Asphyxia Neonatorum

Dr. Julniar M Tasli, SpA(K) Dr. Herman Bermawi, SpA(K)

OBJECTIVE:
Know the definition, Risk factor, Diagnosis and management of asphyxia neonatorum

SKILLS
1.

2.
3.

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 of ventilation (hypercapnea)

INCIDENCE:

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

< 36 week : 9 % > 36 week : 0,5 %

20 % o perinatal death

A. Antepartum Conditions
a.

Matenal Factors: DM Toxemia Hypertension Cardiac disease Collagen vascular disease Infections Insoimmunization Drug addiction Obstetric Factor: Placenta Previa Cord prolaps PROM Polyhidramnion Placenta insuffeciency Chorioamnionitis

b.

B. Inpartum Conditions
1. 2. 3. 4. 5.

Abnormal plasentation Pricipitate or prolonged delivery Difficult delivery Post term delivery Forceps or vacum delivery

C. Fetal or neonatal conditions

1. 2. 3. 4. 5.

Prematurity Respiratry distress syndrome Meconium aspiration syndrome Sepsis, pneumonia, hemolitic disease Cardiac or pulmonary anomalies

NEONATAL RESUSCITATION EQUIPMENT

1.Suction Equipment Bulb Syringe/ mechanical suction and tubing, suction catheter 5F or 6 F, 10 F or 12 F 8 F feeding tube and 20 ml syringe meconium aspirator 2. Bag and mask equipment 3. Intubation equipment 4. Medications : Epinephrine 1/10.000 Isotonic crystaloid Naloxone hydrocloride Dextrose 40 % Normal saline Umbilical Vessel catetherization supplies 5. Miscellaneous Gloves, radiant warmer, linens, stethoscope, oropharyngeal airway

HOW DOES A BABY RECEIVE O2 ?

BEFORE BIRTH

All O2 difuse across the palcental membrane from the mothers blood to the baby blood Only a small fraction of the fetal blodood passed through the fetal lungs Alveoli is filled with fluid The blood vessels in the fetal lungs are markedly constricted Most of the blood flow through the ductus arteriosus into the aorta

After Birth:
+ Noconnection to the placenta + A baby get oxygen from the lung 1. The fluid in the alveoli is absorbed into the lungs tissue and replace by air 2. The umbilical arteri and vein clamped increases systemic blood presure 3. O2 in the alveoli relaxation of blood vessel in the lungs 4. The ductus arteriosus begin to constrict more blood flow trough the lungs O2 to tissues

PATHOPHYSIOLOGY OF ANTEPARTUM ASPHYXIA

1.

2.

3.

4. 5.

Cardiac output is maintenaned early, but changes radically Selective vasocontrictor to gut, kidneys, muscles, skin Pulmonary blood flow by hypoxia and asidosis Respiration center is depressed Severe stage of asphyxia O2 to the heart & brain - myocardial function O2 to the vital organ - brain injury

APGAR SCORE
Score
Sign Heart Rate Respiratons Muscle tone 0 Absent Limp 1 < 100/ m Some flexion 2 100/ m Active motion

Slow, irregular Good, crying

Reflex irritability
Colour

No response
Blue or pale

Grimace
Pink body, blue extremitas

Cough, sneeze,cry
Completely pink

- Assigned at 1 and 5 minute after birth

- If < 7 every 5 minute 20 minute

INITIAL STEPS
Provide warm therapy Position, clear airway (as necessary) Dry, stimulate, reposition Give oxygen (as necessary) - Free-flow O2 - Tactile stimulation

MECONIUM STAINNING
Vigourus baby if : - strong respiratory efforts - good muscle tone - heart rate > 100 / minute

IF THE BABY IS NOT VIGOROUS 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 catheher to clear the mouth & posterior pharynx Attack the endotracheal tube to a suction source Apply suction as tube is slowly with drawn Repeat as necessary until clear

POSITIVE PRESSURE VENTILATION

Indication: 1. Apnea or gasping breath 2. Heart rate < 100 bpm 3. Persistant central cyanosis despite FI O2 100% Use : 1. Flow inflating bag volume 240 750 mL 2. Self inflating bag Rate : 40 60 breath per minute Pressure : 30 40 am H2O and then Mask : - Face Mask : - Full term - Pre term - Round - Anatomical shape - With cushioned rim

APPROPRIATE PPV IS FOLLOWED BY :

Increase of heart rate Improved in color Spontaneous breathing

CHEST COMPRESSIONS IF HR < 60 BPM DESPITE 30 SECOND OF EFFECTIVE PPV

Provided by : - The thumb technique - The two finger technique Place : on the externum above xyphoid Rate : 90 per minute Ratio chest compreton to ventilator 3 : 1 Depth : 1/ 3 the depth of the chest

ENDOTRACHEAL INTUBATION
Indications : 1. to suction meconium 2. to improve ventilation in bag and mask ventilation in effective 3. To coordinate ventilation and chest compression 4. To administration medication such as ephinephrine 5. When prolonged ventilation is needed 6. Administer surfactant 7. When congenital diaphagmatic hernia is suspected.

EQUIPMENT
1. 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

MEDICATIONS
1. Epinephrine Indications : HR < 60 bpm after 30 sec of PPV and mother 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 1.0 mL / kg of a 1 : 10.000 sol ( ET ) Repeat every 3 5 minutes 2. IV normal saline / ringer lactate 10 h/ kgBB

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

SEQUALLAE OF BIRTH ASPHYXIA I. Early sequallae :

1. Metabolic a. Metabolic acidosis b. Inapropiate anti diuretic hormone secretion 2. Rerpiratory a. RDS : increase severity of RDS b. Transient tachypnoe of the new born c. Respiration of meconium antenatally may lead to MAS

3. Cardiac

a. myocardial ischemia b. Persistent pulmonary hypertention of the new born c. PDA 4. CNS : hypoxic ischemia encephalopathy (HIE) 5. Renal Inpairment : ATN 6. Hemathological : DIC 7. Gastrointestinal : NEC

II. Late Sequalance

Depend on the severity of asphyxia. Clinical severity of HIE is a better predictor of long outcome

DISCONTINUATION OF RESUCITATION Discontinuation of resucitation of despite all step resuscitation heart beat remain absent after 15 minute stop resuscitation

HYPOXIC ISCHEMIC ENCEPHALOPATHY (HIE)

Hypoxia - Ischemia - Clinical neurological syndrome Sarnat and Sarnat Classified HIE into 3 gradies 1. Grade I (mild) 2. Grade II (moderate) 3. Grade III (severe)
-

Grade I HIE
-

Alternating period of lethargy, irritability, Hyperalertness, jitteriness Poor feeding Increased muscle tone, exaggerated deep tendon reflex. Increase heart rate Pupils : dilated No seizures Symtomps resolver in 24 hour

Grade II HIE
-

Lethargy Poor feeding, depressed gag reflex Hypotonia Low heart rate and pupillary constriction indicating parasympathetic stimulation 50 70 % neonates display seizures usually in the first 24 hour after birth

Grade III HIE :

Neurological abnormality progressing : - Coma - Flacidity - Absent reflexes - Pupil : fixed, slight reactive - Apnea, bradycardia, hypotension - Seizzure 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 Persistent pulmonary hypertension : tachypnea, hypoxemia

OTHER MULTIORGAN SYSTEM

DYSFUNCTION
-

Hepatic necrosis : ammonia, jaundice, AST/ ALT NEC : distention, bloody stools Adrenal insufficiency : glucose, Na, BP Inappropiate 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 delay can lead to 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 ( D 10 % at 60 cc/kg/day )

7. Correct hypovolemia (whole blood) 8. Avoid fluid overload, hypertension, hyperviscocity 9. Administerb phenobarbital for treatment of seizzurnes - Administer phenobabital 20 mg/kg iv over 5 minute - can be increased in dose 5 mg/kg every 5 minute until seizurnes are controlled or until maximum dose if 40 mg/kb is reached 10. No other theraoeutic interventions have been proven helpful ie. Corticosteroids, prophylactic phenobarbital, furosemite, manitol, etc

TERIMAKASIH