Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Birth asphyxia

54,868 views

Published on

A simple guide to Perinatal Asphyxia and HIE

Published in: Health & Medicine
  • Hi there! I just wanted to share a list of sites that helped me a lot during my studies: .................................................................................................................................... www.EssayWrite.best - Write an essay .................................................................................................................................... www.LitReview.xyz - Summary of books .................................................................................................................................... www.Coursework.best - Online coursework .................................................................................................................................... www.Dissertations.me - proquest dissertations .................................................................................................................................... www.ReMovie.club - Movies reviews .................................................................................................................................... www.WebSlides.vip - Best powerpoint presentations .................................................................................................................................... www.WritePaper.info - Write a research paper .................................................................................................................................... www.EddyHelp.com - Homework help online .................................................................................................................................... www.MyResumeHelp.net - Professional resume writing service .................................................................................................................................. www.HelpWriting.net - Help with writing any papers ......................................................................................................................................... Save so as not to lose
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
  • Hello! I have searched hard to find a reliable and best research paper writing service and finally i got a good option for my needs as ⇒ www.HelpWriting.net ⇐
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
  • If you have a few spare minutes per day, we have some very exciting news for you! ★★★ https://t.cn/A6Z4M4sy
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
  • The TRUTH... ●●● https://url.cn/5ODOLl4
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
  • I was overwhelmed by all the love and support really. It's such a powerful program and the fact that you make it so personal and affordable is incredible. You are doing a beautiful thing Shaye. It makes me tear up just thinking about the love you are pouring out over this community. ■■■ http://scamcb.com/bulimiarec/pdf
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here

Birth asphyxia

  1. 1. Perinatal Asphyxia & Hypoxic Ischemic Encephalopathy DR. M. S. PRASAD 7/6/2016 1
  2. 2. Definitions • Anoxia: – Complete lack of oxygen. • Hypoxia: – Decreased availability of oxygen • Hypoxemia: – Decreased arterial concentration of oxygen. • Ischemia: – Insufficient blood flow to cells or organ resulting in interrupted metabolism and death of the cell or organ affected. 7/6/2016 2
  3. 3. Perinatal Asphyxia (PA) Perinatal asphyxia, neonatal asphyxia, or birth asphyxia is the medical condition resulting from deprivation of oxygen to a newborn infant that causes physical harm, mainly to the brain. 7/6/2016 3
  4. 4. Definition The Perinatal Asphyxia may be defined as hypoxic insult to the fetus severe enough to cause metabolic acidosis, neonatal encephalopathy, and multiorgan system dysfunction. 7/6/2016 4
  5. 5. Perinatal Asphyxia The NNF of India has defined asphyxia as “gasping or ineffective breathing or lack of breathing at one minute of life” 7/6/2016 5
  6. 6. AAP Criteria • Umbilical artery blood pH < 7.0. • 5 minute apgar score < 3, • Neonatal Encephalopathy manifesting as seizures, hypotonia or coma in the immediate neonatal period. • Evidence of multiorgan dysfunction. 7/6/2016 6
  7. 7. Birth Asphyxia • Birth Asphyxia = Perinatal Asphyxia = Neonatal Asphyxia. • Incidence: 1 – 6 /1000 live births. 7/6/2016 7
  8. 8. Perinatal Asphyxia • Perinatal Asphyxia is the leading cause of neonatal death (along with infection, prematurity and LBW). • It is the leading cause of neurodevelopmental disability in children. • The term perinatal asphyxia is preferred to Birth Asphyxia as asphyxia may occur before, during and after birth. 7/6/2016 8
  9. 9. Why it is important? 7/6/2016 9
  10. 10. 10 Primary cause of death: NNPD Cause Deaths (n = 1800) Prematurity 27 % Infection 17 % Perinatal hypoxia 29 % Malformation 09 % Other causes 18 % 7/6/2016
  11. 11. 11 4 million newborn deaths – Why? almost all are due to preventable conditions 7/6/2016
  12. 12. 12 Causes of neonatal death (n=258) Not established 14.7% Others 10.7% Birth asphyxia 20.9% Infection 33.2% Prematurity 15.2% Congenital malformation 5.4% Others: Hypothermia, RD, Jn, Pulm. Haemorrhage, Seizure etc. ICMR 2006 7/6/2016
  13. 13. Physiology of Asphyxia When babies become asphyxiated (either in utero or after delivery), they undergo a well defined sequence of events, ie primary apnea followed by secondary apnea. 7/6/2016 13
  14. 14. Primary Apnea • When an infant is deprived of oxygen, an initial brief period of rapid breathing occurs. • If the asphyxia continues, the respiratory movements cease, the HR begins to fall, muscle tone gradually diminishes, and the infant enters a period of apnea known as primary apnea. • The initial steps will induce breathing. 7/6/2016 14
  15. 15. Secondary Apnea • If the asphyxia continues, the infant develops deep gasping respiration, the HR continues to decrease, the BP begins to fall, and the infant becomes nearly flaccid. • The respirations become weak and weaker until the infant takes a last gasp and enters a period of apnea called secondary apnea. • During secondary apnea the infant does not respond to initial steps. 7/6/2016 15
  16. 16. Effects of PA • Hypoxic damage to most of the infant's organs (heart, lungs, liver, gut, kidneys), but brain damage is of most concern and perhaps the least likely to heal. • In more pronounced cases, an infant will survive, but with damage to the brain manifested as either mental or physical disability, such as developmental delay or intellectual disability, or physical, such as spasticity 7/6/2016 16
  17. 17. Effects (continued) • Mental Disability: – Developmental Delay, – Intellectual Disability. • Physical Disability: – Spasticity, – Motor Deficit. • Cerebral Palsy. 7/6/2016 17
  18. 18. What to do? Baby Cried immediately after birth Yes Routine Care No NNR 7/6/2016 18
  19. 19. Routine Care • Dry, • Provide warmth, • Clear airway, if needed, • Initiate Breastfeeding, and • Monitor Breathing, Heart-Rate and Color. 7/6/2016 19
  20. 20. NNR (Neonatal Resuscitation) • Initial Steps, • Assisted Ventilation, – Bag & Mask, – Endotracheal Intubation. • Chest Compression, • Medication. 7/6/2016 20
  21. 21. Global Hypoxic Ischemic Insult Global Hypoxic Ischemic Insult of Brain Hypoxic Ischemic Encephalopathy (HIE) 7/6/2016 21
  22. 22. Hypoxic-Ischemic Encephalopathy (HIE) • The HIE refers to the characteristic neurological manifestations in term and near-term newborns which develop soon after birth following perinatal asphyxia. • Incidence: 3-5 per 1000 full-term live births. • Half of them progress to moderate to severe HIE. 7/6/2016 22
  23. 23. HIE • The encephalopathy resulting from hypoxia (low oxygen) and ischemia (low blood flow) mainly to the brain. • The HIE refers to the characteristic neurological manifestations in term and near- term newborns which develop soon after birth following perinatal asphyxia. 7/6/2016 23
  24. 24. Pathology • Lack of adequate breathing  lack of oxygen supply to heart  Inability of heart to pump adequate blood  hypoxia + ischemia to organs (particularly brain). • Longer Arrest  Infarct  Brain Death. 7/6/2016 24
  25. 25. Brain Regions vulnerable for damage • Hippocampus, • Purkinje Neurons in Cerebellum, • Basal Ganglia, and • Brain-stem. 7/6/2016 25
  26. 26. Pathogenesis • Poorly understood, • Hypoxic Ischemic insult can damage periventricular white matter tracks. 7/6/2016 26
  27. 27. Etiology • Perinatal Asphyxia, • Drowning, • Airway Obstruction, • Trauma, • Hanging, • Infection 7/6/2016 27
  28. 28. Outcome • Immediate outcome: Death. • Late outcome (if survived): –Cerebral Palsy, –Developmental Delay, –Mental Retardation. 7/6/2016 28
  29. 29. Further Outcome (complications) • Death, • Vegetative State, • Severe Disability, • SIRS, • Multiple Organ Dysfunction Syndrome. 7/6/2016 29
  30. 30. Etiology of Perinatal Asphyxia • Multifactorial, • Antepartum: – Placental Insufficiency. • Intrapartum, and • Postpartum period. 7/6/2016 30
  31. 31. Placental Insufficiency • Impaired maternal oxygenation, • Decreased blood flow from the mother to the placenta, • Decreased blood flow from placenta to fetus, • Impaired gas exchange across placenta or fetal tissues, • Increased fetal oxygen requirement. 7/6/2016 31
  32. 32. Impaired Maternal Oxygenation • Anemia, • Pulmonary, or • Cardiac, or • Neurologic disease in mother. 7/6/2016 32
  33. 33. Decreased Blood Flow from the mother to the placenta • Maternal Infection, • Shock, • Dehydration, and • Hypotension. 7/6/2016 33
  34. 34. Decreased Blood Flow from the Placenta to the Fetus • Placental abruption, • Cord Prolapse, • Cord Entanglement, • True Knot, • Cord Compression, • Abnormality of the umbilical vessels. 7/6/2016 34
  35. 35. Impaired Gas Exchange across placenta or fetal tissues • Maternal Hypertension, • Vascular Disease, • Diabetes, • Drug Abuse, • Post-Maturity, • Placental Calcification, infarct or fibrosis. 7/6/2016 35
  36. 36. Increased Fetal Oxygen Requirement • Fetal Anemia, • Fetal Infection, or • IUGR 7/6/2016 36
  37. 37. Causes • Before Birth (Maternal Causes). – Inadequate oxygenation of maternal blood. – Low Maternal Blood Pressure. • At Birth (Fetal or Neonatal Causes). 7/6/2016 37
  38. 38. Inadequate Oxygenation of maternal blood • Hypoventilation during anesthesia, • Cyanotic Heart Disease, • Respiratory Failure, • CO Poisoning. 7/6/2016 38
  39. 39. Low Maternal BP • Acute Blood Loss, • Spinal Anesthesia, • Great Vessels compression by gravid uterus. • Uterine Tetany (oxytocin induced) 7/6/2016 39
  40. 40. Low Maternal BP (continued) • Premature separation of placenta, • Compression of knotting of umbilical cord, • Placental insufficiency due to toxemia or postmaturity. 7/6/2016 40
  41. 41. At Births • Failure of oxygenation: – Fetal Cyanotic Congenital Heart Disease, – Severe Pulmonary Distress. • Severe Anemia – Severe Hemorrhage, – Hemolytic Disease. • Shock 7/6/2016 41
  42. 42. Shock • Sepsis, • Massive Blood Loss, • Intra-Cranial Hemorrhage, • Adrenal Hemorrhage. 7/6/2016 42
  43. 43. Pathophysiology Hypoxia Ischemia Anaerobic Metabolism Lactate Inorganic Phosphate 7/6/2016 43
  44. 44. Vulnerable Organ • Brain, • Neonatal Brain has very high requirements for oxygen and baseline blood flow. • Hypoxic insult to the fetus initiates diving seal reflex. 7/6/2016 44
  45. 45. Diving Seal Reflex • Shunting of blood to brain, heart and adrenals and away from lungs, gut, kidneys, liver, spleen and skin, in an attempt to maintain perfusion to more vital organs. 7/6/2016 45
  46. 46. Pathophysiology • Accumulation of excitatory and toxic amino acids (glutamate) in the damaged tissue. • Increased production of free radicals and NO in damaged tissue. 7/6/2016 46
  47. 47. Pathophysiology Accumulation of AA (glutamate) in damaged tissue. Increased amount of intracellular Na & Ca Tissue Swelling Cerebral Oedema 7/6/2016 47
  48. 48. Fetal Hypoxia & Ischemia Term Cortical Atrophy Preterm 1. PVL 2. IVH 7/6/2016 48
  49. 49. Biochemical Changes • Hypoxia impairs cerebral oxidative metabolism   – Increase in lactate,, – Fall in pH (acidosis), and – Decrease in ATP level. • Acidosis   Myocardial Depression   Reduced Cardiac Output. 7/6/2016 49
  50. 50. Acidosis Myocardial Depression Reduced Cardiac Output Hypotension Reduced Blood-Flow to Brain Ischemia + Hypoxia 7/6/2016 50
  51. 51. Energy Failure Impaired ion-pumps Intracellular Na++, Cl-, H2O, Ca++ Extracellular K+, Glutamate, Aspartate 7/6/2016 51
  52. 52. Reperfusion of ischemic tissue Generation of oxygen free radicals Neuronal Damage 7/6/2016 52
  53. 53. Brain Damage • Term Newborn: –Cerebral Cortex, and –Basal Ganglia • Preterm Newborn: –Periventricular White Matter. 7/6/2016 53
  54. 54. Circulatory Response of Fetus • Increased shunting through Ductus Venosus, Ductus Arteriosus and Foramen Ovale. • Inadequate perfusion of periventricular white matter    PVL (periventricular leucomalacia). 7/6/2016 54
  55. 55. Causes of Hypotension • Myocardial Dysfunction, • Capillary Leak Syndrome, and • Hypovolemia. 7/6/2016 55
  56. 56. Clinical Features 7/6/2016 56
  57. 57. Clinical Features • Perinatal Asphyxia (no breathing or difficult breathing at birth). • IUGR, • MSAF (Fetal Distress), Meconium Stained Amniotic Fluid • Hypotonic State. 7/6/2016 57
  58. 58. Clinical Features • Mild HIE, • Moderate HIE, and • Severe HIE. 7/6/2016 58
  59. 59. Mild HIE • Transient abnormalities, • Poor Feeding, • Irritability, or excessive crying, or sleepiness, • Slightly increased muscle-tone, • Brisk DTR. 7/6/2016 59
  60. 60. Moderate HIE • Lethargic, • Significant hypotonia, • Diminished DTR, 7/6/2016 60
  61. 61. Moderate HIE (continued) • Sluggish or absent Grasp, Moro and Sucking Reflexes. • Occasional Apnea, • Seizures. 7/6/2016 61
  62. 62. Severe HIE • Coma, • Difficult breathing requiring ventilator support, • Decreased Tone, • Depressed DTR, • Absent neonatal reflexes. 7/6/2016 62
  63. 63. Severe HIE (continued) • Disturbance of ocular motions, • Loss of “doll’s eye” movement, • Dilated and fixed pupils with poor LR, • Seizures, • Full & bulging AF, 7/6/2016 63
  64. 64. Investigations • No confirmatory laboratory tests to diagnose perinatal asphyxia, • Tests are helpful to assess the severity of brain injury and to monitor the functional status of systemic organs. 7/6/2016 64
  65. 65. Investigation • Blood Sugar, • ABG, • SpO2 • US in preterm, • Serum Electrolytes, • Diffuse mediated MRI, • CT, • aEEG 7/6/2016 65
  66. 66. Investigations (continued) • Renal Function Tests: – Blood Urea, – Serum Creatinine. • Liver Function Tests, • Coagulation Profile – PT and – PTT. 7/6/2016 66
  67. 67. Management 7/6/2016 67
  68. 68. Goal of Treatment • Maintain TABC, • Optimize Cardiac Output and Cerebral Perfusion, • Maintain SpO2 • Treat / Prevent Hypoglycemia, 7/6/2016 68
  69. 69. Principles of Management • Supportive Therapy, • Anticonvulsants, • Cerebroprotective interventions, and • Monitoring. 7/6/2016 69
  70. 70. Supportive Therapy • IV Fluid: – 10% Dextrose, – 60 ml/kg/day. • Treat Hypotension: – Dobutamine, and – Dopamine. • Temperature: – Cool Therapy (33-340 C) 7/6/2016 70
  71. 71. Supportive Therapy (continued) • Glucose: – Treat hypoglycemia, – Maintain BS at 75 to 100 mg/dl. • Calcium: – Calcium level should be kept in the normal range (9 – 11 mg/dl) 7/6/2016 71
  72. 72. Anticonvulsants • Control Seizures: – Phenobarbitone: • Loading Dose: 20 mg/kg slowly • Maintenance Dose: 5 mg/kg/day – Phenytoin as a second line drug – Lorazepam • (0.05-0.1 mg/kg/dose I. V.) for seizures not responding to Phenobarbitone and/or Phenytoin. 7/6/2016 72
  73. 73. Cerebroprotective Interventions • Therapeutic Hypothermia (cool therapy), • Free Radical Scavengers, • Antagonists of excitotoxic amino acids, • Calcium Channel Blockers. 7/6/2016 73
  74. 74. Caution! • Drugs like mannitol, steroids, and furosemide used in past are no longer recommended. 7/6/2016 74
  75. 75. Treatment • Selective Cerebral or Whole Body Therapeutic Hypothermia (Cool Therapy), • Control Seizures, – Phenobarbitone/Phenytoin/Midazolam. • Mechanical Ventilation, (or ECMO), • Volume Expansion, • Pressure Amines. 7/6/2016 75
  76. 76. Monitoring • Regular clinical assessment, • Biochemical monitoring, • SpO2. 7/6/2016 76
  77. 77. Clinical Assessment • Respiratory Rate, • Heart Rate, • CRT, • BP • Temperature, • Oxygen Saturation, • Urine Output. 7/6/2016 77
  78. 78. Prognosis • Early Treatment   Better Prognosis. • Bad Prognosis: – Initial cord or initial blood pH < 6.7, – Low Apgar Score (0-3), – High Base Deficit, – Decrebrate Posture, – Lack of spontaneous activity. 7/6/2016 78
  79. 79. Mortality • Moderate Encephalopathy: –10 to 30% • Severe Encephalopathy: –Mortality: 60% –Disability: 100%. 7/6/2016 79
  80. 80. Long Term Handicaps • Developmental Delay, • Cerebral Palsy, • Microcephaly, • Seizures • Blindness, • Deafness, • Problems with cognition, memory, fine motor skills and behaviour. 7/6/2016 80
  81. 81. Staging of HIE Stage-I Stage-II Stage-III Level of consciousness Hyper-alert Lethargic Stupor/coma Muscle Tone Normal Hypotonic Flaccid Posture Normal Flexion Decerebrate DTR/Clonus Hyperactive Hyperactive Absent Myoclonus Present Present Absent Moro Reflex Strong Weak Absent 7/6/2016 81
  82. 82. HIE Staging Stage-I Stage-II Stage-III Pupils Dilated Constricted Unequal Seizures None Common Decerebrate Duration < 24 hrs 24 hrs-14 d Days & Weeks Outcome Good Variable Death or Severe Deficit EEG Normal Low Voltage Bursts 7/6/2016 82

×