Nature and Science 2015;13(3)

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1 Naure and Science 2015;13(3) hp:// Ionized Serum Calcium and Serum Toal Magnesium, Predics Oucome in Neonaal Hypoxic-Ischemic Encephalopahy Lila A, Abdrabuo 1, Ahmed M. Ismail, Ahmed H. Elsayed, Gamal A. Alkheshen 2, and Mohamed A. Ibrahim 1 Pediarics 1 and clinical pahology 2, Faculy of Medicen, Al-azhar Universiy, Cairo, Egyp Absrac: Perinaal asphyxia, more appropriaely known as hypoxic ischemic encephalopahy (HIE), is characerized by clinical and laboraory evidence of acue or subacue brain injury due o asphyxia. The primary causes of his condiion are sysemic hypoxemia and/or reduced cerebral blood flow. Birh asphyxia causes weny hree percen of all neonaal deahs worldwide. Hypoxic-ischemic cerebral injury is a recognized cause of permanen long-erm neurologic disabiliy in children. Daa abou changes of serum ionized calcium and oal serum magnesium concenraions described in asphyxiaed infans were conroversial. This sudy aimed o deermine he serum levels of oal serum magnesium (Mg+2) and ionized calcium (Ca+2) levels in newborn infans wih hypoxic ischemic encephalopahy in he firs wo days of life and i is relaion o he severiy of hypoxic-ischemic encephalopahy and he disease oucome. Our sudy was case conrol sudy conduced on 25 erm newborn infans in heir firs wo days of life and born in Bab-Elsheria Universiy Hospial and referred o he neonaology uni of pediaric deparmen wihin he firs 24 hours of life wih he diagnosis of HIE. A conrol group of 25 mached (weigh and gesaional age) full-erm newborns wih no hisory of perinaal asphyxia. Exclusion crieria included newborns wih neonaal sepsis confirmed by laboraory sudies, congenial anomalies, inrauerine growh rearded newborns, and premauriy. All sudied newborns were subjeced o horough hisory, full clinical examinaion, and clinical saging according o Sarna and Sarna s crieria ino 3 groups: group I (mild HIE; 8), group II (moderae HIE; 8), group III (severe HIE; 9). Serum levels of oal magnesium and ionized calcium were esimaed via sampling during he 1 s 48 hr of life (median age of sampling was 30 hr). Babies were managed according o uni s managemen proocol. From our sudy we concluded ha significan correlaion beween severiy of HIE and decreased serum levels of oal magnesium and ionized calcium, significan relaion beween decreased serum levels of oal magnesium and ionized calcium decreased survival rae. [Lila A, Abdrabuo, Ahmed M. Ismail, Ahmed H. Elsayed, Gamal A. Alkheshen and Mohamed A. Ibrahim. Ionized Serum Calcium and Serum Toal Magnesium, Predics Oucome in Neonaal Hypoxic-Ischemic Encephalopahy. Na Sci 2015;13(3): ]. (ISSN: ). hp:// 19 Key words: Ionized Serum Calcium; Magnesium, Neonaal Hypoxic-Ischemic Encephalopahy 1. Inroducion Perinaal asphyxia is an insul o he feus or newborn due o a lack of oxygen (hypoxia) and/or a lack of perfusion (ischemia) o various organs. Hypoxic-ischemic encephalopahy implies he inerrupion of supply of nuriens o he brain, mainly oxygen and glucose, sufficienly subsanial o cause irreversible damage (Marinez e al., 2013). Fifeen percen o weny percen of affeced newborns will die in he posnaal period and an addiional weny five percen will develop severe and permanen neuropsychological sequelae, including menal reardaion, visual moor or visual percepive dysfuncion, increased hyperaciviy, cerebral palsy and epilepsy (Wu, 2012 ). There are muliple, biochemical mechanisms and pahways ha conribue o he progression of he brain damage ha subsequenly follows a hypoxicischemic insul. These evens include energy failure, membrane depolarizaion, an increase of neuroransmier release, an increase of inracellular calcium, he producion of oxygen-free radicals, and he release of inflammaory mediaors (Verklan, 2009). N-Mehyl-D-asparic (NMDA) acid channel is normally closed by magnesium ions in a volage dependen manner. Hypoxia decreases he blocking effec of magnesium ion he channel hus causes a rapid influx of Ca+2 ino he cell which has been repored o be he major cause of cell deah (Calver, 2005). Aim of The Work The aim of his sudy is o assess and correlae he serum levels of oal serum magnesium and ionized calcium in full erm newborns wih hypoxic ischemic encephalopahy in he firs wo days of life and compare ha levels o levels in healhy conrols. 2. Subgecs and Mehods Sudy design: Prospecive sudy including weny five full erm newborn infans born in Bab El-Sharyia Universiy Hospial and referred o he neonaology uni of pediaric deparmen wih he diagnosis of HIE during he period of Ocober Sepember A conrol group of 25 mached healhy fullerm newborns wih no hisory of perinaal asphyxia. 127

2 Naure and Science 2015;13(3) hp:// The following crieria were used for he diagnosis of HIE, wih one or more of he following: (1) 5 minues Apgar score < 6, sever meabolic acidosis (PH 7), and/or delayed firs breah beyond 5 minues afer birh; (2) mechanical venilaion a birh; (3) evidence of encephalopahy and (4) evidence of mulisysem involvemen (i.e. encephalopahy and a leas one oher sysem) (American Academy of Pediarics, 1994). Infans were excluded from he sudy if hey had any of he following: 1. Premaure < 37 week 2. Infan wih Apgar score > 6 a 5 minue 3. Infan wih early neonaal sepsis confirmed by posiive sepsis screen was excluded laer on from he sudy. 4. Congenial malformaions. 5. Inracranial hemorrhage Mehods: All sudied newborns were subjeced o horough hisory, full clinical examinaion wih sress on neurologic evidence of HIE including reflexes, one, posure, movemen, seizures and cranial nerve funcion, Paiens group were classified according o Sarna and Sarna s (1976) crieria ino 3 groups: Group I (Mild HIE): This group included 8 full erm newborn infan. Group II (Moderae HIE): This group included 8 full erm newborn infans. Group III (Severe HIE): This group included 9 full erm newborn infans. Esimaion of serum levels of oal magnesium and ionized calcium, and oher invesigaions as required. Shor erm oucome was esimaed a ime of discharge as alive or deah. Sample Collecion: Blood samples were obained by veinpuncure of a peripheral vein under sric asepic echniques. Samples obained from paiens and conrols were allowed o clo in plasic es ubes for 30 minues a room emperaure. Nex, he ubes were cenrifuged for 5 minues a room emperaure. Principle of ionized calcium assay: Ionized calcium in he sample was deermined by poeniomeric ion selecive elecrode. I was done on AVL-908 (Roche diagnosic). I was based on he measuremen of an elecrical poenial difference beween 2 elecrodes (half-cell) in an elecrochemical cell (Baker e al., 2000). Principle of magnesium: The magnesium ions in he sample is deermined by xylidyl blue colorimeric mehod producing a coloured complex is inensiy is direcly proporional o he magnesium ions concenraion presen in he sample. Glycoleherdiamine- N,N,N'N'- eraceic acid (GEDTA) performs as a chelaing agen (Bohuon, 1962). 3. Resuls The resuls of his work were saisically analyzed and illusraed in he following ables: Table (1):Gender, birh, weigh and mode of delivery of conrols and paiens wih differen grades of HIE. * Conrol Group Paiens group Chi-square es No. % No. % X2 P value Sex Female Male % 48.0% % 48.00% Modeof delivery C.S Vaginal % 56.0% % 60.00% Gesaional age Range 39.36± ± ± ± Birh weigh Range This able shows gender, birh weigh, mode of delivery and gesaional age of conrol group and paiens wih differen grades of HIE. Chi-square es es was used where no significan difference is eviden. 128

3 Naure and Science 2015;13(3) hp:// Table (2): Comparison beween he wo sudied groups regarding ionized Ca+2 and serum oal Mg+2. Conrol group Paiens group This able shows highly significan differences beween paiens and conrols regarding mean ionized Ca+2 and mean serum oal mg+2. Table (3): Comparison beween paiens wih mild HIE and conrol groups regarding ionized Ca+2 and serum oal Mg+2 Conrol Mild HIE There is a highly significan lower mean ionized Ca+2 and mean serum oal Mg+2 in paiens wih mild HIE compared o conrols. Table (4): Comparison beween paiens wih moderae HIE and conrol groups regarding ionized Ca+2 and serum oal Mg+2. Conrol 0.21 Moderae HIE Ionized ca Serum Mg There is a highly significan lower mean ionized Ca+2 and mean serum oal Mg+2 in paiens wih moderae HIE compared o conrols. Table (5): Comparison beween paiens wih severe HIE and conrol groups regarding ionized Ca+2 and serum oal Mg+2. Conrol Severe HIE There is a highly significan lower mean ionized Ca+2 and mean serum oal Mg+2 in paiens wih sever HIE compared o conrols

4 Naure and Science 2015;13(3) hp:// Table (6): Serum ionized Ca+2 and oal serum Mg+2 levels in paiens wih favorable and unfavorable oucome. Unfavorable Favorable Ionized ca Serum Mg Paiens wih unfavorable oucome showed highly significan lower serum ionized Ca+2 and oal serum Mg+2 levels compared o hose wih favorable oucome Discussion This sudy was aimed o deermine serum ionized Ca and oal serum Mg levels in erm neonaes wih hypoxic-ischemic encephalopaly (HIE) and correlaing he resuls wih he disease severiy and oucome.this was done hrough evaluaion of 25 erm newborns diagnosed as HIE based on he inclusion crieria and 25 age and sex mached healhy full erm newborns as conrol group recruied from NICU. Our resuls revealed ha gesaional age, birh weigh, sex and mode of delivery were no significanly differen in sudied newborns. In our sudy we found ha neonas wih HIE had significanly lower serum ionized Ca level (1.05±0.15mmol/L) as compared o conrol group (±mmol/l). Serum ionized ca was lower in mild, moderae and severe cases han conrol group. This comes wih agreemen o Peersen e al. (1981), Jajoo e al (1995) Meha e al. (1998), hey described hypocalcemia in asphyxiaed infans wih more severe degrees of asphyxia. Also, Yoneda e al. (2004) showed ha adjused (Ca+2) shorly afer birh was significanly lower in infans wih HIE and ha decrease in serum ionized Ca migh be he resul of hypoxic-ischemic reperfusion injury in he whole body. On he oher hand, Jajoo e al. (1995) and Ilves e al., (2000) found ha good porion of asphyxiaed infans had iniially normal (Ca+2) level in cord blood sample a birh however decreased (Ca+2) level occurs on he second day of life. The difference in he above resuls shown by boh auhors and our resuls can be explained by he fac ha we did no obain our samples from cord blood bu from serum samples in he firs wo days of life. In our sudy we found ha neonaes wih HIE had significanly lower mean oal serum Mg+2 level (1.36±0.42m/dl) as compared o mean oal serum Mg+2 level of conrol group (±mg/dl). The daa abou changes in oal serum Mg+2 level in asphyxiaed erm babies described by differen auhors were conroversial (Ilves e al., 2000). serum oal magnesium was lower in mild, moderae and severe cases han conrol group. This comes wih agreemen o Geven e al. (1993), Jajoo e al. (1995) described hypomagnesemia afer birh asphyxia. Our daa abou lower Mg+2 concenraion in severe HIE infans suppor he suggesion of a possible neuroproecive effec of Mg SO4 in asphyxiaed infans (Greher e al., 1998; Ilves e al., 2000; Berger and Garnier, 2001). Afer asphyxia, aleraions in inra-and-exracellular Mg concenraions affecing cell funcion hrough is ineracion wih Ca+2 by binding compeiively o is same sies and by aleringis disribuion due o changes in Ca +2 influx across cell membrane (Levine and Coburn, 1994). The decreased concenraion of oal Mg+2 may be involved in he developmen of HIE, as Mg+2 akes par in he biochemical cascade afer hypoxicischemic insul. Asphyxia can disurb he neurone's abiliy o mainain is membrane proenial and reduce Mg+2 blockade of he NMDA recepor resuling in increased Ca+2 enry which is he key mechanism in delayed deah in asphyxiaed infans (Delivoria-Papadopoulos and Mishra, 1998, Meha e al. (1998). On he oher hand, (Engel and Elin, 1970; Bachman e al., 1976; Jukarinen, 1979 and Ilves e al., 2000). Described hypermagnesemia afer birh, he cause of such hypermagnesemia may be aribued o acidosis which depolarizes he cell membrane leading o some loss of inracellular Mg+2. (Cadell and Reed, 1989) suggesed ha oal Mg+ deerminaion during acidosis may give a falsely elevaed value and may mask a rue oal Mg deficiency which can be diagnosed only afer homeosasis is reesablished. Hypermagnesemia may be a ype of proecive mechanism, hrough which he body ry o increase exracellular Mg+2 which blocks NMDA recepors prevening Ca+2 enry o brain cells and hus prevening is injury (Hoffman e al., 1994). From our sudy we found ha neonaes wih HIE who showed unfavorable oucome (neurological abnormaliy or deah) had significanly lower serum ionized Ca+2 level compared o hose wih favorable oucome (clinically normal). 130

5 Naure and Science 2015;13(3) hp:// Yoneda e al. (2004), also found ha a significan low serum ionized calcium level occurs in infans wih HIE who had abnormal oucome (deah or cerebral palsy developmen) compared o hose wih normal oucome (full neurological recovery), suggesing greaer inracellular shif of Ca+2 ino muliple organs, paricularly he brain. Differen resuls sugges ha serum ionized calcium may be useful for predicing he oucome of infans wih HIE (Ilves e al., 2000). Also we found in our resuls ha neonaes wih HIE who showed unfavorable oucome (neurological abnormaliy or deah) had significanly lower oal serum Mg level compared o hose wih favorable oucome (namely, clinically normal). Jajoo e al. (1995) also found ha hypomagnesemia was a frequen finding in seizures resuling from asphyxia brain damage, highlighing he poenial role of Mg as a predicor o he oucome of HIE. Also our resuls comes in agreemen o Ilves e al. (2000) who suppored he link beween hypomagnesemia and neuronal injury in severe HIE and hence poor oucome. In conclusion we have deermined ha low serum ionized Ca+2 and oal serum Mg+2 levels in neonaes wih HIE. Significan correlaion beween low serum ionized Ca+2 and oal serum Mg+2 levels o HIE grade and he disease oucome. Therefore, boh serum ionized Ca+2 and oal serum Mg+2 have combined diagnosic and prognosic values in neonaes wih HIE. References 1. American Academy of Pediarics/American College of Obsericians and Gynecologiss: Relaion beween perinaal facors and neurological oucome. In: Guidelines for Perinaal Care. 3rd ed. Elk Grove Village, Ill 1994; Bachman KD, Feenders O, and Dominick H Chr: Die klinische Bedeuung des Magnesiums in der Neugeborenenperiode. Gebursh und Frauenheilkunde 1976; 36: Baker E, Persch E, and Buhlmann P.: Seleciviy of poeniomeric ion sensors, Anal Chem.; 72: , Berger R and Garnier Y: Perinaal brain injury. J Perina Med 2001; 29 (1): Bohuon: Magnesium assay wih calmagie or erichrome black T reagens. Anal. Chim, Aca, 7: , Cadell JL and Reed GF.Unreliabiliy of plasma magnesium value in asphyxiaed neonaes. Magnesium 1998; 8: Calver J. W.: Pahophysiology of an hypoxic-ischemic insul during he perinaal period: Neurol Res 2005; 27: Delivoria-Papadopoulos M and Mishra OP: Mechanisms of cerebral injury in perinaal asphyxia and sraegies for prevenion. J Pediar : 30S-4S. 9. Engel RR and Elin RJ.: Hypermagnesemia from birh asphyxia. J Pediar 1970; 77: Geven WB, Monnens LAH, Willems JL: Magnesium meabolism in childhood. Miner Elecrolye Meab 1993; 19: Greher JK, Hoogsrae J, Selvin S e al.: Magnesium sulphae ocolysis and risk of neonaal deah. Am J Obse Gynecol 1998; 178: Hoffman DJ, Marro PJ, McGowan JE, Mishra OP, Delevoria- Papadopoulos M e al. Proecive effec of Mg sulfae infusion onnmda recepor binding characerisics during cerebral corical hypoxia in he newborn pigle. Brain Res 1994; 664: Ilves P, Kiisk M, Soopold T, e al.: Serum oal magnesium and ionized calcium concenraions in asphyxiaed erm newborn infans wih hypoxic-ischemic encephalopahy. Aca Paedir 2000 ;89: Jajoo D, Jajoo A, Shankar R, e al.: Effecs of birh asphyxia in serum calcium levels in neonaes. Indain J Pediar1995, 62(4): Jukarinen J: Plasma magnesium concenraions during he firs five days of live. Aca Paediaer Scand 1979; S222: for reducion of birh asphyxia induced brain damage. 16. Levine BS and Coburn JW: Magnesium, he mimic/anagonis of calcium. N Eng J Med 1994; 310: Marinez-Biarge M, Diez-Sebasian J, Wushoff CJ, e al.: Aneparum and inraparum facors preceding neonaal hypoxic-ischemic encephalopahy. Pediarics 2013; 132:e Meha KC, Kalkwarf HJ, Mimouni F, e al.: Randomized rial of magnesium adminisraion o preven hypocalcemia in infans of diabeic mohers. J Perinaol 1998; 18(5): Peersen S, Chrisensen NC, Fogh-Andersen N.: Effec on serum calcium of 1 -hydroxy-viamin D3 supplemenaion in infans of low birh weigh,infans wih perinaal asphyxia, and infans of diabeic mohers. Aca Paediar Scand 1981; 70: Sarna HB and Sarna M: Neonaal encephalopahy following feal disressaclinical and elecroencephalographic sudy.arch Neurol 1976; 33: Verklan MT: The Chilling Deails: Hypoxic-Ischemic Encephalopahy. J Perina Neonaal Nurs 2009; 23 (1): Wu Y: Brain injury in newborn babies: we can' afford o ge i wrong. Ann Neurol 2012; 72: Yoneda S, Ibara S, Kobayashi K, Kao E, Maruyama Y, Maruyama H, Sumida Y, Sunami R, Sakai M, Ikenoue T and Saio S e al.: Low adjused serum ionized calcium concenraion shorly afer birh predics poor oucome in neonaal hypoxic-ischemic encephalopahy. J Obse Gynecol Res Vol. 31, no. 2004; 6: /21/