAGNOSIS
B.Electrofysiological:
Severe pathological fetus heart rate will lead

to cessation of the delivery with Caesarean section. Fetal heart rate: Episodes of bradycardia can be dangerous and lead to brain damage. The problem is to do this type of measurement during long periods and on every pregnant woman

DIAGNOSIS
II. Extrauterine assessment
C. Biochemical -

C blood sample drawn from the umbilical artery is an ideal way to evaluate whether an intrapartum asphyxia exist or not. Low pH (< 7, 00) indicates the intrapartum asphyxia. PC02 and P02 will also be deranged as you have a diminished gas exchange. The low pH is the result of an increased level of H+ and lactate.

EEG

ABC resuscitation
A- Airways (maintenance of passable

ness of airway) B- breathing (stimulation of breathing) C- circulation (to support of circulation) D-drug

ABC resuscitation
Step A- immediately after delivery the

infants head should be placed in a neutral or slightly extended position Rolled towel under the shoulders

Step A- immediately after delivery the infants head should

be placed in a neutral or slightly extended position

And airway established by clearing the mouth, then the nose by rubber bag

If meconium is present in amniotic fluid, after sucking of mouth and nose we must suck a pharynx by tube after laryngoscopes

If it is inadequate we must use step B. At first the tactile stimulation should be given to newborn, for example- gentle flicking of the feet or heel

ABC resuscitation
or rubbing of the back

If these measures are inadequate, mechanical ventilation should be initiated, using mask and bag ventilation

If ventilation is adequate supplemental oxygen may be given to improve heart rate or skin colour

If mechanical ventilation does not improve the respiration, heart rate or colour skin, the following step is C-circulation. At first the assessment of heart rate is necessary

If heart rate is less than 60 beats/minute, or between 60 and 80 beats and is not improving, cardiac compression is a lower on/third of sternum

Chest compressions with two fingers

ABC resuscitation
Your big fingers must be lie on the sternum, other finder should lie

under the back of newborn

ABC resuscitation
If heart rate is less then 80 beats per minute the cardiac

compression should be continued. If heart rate is 80 beats per minute or more the cardiac compression should be stop .

Brain death
The clinical diagnosis of brain death is made on the basis of - coma manifested by lack of response to pain, light, or auditory stimulation; - apnea confirmed by documentation of failure to breathe when pCO2 is greater then 60 mm Hg tested by 3 minutes; - absent bulbar movements and brainstem reflexes (including midposition or fully dilated pupils with no response to light or pain and with absent oculocephalic, caloric, corneal, gag, cough, rooting and sucking reflexes, flaccid tone and absence of spontaneous or induced movements (excluding activity mediated at the spinal cord level)

Different painless is possible

PROGNOSIS.
Prognosis is difficult because of the inability to

establish the precise extent and duration of cerebral insult and injury. At the time of delivery low delayed Apgar scores between 0 and 3 at 10, 15 and 20 minutes' of age are associated with significantly increased mortality and morbidity, e.g. cerebral palsy. The single most useful prognostic factor is the severity of the neonatal neurological syndrome.

HI brain injure is the most impotent consequence of perinatan Asphyxia

Leads to increase lactate, fall in pH, ATP,

glucose utilization, loss of cerebrovascular autoregulation Impairs ion pumps with accumulation Na,Cl,H2O, Ca intracellularly amino acid neurotransmitters (glutamate, aspartate) Generation of free radicals & leukotriens wich they overwhelm endogeneous scavenger mechanism Damage nucleic acids, lipids & proteins

HIE

Following lesions may be seen after moderate & severe Asphyxia

Focal or multifocal cortical necrosis (with

resultant cyatic encephalomalacia and/or ulegyria attenuation) Watershed infarcts is boundary zones between cerebral arteries in the pretermperiventicular leucomalacia Selective neuronal necrosis Necrosis of thalamic nuclei & basal ganglia (status marmoratus)

Clinic HIE (Learn Sarnat scale from

your methodical book)
Development during 6-24 hours in 50%

infants Apnea, RDS, progressive deterioration of CNS, coma, seizures, oliguria Brein stem dysfunction ( abnormalities of pupillary reactivity, loss of oculomotor & caloric response, loss of bulbar function Brain death

Whom I was delivered?