PowerPoint Presentation

Birth AsphyxiaDr.Anup John ThomasAssistant ProfessorDepartment of PediatricsMGMC&RI

2010 Guidelines for Neonatal Resuscitation

Techniques for Achieving Effective Ventilation(MR. SOPA)

NRP Video

Neonatal Evaluation and ResuscitationAPGAR ScoringA AppearanceP PulseG GrimaceA Activity R RespirationsTake the APGAR score at one minute and five minutes.

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APGAR Score

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APGAR Score

7-10 points - The newborn should be active and vigorous. Provide routine care.4-6 points - The newborn is moderately depressed. Provide stimulation and oxygen.0-3 points - The newborn is severely depressed and requires extensive resuscitation.

Apgar ScoreTotal Score = 10score 7-10normalscore 5-6mild birth asphyxiascore 3-4moderate birth asphyxiascore 0-2severe birth asphyxia

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Causes of Neonatal Mortality

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Asphyxia neonatorum is respiratory failure in the new-born, a condition caused by the inadequate intake of oxygen before, during, or just after birth.

DefinitionBirth asphyxia is defined as a reduction of oxygen delivery and an accumulation of carbon dioxide owing to cessation of blood supply to the fetus around the time of birth.

ESSENTIAL CRITERIA FOR PERINATAL ASPHYXIAAAP and ACOG

Profound metabolic or mixed acidemia (pH< 7.00) in umbilical cord blood Persistence of low Apgar scores less than 3 for more than 5 minutes Signs of neonatal neurologic dysfunction (e.g., seizures, encephalopathy, tone abnormalities) Evidence of multiple organ involvement (such as that of kidneys, lungs, liver, heart and intestine).

EtiologyPathologically, any factors which interfere with the circulation between maternal and fetal blood exchange could result in the happens of perinatal asphyxia. These factors can be maternal factor, delivery factor and fetal factor.

EtiologyHigh Risk FactorsMaternal factor: hypoxiaAnemiaDiabetesHypertensionSmokingNephritisheart diseasetoo old or too youngDelivery condition:Abruption of placentaplacenta Previaprolapsed cordpremature rupture of membranesFetal factor:Multiple birthcongenital or malformed fetus

Pathophysiology When fetal asphyxia happens, the body will show a self-defended mechanism which redistribute blood flow to different organs called inter-organs shunt in order to prevent some important organs including brain, heart and adrenal from hypoxic damage.

PATHOPHYSIOLOGYHypoxiaDiving sea reflexShunting of blood to brain adrenals & heartAway from lungs, kidney gut & skin

NON BRAIN ORGAN INJURY

PATHOPHYSIOLOGYAsphyxia continuesShunting within the brainAnterior Circulation SuffersPosterior Circulation Maintained

CEREBRAL CORTICAL LESIONS

PATHOPHYSIOLOGYHypoxia ABRUPT & SEVERENo time for compensationTHALAMUS & BRAIN STEM INJURY, CORTEX SPARED

Pathophysiology(I) Hypoxic cellular damages:Reversible damage(early stage): Hypoxia may decrease the production of ATP, and result in the cellular functions . But these change can be reversible if hypoxia is reversed in short time.

b. Irreversible damage: If hypoxia exist in long time enough, the cellular damage will become irreversible that means even if hypoxia disappear but the cellular damages are not recovers. In other words, the complications will happen.

Pathophysiology(II)Asphyxia development:Primary apneabreathing stops but normal muscular tone or hypertonia, tachycardia (quick heart rate), and hypertension Happens early and shortly, self-defended mechanismNo damage to organ functions if corrected quickly

b. Secondary apnea Features of severe asphyxia or unsuccessful resuscitation, usually result in damage of organs function.

PATHOLOGYTarget organs of perinatal asphyxiaKidney 50%Brain 28%Heart 25%Lung 23%Liver, Bowel, Bone marrow < 5%

Clinic manifestationsFetal asphyxiafetal heart rate: tachycardia bradycardia fetal movement: increase decreaseamniotic fluid: meconium-stained

AssessmentFetal heart rate slowsElectronic fetal monitoring persistent late deceleration of any magnitude persistent severe variable deceleration prolonged bradycardia decreased or absent beat-to-beat variabilityThick meconium-stained amniotic fluidFetal scalp blood analysis show pH less than 7.2

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Effects of AsphyxiaCentral nervous systemintracranial hemorrhagehypoxic-ischemic encephalopathy

CardiovascularBradycardiaArrhythmiaHypotensionmyocardial ischemia

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Effects of AsphyxiaRespiratory systemApnea

KUBacute tubular necrosis

Gastrointestinal tractnecrotizing enter colitis

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Effects of AsphyxiaHematologyDisseminated intravascular coagulation

MetabolicHypoglycemiaHyperglycemiaHypocalcemiahyponatremia

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CLASSIFICATION OF HIE (LEVENE)MildModerateConsciousnessToneSeizureSucking / Resp.IrritableHypotoniaNoPoor SuckLethargyMarkedYesUnable to suck

FeatureSevereComatoseSevereProlongedUnable to sustain spont. Resp.

SPECIFIC MANAGEMENTPREVENT FURTHER BRAIN DAMAGEMaintain temperature, perfusion, oxygenation & ventilationCorrect & maintain normal metabolic & acid base milieuPrompt management of complications

Management of a neonate with perinatal asphyxia Delivery room care Obtain arterial cord blood for analysisTransfer the infant to NICU if Apgar score 0-3 at 1 minute Prolonged bag and mask ventilation (60 seconds or more ) Chest compression

Management of a neonate with perinatal asphyxia NICU care 1. Maintain normal temperature Avoid Hyperthermia 2. Maintain normal oxygenation and ventilation Maintain saturations between 90% and 95% and avoid any hypoxia or hyperoxia Avoid hypocarbia, as this would reduce the cerebral perfusionAvoid hypercarbia, which can increase intracranial pressure and predispose the baby to intracranial bleed.

Management of a neonate with perinatal asphyxia NICU care 3. Maintain normal tissue perfusion Start intravenous fluid Administer dobutamine (preferred) or dopamine to maintain adequate cardiac output, as required. Do not restrict fluid as this practice may predispose the babies to hypo perfusion. Restrict fluid only if there is hyponatremia (Sodium