Nucleated Red Blood Cell Counts in Term Neonates with Umbilical Artery pH 7.

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Sean C. Blackwell, M.D.,1 Jerrie S. Refuerzo, M.D.,1 Sonia S. Hassan, M.D.,1 Honor M. Wolfe, M.D.,1 Stanley M. Berry, M.D.,1 and Yoram Sorokin, M.D.1

ABSTRACT

The purpose of this study was to determine whether nucleated red blood cell (NRBC) counts are elevated in term neonates who have severe fetal acidemia at birth. The neonatal NRBC counts of term (gestational age 37 weeks) neonates with pathological acidemia were compared with those from control neonates who met the following criteria: gestational age 37 weeks, birth weight 2800 g, umbilical artery pH 7.25, and a 5-minute APGAR >7. Pathological acidemia was defined as an umbilical artery pH 7.0 and a base excess > 12 mEq/L. Twenty-six neonates met all inclusion criteria and were compared to 78 controls. The mean NRBC/100 WBC was 11.9 13.5 (range 0 to 45) for acidemic neonates compared to 3.9 2.9 NRBC/100 WBC (range 0 to 11) for control neonates [ p <0.001]. Our findings suggest that the onset of hypoxia-ischemia in pregnancies complicated by severe fetal acidemia often begins prior to the intrapartum period.
KEYWORDS: Nucleated red blood cell counts, fetal acidemia, pathological

acidemia

Fetal nucleated red blood cell (NRBC) production is primarily regulated by hypoxia-induced erythropoietin stimulation, but may also be induced by other factors including interleukin-6.1,2 Conditions associated with increased NRBC counts at birth include maternal diabetes,3,4 maternal tobacco use,5 preterm birth,6,7 fetal growth restriction,811 fetal anemia,12 intrauterine infection,1315 post-dates,16 meconium-stained amniotic

fluid,17 fetal hypoxia-ischemia,1719 and fetal neurological injury.2025 Animal studies suggest that NRBC counts do not increase until 4872 hours after an asphyxial insult.2628 It is this physiological time lag that has prompted interest in using NRBC counts in the peripheral blood to aid in the timing of hypoxia-induced fetal brain injury.2023 An umbilical artery pH value 7.00 has been suggested as the threshold for clinically sig-

American Journal of Perinatology, Volume 18, Number 2, 2001. Reprint requests: Dr. Blackwell, Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Hutzel Hospital, 4707 St. Antoine Boulevard, Detroit, MI 48201. 1Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Wayne State University, Detroit, Michigan. Copyright 2001 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662. 0735-1631,p;2001,18,02,093,098,ftx,en;ajp35580x.

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nificant or pathologic fetal acidemia.29,30 While an elevated umbilical blood gas base deficit indicates a metabolic component and thus a nonacute process, the exact duration of hypoxic-ischemic exposure remains unclear.31 In cases where there is an adverse outcome or fetal injury, data on the timing and chronicity of this insult may have important clinical and medico-legal implications.32,33 The purpose of this study was to examine whether NRBC counts are elevated in term neonates who suffer severe hypoxia-ischemia resulting in pathological acidemia at birth.

formed to determine a sample size of control pregnancies necessary to detect a 33% difference in NRBC counts between groups (1- = 0.8 and <0.05). Statistical analysis included the Students t-test and Chi-square where appropriate. A p-value <0.05 was considered significant.

RESULTS Over this 4-year study period, a total of 26 neonates met all inclusion criteria. The mean umbilical pH for this group was 6.90 0.12 (range 6.53 to 7.00), pCO2 90.4 18.3 (range 57 to 136), and base excess 18.1 4.9 (range 12.9 to 32.3). Table 1 describes the demographic and clinical characteristics of the study cases compared with 78 control pregnancies. Pregnancies complicated with pathological acidemia were more likely to have meconium-stained amniotic fluid (p <0.01) and be delivered by cesarean delivery (p <0.01). Figure 1 describes the NRBC count for both groups. Neonates with pathological acidemia had counts significantly increased compared to controls (11.9 13.5 NRBC/100 WBC [range 0 to 45] vs. 3.9 2.9 [range 0 to 11]; p <0.001). Of the 26 neonates with pathological acidemia, 12 (46%) had either respiratory failure requiring mechanical ventilation (n = 12), earlyonset seizures (n = 2), or major intraventricular hemorrhage (n = 1). There were no differences in the incidence of meconium-stained amniotic fluid or operative delivery for fetal indications between neonates with and without complications. Nor were there differences in mean pH, pCO2, base deficit, or NRBC between groups. Table 2 describes the clinical characteristics of the three patients with neurological morbidity. All underwent cesarean delivery for fetal indications and had NRBC counts >10/100 WBC. The one neonate who developed a grade 3 intraventricular hemorrhage (IVH) had no evidence of trauma, structural

METHODS A computerized perinatal database was used to identify patients delivered from Jan 1, 1994 to December 31, 1998 at term (gestational age 37 weeks) whose intrapartum course was complicated by pathological acidemia. Pathological acidemia was defined as an umbilical artery pH 7.0 with a base deficit > 12 mEq/L. Maternal and neonatal charts were reviewed for confirmation of the diagnosis, pertinent demographic and clinical data, and neonatal outcomes. Pregnancies in which measurement of NRBC counts within the first 24 hours of life was performed were included in the analysis. Exclusion criteria were multiple gestations, maternal diabetes, fetal anemia (Hct < 40), birth weight <10th percentile for gestational age, clinical chorioamnionitis, or fetal structural or chromosomal abnormalities. Neonatal NRBC counts were determined using a Wright stain blood smear and expressed as the number of NRBC per 100 white blood cells (NRBC/100 WBC). The demographic characteristics, clinical data, and neonatal NRBC counts of neonates with pathological acidemia were compared with those from control neonates who met the following criteria: gestational age 37 weeks, birth weight 2800 g, umbilical artery pH 7.25, and a 5-minute APGAR >7. A power analysis was per-

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Table 1 Comparison of the Clinical Characteristics Between Term Neonates with Pathological Acidemia Compared with Control Neonates
Variable Maternal age (y)* African-American race+ Gestational age (wk)* Meconium staining+ Cesarean delivery+
*Mean standard deviation. +Number (%).

Acidemia Group n = 26 25.6 6.5 23 (88.5) 39.7 1.8 12 (46.2) 20 (76.9)

Control Group n = 78 24.9 7 .9 63 (80.1) 39.4 1.8 9 (11.5) 12 (15.4)

P NS NS NS <0.01 <0.01

defect, or bleeding disorders. To evaluate for the possibility of an infectious stimulation of NRBC counts, the WBC counts and culture results of these study infants were reviewed. None of the infants evaluated in the study group had a positive culture (urine, blood, cerebral spinal fluid) or a WBC count >95th percentile.

DISCUSSION Our findings indicate that NRBC counts in neonates with pathological acidemia are significantly elevated when compared with a control population. Based on the known physiology of NRBC stimulation and production, this data suggest that fetuses

Figure 1 Distribution of NRBC counts (NRBC/100WBC) for neonates with pathological acidemia as compared with control neonates. Those with pathological acidemia had counts significantly elevated compared to controls (11.9 13.5 NRBC/100 WBC [range 0 to 45] vs. 3.9 2.9 [range 0 to 11]; p <0.001).

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Table 2 Clinical Characteristics of Patients with Pathological Acidemia at Birth Who Developed Major Neurological Complications
Umbilical Gases Demographics 20 yo G-4 P-1 27 yo G-4 P-3 29 yo G-2 P-1 GA (wk) 38 37 37 pH 6.53 6.57 6.98 pCO2 1.32 136 92 BE 32.3 31.5 13.2 NRBC Count 16 18 11

Outcome Seizure Seizure Grade 3 IVH

Umbilical artery blood gas parameters expressed as pH (units), pCO2 (mmHg), and base excess (BE) [mEq/L]. NRBC counts are expressed as NRBC/100 WBC.

who develop metabolic acidemia may also often suffer hypoxia-ischemia beginning at least 48 hours prior to the onset of labor. Our findings are consistent with data from clinical3436 and autopsy series3739 that biochemical fetal asphyxia40 and hypoxic-ischemic neurological injury2022 can occur prior to labor. The incidence of newborn complications in our study (46%) was consistent with results of other series.4147 We found that NRBC counts were not different between neonates with and without complications. To avoid the confounding effects of other maternal and/or fetal disease states, we excluded conditions known to affect NRBC counts such as fetal growth restriction, fetal anemia, clinical chorioamnionitis, and maternal diabetes. The definition of pathological acidemia, an umbilical pH 7.0 and a base excess > 12 mEq/L, was chosen because these values have been established in the literature and represent the threshold at which there is a substantial increased risk for neonatal complications.29,30 We included cases with a high base excess to ensure that neonates with metabolic component would be studied, rather than those with pure respiratory acidemia who are not a high risk for serious complications. We used the NRBC/100 WBC as the primary unit of measure of NRBC counts to be consistent with the majority of prior studies that use NRBC counts per 100 WBC as the unit of measure. Data from HanlonLundberg18 indicate a strong correlation between the two methods, and Phelan et al23 have validated the use of NRBC/100 WBC compared with ab-

solute NRBC counts in the timing of fetal brain injury. There is limited data on the relationship between NRBC counts and umbilical artery blood gas findings in term neonates. HanlonLundberg et al17 found that umbilical pH was inversely related to NRBC counts. In their prospective series of 1561 term neonates, there were 9 cases with pH <7.00. The mean NRBC count was 57.4 94.7 (range 2 to 276) for these neonates). This NRBC count was not significantly different from their control population (neonates with pH 7.307.39). In conclusion, the results of this study may improve our understanding of fetal metabolic reserve and explain why some fetuses are able to tolerate profound insults and avoid any permanent injury while others decompensate with much less observed stress. Future prospective studies with larger sample size and correlation with other biochemical markers or diagnostic studies are needed to determine the role of neonatal NRBC count measurement in clinical practice.

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