Asphyxia Neonatorum

Dr. Liza Chairani, SpA, Mkes FK UMP

OBJECTIVE
Know the definition, risk factor, diagnosis, and

management or asphyxia neonatorum

SKILL
Define perinatal asphyxia

Know the criteria to diagnose asphyxia

Define risk conditions that predispose the fetus

and neonate to asphyxia

DEFINITION
Prinatal asphyxia is an insult to the fetus or

newborn, due to: Lack of oxygen (hypoxia) and/or Lack of perfusion (ischemia) to various organ, and maybe associated with Lack af ventilation (hypercapnea)

INCIDENCE
1 % - 1,5 % of total live birth

< 36 week: 9 % > 36 week: 0,5 % 20 %: perinatal death

A. Anterpartum Conditions
Maternal Factors:

DM, Toxemia, Hypertension, Cardiac disease, Collagen vascular disease, Infections, Insoimmunization, Drug addiction Obstetric Factors: Plasenta Previa, Cord prolaps, Polihidramnion, Placenta insufficiency, Chorioamnionitis

B. Inpartum Conditions
Abnormal plasentation

Pricipitate or prolonged delivery

Difficult delivery Post term delivery Forceps or vacum delivery

C. Fetal or Neonatal Conditions

Prematurity

Respiratory distress syndrome

Meconium aspiration syndrome Sepsis, penumonia, hemolitic disease Cardiac or pulmonary anomalies

Neonatal Resucitation Equipment

1. Suction equipment Bulb syringe/mechanical suctioin and tubing, suction catheter 5F or 6F, 10 F, 12 F 8F feeding tube and 20 ml syringe meconium aspirator 2. Bag and mask equipment 3. Intubation equipment 4. Medication: epinephrine 1/10.000, isotonic crystaloid, naloxone hydrocloride, dextrose 40%, normal saline, umbilical vessel catetherization supplies 5. Miscellaneous: glove, radiant warmer, linens, stethoscope, oroharyngeal airway

HOW DOES THE BABY RECEIVE O2 BEFORE BIRTH ?

All O2 difuse across the placental membrane from

the mothers blood to the baby blood Only a small fraction of the fetal blood passed through the fetal lungs Alveoli is filled with fluid The blood vassels in the fetal lungs are markedly constricted Most of the blood flow through the ductus arteriosus into the aorta

After Birth:
No connection to the placenta

A baby get oxygen from the lung

The fluid in the a;veoli is absorbed into th elungs tissue and replace by air 2. The umbilica larteri and vein clamped increase systemic blood pressure 3. O2 increase in alveoli relaxation of blood vessel int the lung 4. The ductus arteriosus begin to consrtict more blood flow through the lungs O2 increase to tissues
1.

PATHOPHYSIOLOGY OF ANTERPARTUM ASPHYXIA

1. 2. 3. 4. 5.

Cardiac output is maintenaned early, but changes radically Selective vasoconstrictor to gut, kidneys, mucles, skin Pulmonary blood flow decrease by hypoxia and asidosis Respirationcenter is depressed Severe stage of asphyxia O2 decrease to the heart dan brain myocardial function decrease O2 decrease to the vital organ brain injury

APGAR SCORE
- assigned at 1 and 5 minute after birth - if < 7 every 5 minute 20 minute

Score Sign Heart rate Respirations 0 absent 1 < 100x/m Slow, irregular 2 > 100 x/m Good , crying

Muscle tone Reflex iritability

Colour

Limp No respones
Blue or pale

Some flexion Grimace

Pink body, blue extremities

Active motion Cough, sneeze, cry

Completely pink

INITIAL STEPS
Provide warm therapy

Positiom clear airway (as necessary)

Dry, stimulate, reposition Give oxygen (as necessary)

- free-flow O2 - tactile stimulation

Vigourus baby if: Strong respiratory eeforts Good musle tone Heart rate > 100/m

IF THE BABY IS NOT VOGOROUS DIRECT SUCTIONARY OF THE TRACHEA SOON AFTER DELIVERY
Free flow O2 throughout the suctioning procedure

Insert a laryngoscope and use a 12 F or 14 F

catheter to clear the mouth and posterior pharyx Attack the endotracheal tube to a suction source Apply suction as tube is slowly with drawn Repeat as necessary untli clear

POSITIVE PRESSURE VENTILATION

Indication: 1. apnea or gasping breath

2. heart rate: < 100 bpm 3. Persisten central cyanosis despite FI 02

100 % Use: 1. Flow inflating bag, volume 240-750 ml 2. self inflating bag Rate: 40-60 breath per minuter Pressure: 30-40 mmH2O and then decrease Mask: face mask (full term, preterm) Round Anatomical shape With cushioned rim

APPROPIATE PPV IS FOLLOWED BY:

Increase of the heart rate

Improved in color
Spontaneous breathing

CHEST COMPRESSION IF HR , 60 BPM DESPITE 30 MINUTER SECOND OF EFFECTIVE PPV

Provide by: - the tumb tecnique

- The two finger technique Place: on the externume above xyphoid Rate: 90 per minuter Ratio chest compresion to ventilator 3:1 Depth: 1/3 the depth of the chest

ENDOTRACHEAL INTUBATION
INDICATION:

1.
2. 3. 4. 5. 6. 7.

To suction meconium To improve ventilation in bag and mask ventilation in effective To coordinate ventilation and chest compression To administration medication such as ephinephrine When prolonged ventilation is needed Administer surfactant When congenital diaphragmatic hernia is suspected

EQUIPMENT
Endotracheal tube: uniform type, size 2,5 3,5 mm 2. Laryngoscope - small handle - blade handle no 1 = full term 0 = preterm 00 = extremelly preterm
1.

MEDICATIONS
Epinephrine Indication: HR < 60 bpm after 30 sec of PPV + chest compressions How: ET, umbilical vein Doze: 0,1-0,3 ml/kg of a 1:10.000 sol (UV) 0,3-0,5 ml/kg of a 1:10.000 sol (ET) Repeate every 3-5 minuters 2. IV normal saline/ ringer lactate 10 ml/kgBB
1.

3. Naloxone hydrocloride indication: respiratory depression caused by maternal narcotics (morphine, micpheridium, butorphanol tartrate): in 4 hours before delivery dose: 0,1 mg/kg via ET

SEQUALLAE OF BIRTH ASPHYXIA

Early Sequellae:

1. Metabolic: metabolic asidosis, inapropriater anti diuretic hormone secretion 2.Respiratory a. RDS: increse severity of RDS b. TTN c. Respiration of Meconium antenatally may lead to MAS 3. Cardiac: myocardial ischemia, PPHN, PDA

4. CNS: HIE 5. Renal inpairment: ATN 6. Hemathological: DIC 7. Gastrointestinal: NEC II. Later Sequalae Depend on the severity of asphyxia. Clinical severity of HIE is a better predictor of long outcome

DISCONTINUATION OF RESUSITION
Discontinuation of resusitation of despite all step

resucitation heart beat remain absent after 15 minute stop resucitation

HYPOXIC ISCHEMIC ENCEPHALOPATY (HIE)

Hypoxia

Ischemia
Clinical neurological syndrome Sarnat and sarnat classified HIE into 3 grade:

1. grade I (mild) 2. grade II (moderate) 3. grade III (severe)

Grade I HIE
Alternating periode of lethargy, iiritability,

hyperalertness, Jitterness Poor feeding Increased muscle tone, exaggerate deep tendon reflex increase heart rate Pupils: dilated No seizures symptomps resolver in 24 hour

Grade II
Letarghy

Poor feeding, depressed gag reflex

Hypotonia Low heart rate and pupillary constriction

indicating parasympathetic stimulation 50-70 % neonatues display seizures usually in the 24 hour after birth

Grade III
Neurological abnormality progressing:

Coma
Flacidity Absent reflexes Apne, bradycardia, hypotension Seizure are uncomon but if present they are

intractable

MULTIORGAN SYSTEM DYSFUNCTION THAT MAYBE CAUSED BY NEONATAL ASPHYXIA

Acute tubular necrosis: oliguria, hematuria,

polyuria Cardiomyopathy: hypotension PPH: tachypnea, hypoxemia

OTHER MULTIORGAN SYSTEM DYSFUNCTION

Hepatic necrosis: increasing ammonia, jaundice

Increasing AST/ ALT

NEC: distention, bloody stools Adrenal insufficiency: decreasing glucose,

decreaseing Na, decresing BP Inapproriate secretion of ADH: oliguria, Na

MANAGEMENT OF HIE
1.

2.

3. 4. 5. 6.

Prevention in the best management Timing is very crucial and a few minute of delayed can lead do death or life long suffering from handicap Maintain oxygenation and acid base balance start mechanical ventilation if necessary Monitor and maintain body temperature Correct and maintain caloric, fluid, electrolyte and glucose levels (D10% at 60 cc/kg/day)

7. Correct hypovolemia (whole blood) 8. Avoid fluid overload, hypertension, hyperviscocity 9. Administer phenobarbital for treatmen of seizurenes - Administer phenobarbital 20 mg/kg iv over 5 minute - Can be incresed in dose 5 mg/kg every5 minute until seizurenes are controled or until maximum dose 40 mg/kg is reached 10. No other therapeutic interventions have been proven helpful ie. Corticosteroid, furosemid etc

Alhamdullilah