Guslihan Dasa Tjipta Division of Perinatology Department of Child Health Medical School University of Sumatera Utara

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Marlene Nichols
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1 Guslihan Dasa Tjipta Division of Perinatology Department of Child Health Medical School University of Sumatera Utara 1

2 Definition Perinatal asphyxia is a fetus/newborn, due to: is an insult to the Lack of oxygen (hypoxia) and/or Lack of perfusion (ischemia ischemia) i to various organ, and may be associated with Lack of ventilation (hypercapnia). 2

3 Definition Essential characteristics: American Academy of Pediatrics (AAP) and the American College Of Obstetricians and Gynecologists (ACOG): 1. Profound metabolic or mixed acidemia (ph < 7) 2. Apgar score of 0-3 for >5 min 3. Neurologic manifestations: seizures, hypotonia, coma, or hypoxic ischemic encephalopathy (HIE) 4. Evidence of multiorgan system dysfunction in the immediate neonatal periode. 3

4 Incidence % 1.5% of total live birth : <36 wk : 9% >36 wk : 0.5% ~20% of perinatal death 4

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6 Apgar score (1952) A scoring system to help assessing a neonate s transition after birth Conceived to report on the state of the newborn and effectiveness of resuscitation. Poor tool for assessing asphyxia 6

7 APGAR SCORING Appearance (color) Puls (heart rate) Grimace Sign (reflex irritability) Activity (muscle tone) Respirations Blue or pale Absent No response Limp Absent Pink body with blue extr Slow (<100 bpm) Grimace Some flexion Slow, irregular Completely pink >100 bpm Cough or sneeze Active movement Good, crying 7

8 Organ effects of asphyxia CNS Lung Cardiovascular system Renal system Gastrointestinal tract Blood 8

9 Consequences of Asphyxia CNS Cerebral hemorrhage h Cerebral edema Hypoxic-ischemic ischemic encephalopathy p Seizures 9

10 Intrauterine asphyxia Fetal po2, pco2, ph, BP It Intracellular lll edema Cerebral tissue pressure Focal Cerebral blood flow Generalized brain swelling Intracranial pressure Generalized cerebral blood flow Brain necrosis Pathogenesis Intrauterine asphyxia Fetal po2, pco2, ph, BP Loss of vascular autoregulation Cerebral blood flow Brain Necrosis Brain swelling 10

11 Consequences of Asphyxia Lung Delayed onset of respiration Respiratory distress syndrome from surfactant deficiency or dysfunction Pulmonary hemorrhage Persistent pulmonary hypertention 11

12 Consequences of Asphyxia Cardiovascular system Shock Hypotention Myocardial necrosis Congestive heart failure Ventricular dysfunction 12

13 Consequences of Asphyxia Renal system Oliguria-anuriaanuria Acute tubular or cortical necrosis Renal failure 13

14 Consequences of Asphyxia Gastrointestinal system Paralytic ileus or delayed (5-7 days) necrotizing enterocolitis. 14

15 Consequences of Asphyxia Blood Disseminated intravascular coagulation Thrombocytopenia can result from shortened platelet survival Bone Marrow recovers over time 15

16 Acidosis Consequences of Asphyxia Metabolic Hypoglicemia (hyperinsulinism) Hypocalcemia Hyponatremia/ Syndrome of inappropriate antidiuretic hormone secretion (SIADH) 16

17 Management Optimal management is prevention: identify the fetus being subjected Immediate resuscitation: maintenance of adequate ventilation, oxygenation, perfusion. Correct metabolic acidosis: Volume expander: to sustain tissue perfusion NS or Ringers Lactate O neg if (+) evidence of blood loss Albumin: not recommended Na Bicarbonate Only with adequate ventilation and circulation Only when CPR is prolonged and the infant remains unresponsiveness 1-2 meq/kg of a 0.5 meq/l slow IV Temperature: Avoid perinatal hyperthermia 17

18 Management Maintain a normal serum glucosa level ( mg/dl) to provide adequate substrate for brain metabolism. Avoid hyperglycemia to prevent hyperosmolality and a possible increase in brain lactate levels Controle of seizures: phenobarbital is the drug of choice. Prevention of cerebral edema: fluid restriction (eg. 60 ml/kg) 18

19 Neonatal Resuscitation 19

20 Primary versus Secondary Apnea Primary Apnea no respiration decreasing heart rate BP maintained responds to stimulus Secondary Apnea no respiration heart rate very low BP low No response to stimulation 20

21 Signs of a Compromised Newborn Cyanosis Bradycardia Low blood pressure Depressed respiratory effort Poor muscle tone AAP/AHA

22 Preparation for Resuscitation Personnel and de Equipment Trained person to initiate resuscitation at every delivery Recruit additional personnel, for more complex delivery Prepare necessary equipment Turn on radiant warmer Check resuscitation equipment Team concept AAP/AHA

23 Evaluating the Newborn Immediately after birth, the following questions must be asked: AAP/AHA

24 Evaluation Action Decision AAP/AHA

25 Initial Steps AAP/AHA

26 Provide Warmth Prevent heat loss by Placing newborn under radiant warmer Drying thoroughly Removing wet towel AAP/AHA

27 Preventing Heat Loss Premature newborns Special problems Thin skin Decreased subcutaneous tissue Large surface area Additional steps Raise environment temperature Cover with clear plastic sheeting AAP/AHA

28 Opening the Airway Open the airway by Positioning on back or side Slightly extending neck Sniffing position Aligning posterior pharynx, larynx and trachea AAP/AHA

29 Clear Airway: No Meconium Present Suction mouth first, then nose AAP/AHA

30 If meconium present and newborn is vigorous If: respiratory effort is strong muscle tone is good Heart rate > 100/ min Then: Use bulb syringe or large bore catheter to clear mouth and nose 30

31 Meconium present and newborn NOT vigorous Tracheal suction Administer oxygen Insert laryngoscope, use 12F or 14F suction catheter to clear mouth Insert endotracheal tube Attach endotracheal tube to suction source Apply suction as tube is withdrawn Repeat as necessary AAP/AHA

32 Management of Meconium AAP/AHA

33 Dry, Stimulate to Breathe, Reposition AAP/AHA

34 Tactile Stimulation Potentially Hazardous Stimulation shaking hki slapping the back squeezing the rib cage hot and cold compresses dilating anal sphincter AAP/AHA

35 Resuscitation Flow Diagram AAP/AHA

36 Post - Resuscitation Care AAP/AHA

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MODULE VII. Delivery and Immediate Neonatal Care

MODULE VII. Delivery and Immediate Neonatal Care MODULE VII Delivery and Immediate Neonatal Care NEONATAL ASPHYXIA About one million deaths per year In Latin America 12% of newborns suffer some degree of asphyxia A major cause of perinatal and neonatal