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Birth asphyxia
1

JOSEPH GASPER KIMARO, MD
DAR ES SALAAM, TZ

11/28/13
2

Introduction
Risk factors
Pathophysiology
Apgar scoring VS Birth Asphyxia
Management
Complications

11/28/13
Introduction
3

• Birth asphyxia occur when the fetus is deprived of

an adequate supply of oxygen at birth.
–

Failure to...
Introduction ct
4

BA may occur
1.
2.
3.

Immediately prior to(intrauterine),
During( intrapartum) or
Just after delivery...
Requirements for resp
5

• Intact neuro and resp apparatus
• Clear airway
• Adequate alveolar area
• Expanded alveoli with...
Why birth asphyxia?
6

10% NB need some

assistance
1% more adv
measures
717,000 (23%) NB
deaths related to
BA
Inciden...
Where Tz stands
7

2.9miln NB deaths in

2012
1.8mln in 10 countries
alone making up
for 2/3
Same account for
nearly 57...
Local findings
8

Hege et al 2012, Birth asphyxia , a major cause of neonatal mortality in Northern
Tanzania. (Journal Ame...
Risk factors for asphyxia..
9

ANTEPARTUM
–
–
–

maternal hypotension
Reduced maternal oxygenation
Inadequate placental pe...
…
10

• INTRAPARTUM
– Interruption of umbilical circulation
•
•
•

–

True not
Cord prolapse
Cord avulsion

Inadequate pla...
11


Traumatic deliveries





Abnormal maternal oxygenation







Breech delivery
Shoulder dystocia
Pulmonary e...
….
12

POSTNATAL





Persistent pulmonary hypertension of the newborn
Severe circulatory insufficiency (eg, acute blo...
…
13

When deprived of oxygen, either before or after

birth, infants demonstrate a well-defined sequence
of events leadi...
…
14

If such deprivation persists- primary apnea.




This stage is accompanied by a fall in heart rate and loss of
ne...
…
15

If oxygen deprivation and asphyxia persist


the infant will develop deep gasping respirations followed by
seconda...
…
16

Infants in secondary apnea




will not respond to stimulation
will not spontaneously resume respiratory efforts...
..
17

Clinically, primary and secondary apnea are

indistinguishable;



thus, secondary apnea must be assumed
resusci...
Apgar score Vs birth asphyxia
18

Apgar score-based on characteristics of






heart rate,
respiratory effort
, mus...
….
19

1-min As reflects the need for immediate

resuscitation.
5-min score



-effectiveness of resuscitative efforts...
..
20

There has been erroneous definitions of asphyxia

and prediction for subsequent neurological outcome
basing upon l...
..
21

certain elements of the Apgar score are partially

dependent on the physiological maturity of the
infant,


a hea...
…
22

Apgar scores may be influenced by a variety of

factors including,




fetal malformations,
maternal medications...
..
23

to equate the presence of a low Apgar score solely

with asphyxia or hypoxia represents a misuse of the
score
The...
Criteria for Neurological Injury to be related to
Asphyxia
24

• Profound metabolic or mixed acidemia (pH<7.0)
• Early ons...
Management
25

Prophylactic





Antenatal high risk detection
Close fetal monitoring
Intrapartum use of electronic f...
Management
26

Definitive
Warmth
 Airway
 Suction
 drying
 tactile stimulation
- pulse, resp rate and colour


11/28...
27

ABCDE resuscitation



A (air way)



B (breathing)



C (circulation)



D (drug)



E (evaluation)
11/28/13
Complications of BA
28

BA can cause HIE



manifesting with-in 48 hours of birth
This results in an increased mortalit...
HIE classification sarnat and sarnat
29

• Grd1: Mild:
– hyperalert, hyperexcitable, normal muscle tone, no seizures
– sym...
Mgt HIE-investigations
30

RBG
Serum Electrolytes
RFT
LFT
FBC
Sonography (Brain)
EEG

11/28/13
MGT-HIE
31

Adequate resuscitation
Maintaion







Adequte ventilation
Adequate oxygenation
Adequate perfusion
No...
Mgt …
32

Lowering the core body temperature


begun within 6 hours of birth



effective therapy to reduce mortality
...
Other Complications
33

RS: RDS, pulmonary hemorrhage
CVS: heart failure, cardiac shock,myocardial necrosis,
ventricular d...
..
34

Prevention of BA

11/28/13
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Birth asphyxia, with Tanzania perspective

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Birth asphyxia is one of contributors to neonatal death, Some of the causes are easily preventable. Health care workers should be equipped with knowledge, skills, equipment and supplies for management of asphyxiated newborns.

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Birth asphyxia, with Tanzania perspective

  1. 1. Birth asphyxia 1 JOSEPH GASPER KIMARO, MD DAR ES SALAAM, TZ 11/28/13
  2. 2. 2 Introduction Risk factors Pathophysiology Apgar scoring VS Birth Asphyxia Management Complications 11/28/13
  3. 3. Introduction 3 • Birth asphyxia occur when the fetus is deprived of an adequate supply of oxygen at birth. – Failure to initiate or maintain spontaneous resp at birth . • Intrauterine Hypoxia is used to describe inadequate oxygen availability during the gestation period. • Perinatal asphyxia a state of decreased oxygen delivery to the fetus or neonate resulting in inadequate tissue perfusion. – Common cause of perinatal death 11/28/13
  4. 4. Introduction ct 4 BA may occur 1. 2. 3. Immediately prior to(intrauterine), During( intrapartum) or Just after delivery(postpartum). There is considerable controversy over the diagnosis of birth asphyxia due to medicolegal reasons Because of its lack of precision, the term is avoided in modern obstetrics 11/28/13
  5. 5. Requirements for resp 5 • Intact neuro and resp apparatus • Clear airway • Adequate alveolar area • Expanded alveoli with surfactant • Sufficient pulmonary perfusion • Satisfactory lymphatic drainage • Oxygen diffusion and dissociation capacity • Carbonic anhydrase activity of the blood 11/28/13
  6. 6. Why birth asphyxia? 6 10% NB need some assistance 1% more adv measures 717,000 (23%) NB deaths related to BA Incidence for sev. BA. 1/1000 V.S 510 11/28/13
  7. 7. Where Tz stands 7 2.9miln NB deaths in 2012 1.8mln in 10 countries alone making up for 2/3 Same account for nearly 57% of MD worldwide Tz , IMR 65.74 deaths per 1,000 live births and NMR rate of 26 deaths per 1000 live births in 2012 11/28/13
  8. 8. Local findings 8 Hege et al 2012, Birth asphyxia , a major cause of neonatal mortality in Northern Tanzania. (Journal American Academy of Paediatrics) prospective study at 11/28/13 Haidomu
  9. 9. Risk factors for asphyxia.. 9 ANTEPARTUM – – – maternal hypotension Reduced maternal oxygenation Inadequate placental perfusion/gas exchange • • • – – – Maternal hypotension Hypertension Vascular diseases Congenital infections/anomalies IUGR DM 11/28/13
  10. 10. … 10 • INTRAPARTUM – Interruption of umbilical circulation • • • – True not Cord prolapse Cord avulsion Inadequate placental perfusion/gas exchange • • • • Abruptio Ruptured uterus Severe materna l hypotension Abnornal uterine contractions 11/28/13
  11. 11. 11  Traumatic deliveries    Abnormal maternal oxygenation      Breech delivery Shoulder dystocia Pulmonary edema to prolonged labor maternal sedation premature infants Severe cardiopulmonary abnormalities 11/28/13
  12. 12. …. 12 POSTNATAL    Persistent pulmonary hypertension of the newborn Severe circulatory insufficiency (eg, acute blood loss, septic shock) Congenital heart diseaseal 11/28/13
  13. 13. … 13 When deprived of oxygen, either before or after birth, infants demonstrate a well-defined sequence of events leading to apnea Oxygen deprivation results initially in a transient period of rapid breathing. 11/28/13
  14. 14. … 14 If such deprivation persists- primary apnea.   This stage is accompanied by a fall in heart rate and loss of neuromuscular tone. Simple stimulation and exposure to oxygen will usually reverse primary apnea. 11/28/13
  15. 15. … 15 If oxygen deprivation and asphyxia persist  the infant will develop deep gasping respirations followed by secondary apnea.    a further decline in heart rate, falling blood pressure, loss of neuromuscular tone 11/28/13
  16. 16. … 16 Infants in secondary apnea    will not respond to stimulation will not spontaneously resume respiratory efforts. Unless ventilation is assisted, death will occur 11/28/13
  17. 17. .. 17 Clinically, primary and secondary apnea are indistinguishable;   thus, secondary apnea must be assumed resuscitation of the apneic infant must be started immediately. 11/28/13
  18. 18. Apgar score Vs birth asphyxia 18 Apgar score-based on characteristics of      heart rate, respiratory effort , muscle tone, reflex irritability, and color  assessed and assigned a value of 0 to 2 11/28/13
  19. 19. …. 19 1-min As reflects the need for immediate resuscitation. 5-min score   -effectiveness of resuscitative efforts. prognostic significance for neonatal survival, neonatal death   - 1 in 5000 (scores 7 to 10), 1 in 4( scores of 3 or less) 11/28/13
  20. 20. .. 20 There has been erroneous definitions of asphyxia and prediction for subsequent neurological outcome basing upon low Apgar scores 11/28/13
  21. 21. .. 21 certain elements of the Apgar score are partially dependent on the physiological maturity of the infant,  a healthy preterm infant may receive a low score only because of immaturity 11/28/13
  22. 22. … 22 Apgar scores may be influenced by a variety of factors including,    fetal malformations, maternal medications, infection, 11/28/13
  23. 23. .. 23 to equate the presence of a low Apgar score solely with asphyxia or hypoxia represents a misuse of the score The Apgar score alone cannot establish hypoxia as the cause of cerebral palsy 11/28/13
  24. 24. Criteria for Neurological Injury to be related to Asphyxia 24 • Profound metabolic or mixed acidemia (pH<7.0) • Early onset of severe or moderate neonatal encephalopathy in infants born at 34 or more weeks of gestation • Cerebral palsy of the spastic quadriplegic or dyskinetic type • Exclusion of other identifiable etiologies such as trauma, coagulation disorders, infectious conditions, or genetic disorders. • Mulstisystem 11/28/13
  25. 25. Management 25 Prophylactic     Antenatal high risk detection Close fetal monitoring Intrapartum use of electronic fetal monitoring Judicious administration of anaethetics and sedatives during labour 11/28/13
  26. 26. Management 26 Definitive Warmth  Airway  Suction  drying  tactile stimulation - pulse, resp rate and colour  11/28/13
  27. 27. 27 ABCDE resuscitation  A (air way)  B (breathing)  C (circulation)  D (drug)  E (evaluation) 11/28/13
  28. 28. Complications of BA 28 BA can cause HIE   manifesting with-in 48 hours of birth This results in an increased mortality rate, including an increased risk of SIDS.  Oxygen deprivation have been implicated in  epilepsy  Eating disorder  Celebral palsy 11/28/13
  29. 29. HIE classification sarnat and sarnat 29 • Grd1: Mild: – hyperalert, hyperexcitable, normal muscle tone, no seizures – sympathetic over-stimulation with tachycardia, dilated pupils and jitteriness. EEG is normal • Grd2: Moderate: – hypotonia, decreased movements, coupious secretions – EEG is abnormal and 70% of infants will have seizures • Grd3: Severe: – stuporous, flaccid, and absent primitive reflexes, usually with seizures – The infant may have seizures and has an abnormal EEG with decreased background activity and/or voltage suppression. 11/28/13
  30. 30. Mgt HIE-investigations 30 RBG Serum Electrolytes RFT LFT FBC Sonography (Brain) EEG 11/28/13
  31. 31. MGT-HIE 31 Adequate resuscitation Maintaion       Adequte ventilation Adequate oxygenation Adequate perfusion Normal serum glucose Fluid and electrolytes Thermal neutral environment Control seizures Prevent cerebral oedema 11/28/13
  32. 32. Mgt … 32 Lowering the core body temperature  begun within 6 hours of birth   effective therapy to reduce mortality improve neurological outcome in survivors Others  Allopurinol  Calcium chanel blockers 11/28/13
  33. 33. Other Complications 33 RS: RDS, pulmonary hemorrhage CVS: heart failure, cardiac shock,myocardial necrosis, ventricular dysfunction GIS: NEC, stress gastric ulcer, paralytic ileus Renal:Oliguria, Anuria, acute tubular/cortical Necrosis Renal failure Liver: increase in Indirect bilirubin and decrease Clotting factors Hematologic: DIC, Thrombocytopenia Metabolic: Acidosis, hypoglycemia, hypocalcemia, hyponatremia, SIADH 11/28/13
  34. 34. .. 34 Prevention of BA 11/28/13

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