Neonatal Asphyxia

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

Know the definition, risk factor, diagnosis andmanagement of asphyxia neonatorum

Define perinatal asphyxiaKnow the criteria to diagnose asphyxiaDefine risk conditions that predispose the fetus and neonate to asphyxia

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 withLack of ventilation (hypercapnea)

AAP & ACOG ( 2004 ) :1. Apgar score < 5 at age 5 min2. Cord pH < 7.03. Neurological disorders & multiorgan syst. Dysf.

1 % - 1,5 % of total live birth:< 36 week : 9 %> 36 week : 0,5 % 20 % o perinatal death

A. Antepartum condition

1. Matenal Factors: DMToxemiaHypertensionCardiac diseaseCollagen vascular diseaseInfectionsInsoimmunizationDrug addiction

2. Obstetric Factor: Placenta PreviaCord prolapsPROMPolyhidramnionPlacenta insuffeciencyChorioamnionitis

B. Inpartum Conditions

Abnormal plasentationPricipitate or prolonged deliveryDifficult deliveryPost term deliveryForceps or vacum delivery

C. Fetal or neonatal conditions

PrematurityRespiratry distress syndromeMeconium aspiration syndromeSepsis, pneumonia, hemolitic diseaseCardiac or pulmonary anomalies

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 aspirator2. Bag and mask equipment3. Intubation equipment4. Medications :Epinephrine 1/10.000Isotonic crystaloidNaloxone hydroclorideDextrose 40 %Normal salineUmbilical Vessel catetherization supplies5. Miscellaneous Gloves, radiant warmer, linens, stethoscope, oropharyngeal airway

*Balon Mengembang Sendiri (BMS)T-piece resuscitatorBalon Tidak Mengembang Sendiri (BTMS)

All O2 difuse across the palcental membrane from the mothers blood to the baby bloodOnly a small fraction of the fetal blodood passed through the fetal lungsAlveoli is filled with fluidThe blood vessels in the fetal lungs are markedly constrictedMost of the blood flow through the ductus arteriosus into the aorta

After Birth:+ Noconnection to the placenta + A baby get oxygen from the lung1. The fluid in the alveoli is absorbed into the lungs tissue and replace by air2. The umbilical arteri and vein clamped increases systemic blood presure3. O2 in the alveoli relaxation of blood vessel in the lungs4. The ductus arteriosus begin to constrict more blood flow trough the lungs O2 to tissues

Cardiac output is maintenaned early, but changes radicallySelective vasocontrictor to gut, kidneys, muscles, skinPulmonary blood flow by hypoxia and asidosisRespiration center is depressedSevere stage of asphyxia O2 to the heart & brain - myocardial function O2 to the vital organ - brain injury

Assigned at 1 and 5 minute after birth, If < 7 every 5 minute 20 minute

ScoreSign012Heart RateAbsent< 100/ m 100/ mRespiratons-Slow, irregularGood, cryingMuscle toneLimpSome flexionActive motionReflex irritabilityNo responseGrimaceCough, sneeze,cryColourBlue or palePink body, blue extremitasCompletely pink

Newborn Resuscitation Algorithm.2010 by American Academy of Pediatrics

Provide warm therapyPosition, clear airway (as necessary)Dry, stimulate, repositionGive oxygen (as necessary) : Free-flow O2 & Tactile stimulation

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

Insert a laryngoscope and use a 12 F or 14 F catheher to clear the mouth & posterior pharynxAttack the endotracheal tube to a suction sourceApply suction as tube is slowly with drawnRepeat as necessary until clear

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 minutePressure : 30 40 am H2O and then Mask : - Face Mask : - Full term - Pre term- Round- Anatomical shape- With cushioned rim

Increase of heart rateImproved in colorSpontaneous breathing

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

Indications :1. to suction meconium2. to improve ventilation in bag and mask ventilation in effective3. To coordinate ventilation and chest compression4. To administration medication such as ephinephrine5. When prolonged ventilation is needed6. Administer surfactant7. When congenital diaphagmatic hernia is suspected.

1. Endotracheal tube :- uniform type- size : 2,5 3,5 mm2. Laryngoscope- small handle- blade handle no : - 1 = full term - 0 = preterm - 00 = extremelly preterm

1. Epinephrine Indications : HR < 60 bpm after 30 sec of PPV and mother 30 sec of PPV + chest compressions How : - ET - Umbilical veinDoze : 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 mL/ kgBB

3. Naloxone hydrocloride

Indication : respiratory depressons caused by maternal narcotics ( morphine, micpheridium, butorphanol tartrate ) : in 4 hours before deliveryDose 0,1 mg/kg via ET / IT

I. Early sequallae :1. Metabolica. Metabolic acidosisb. Inapropiate anti diuretic hormone secretion2. Rerpiratorya. RDS : increase severity of RDSb. Transient tachypnoe of the new bornc. Respiration of meconium antenatally may lead to MAS

3. Cardiaca. myocardial ischemiab. Persistent pulmonary hypertention of the new bornc. PDA4. CNS : hypoxic ischemia encephalopathy (HIE)5. Renal Inpairment : ATN6. Hemathological : DIC7. Gastrointestinal : NEC

II. Late SequalanceDepend 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 10 minute stop resuscitation

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

Grade I HIEAlternating period of lethargy, irritability, Hyperalertness, jitterinessPoor feedingIncreased muscle tone, exaggerated deep tendon reflex.Increase heart ratePupils : dilatedNo seizuresSymtomps resolver in 24 hour

Grade II HIELethargyPoor feeding, depressed gag reflexHypotoniaLow heart rate and pupillary constriction indicating parasympathetic stimulation50 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

Acute tubular necrosis : oliguria, hematuria, polyuriaCardiomyopathy : hypotensionPersistent pulmonary hypertension : tachypnea, hypoxemia

Hepatic necrosis : ammonia, jaundice, AST/ ALTNEC : distention, bloody stoolsAdrenal insufficiency : glucose, Na, BP Inappropiate secretion of ADH : oliguria, Na

Prevention in the best managementTiming is very crucial and a few minute of delay can lead to death or life long suffering from handicapMaintain oxygenation and acid base balanceStart mechanical ventilation if necessaryMonitor and maintain body temperatureCorrect 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, hyperviscocity9. Administer 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 40 mg/kb is reached10. No other therapeutic interventions have been proven helpful ie. Corticosteroids, prophylactic phenobarbital, furosemite, manitol, etc

Newborn Resuscitation Algorithm.