Asphyxia Neonatorum

Asphyxia Neonatorum

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

OBJECTIVE:

Know the definition, Risk factor, Diagnosis andmanagement of asphyxia neonatorum

SKILLS

1. Define perinatal asphyxia2. Know the criteria to diagnose asphyxia3. Define risk conditions that predispose the

fetus and neonate to asphyxia

DEFINITION

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 with Lack of ventilation (hypercapnea)

INCIDENCE:

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

20 % o perinatal death

A. Antepartum Conditions

a. Matenal Factors: DM Toxemia Hypertension Cardiac disease Collagen vascular disease Infections Insoimmunization Drug addiction

b. Obstetric Factor: Placenta Previa Cord prolaps PROM Polyhidramnion Placenta insuffeciency Chorioamnionitis

B. Inpartum Conditions

1. Abnormal plasentation2. Pricipitate or prolonged delivery3. Difficult delivery4. Post term delivery5. Forceps or vacum delivery

C. Fetal or neonatal conditions1. Prematurity2. Respiratry distress syndrome3. Meconium aspiration syndrome4. Sepsis, pneumonia, hemolitic disease5. Cardiac or pulmonary anomalies

NEONATAL RESUSCITATION EQUIPMENT

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 1/10.000 Isotonic crystaloid Naloxone hydrocloride Dextrose 40 % Normal saline Umbilical Vessel catetherization supplies

5. Miscellaneous Gloves, radiant warmer, linens, stethoscope, oropharyngeal airway

HOW DOES A BABY RECEIVE O2 BEFORE BIRTH ?

All O2 difuse across the palcental membrane from the mother’s blood to the baby blood

Only a small fraction of the fetal blodood passed through the fetal lungs

Alveoli is filled with fluid The blood vessels in the fetal lungs are markedly

constricted Most 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

PATHOPHYSIOLOGY OF ANTEPARTUM ASPHYXIA

1. Cardiac output is maintenaned early, but changes radically

2. Selective vasocontrictor to gut, kidneys, muscles, skin

3. Pulmonary blood flow ↓ by hypoxia and asidosis

4. Respiration center is depressed5. Severe stage of asphyxia O2 ↓to the heart

& brain - myocardial function ↓ O2 ↓↓ to the vital organ

- brain injury

APGAR SCORE

ScoreSign 0 1 2

Heart Rate Absent < 100/ m ≥ 100/ m

Respiratons - Slow, irregular Good, crying

Muscle tone Limp Some flexion Active motion

Reflex irritability

No response Grimace Cough, sneeze,cry

Colour Blue or pale Pink body, blue extremitas

Completely pink

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

INITIAL STEPS

Provide warm therapyPosition, clear airway (as necessary)Dry, stimulate, repositionGive oxygen (as necessary)

- Free-flow O2- Tactile stimulation

MECONIUM STAINNING

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

IF THE BABY IS NOT VIGOROUS DIRECT SUCTIONARY OF THE TRACHEA SOON AFTER DELIVERY :

- Free flow O2 throughout the suctioning procedure

- Insert a laryngoscope and use a 12 F or 14 F catheher to clear the mouth & posterior pharynx

- Attack the endotracheal tube to a suction source

- Apply suction as tube is slowly with drawn- Repeat as necessary until clear

POSITIVE PRESSURE VENTILATION

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 minute

Pressure : 30 – 40 am H2O and then ↓

Mask : - Face Mask : - Full term

- Pre term

- Round

- Anatomical shape

- With cushioned rim

APPROPRIATE PPV IS FOLLOWED BY :

- Increase of heart rate- Improved in color- Spontaneous breathing

CHEST COMPRESSIONS IF HR < 60 BPM DESPITE 30 SECOND OF EFFECTIVE PPV

Provided by : - The thumb technique - The two finger technique

Place : on the externum above xyphoidRate : 90 per minute Ratio chest compreton to ventilator 3 : 1Depth : 1/ 3 the depth of the chest

ENDOTRACHEAL INTUBATION

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.

EQUIPMENT

1. Endotracheal tube :- uniform type- size : 2,5 – 3,5 mm

2. Laryngoscope- small handle- blade handle no : - 1 = full term

- 0 = preterm - 00 = extremelly

preterm

MEDICATIONS1. 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 µh/ kgBB

3. Naloxone hydrocloride

Indication : respiratory depressons caused by

maternal narcotics ( morphine, micpheridium,

butorphanol tartrate ) : in 4 hours before delivery

Dose 0,1 mg/kg – via ET / IT

SEQUALLAE OF BIRTH ASPHYXIA

I. Early sequallae :1. Metabolic

a. Metabolic acidosisb. Inapropiate anti diuretic hormone

secretion2. Rerpiratory

a. 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. PDA

4. CNS : hypoxic ischemia encephalopathy (HIE)5. Renal Inpairment : ATN6. Hemathological : DIC7. Gastrointestinal : NEC

II. Late SequalanceDepend on the severity of asphyxia. Clinical

severityof HIE is a better predictor of long outcome

DISCONTINUATION OF RESUCITATION

Discontinuation of resucitation of despite all step resuscitation heart beat remain absent after 15 minute stop resuscitation

HYPOXIC ISCHEMIC ENCEPHALOPATHY (HIE)

- 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 HIE- Alternating period of lethargy, irritability, Hyperalertness,

jitteriness- Poor feeding- Increased muscle tone, exaggerated deep tendon reflex.- Increase heart rate- Pupils : dilated- No seizures- Symtomps resolver in 24 hour

Grade II HIE- Lethargy- Poor feeding, depressed gag reflex- Hypotonia- Low heart rate and pupillary constriction indicating

parasympathetic stimulation- 50 – 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

MULTIORGAN SYSTEM DYSFUNCTION THAT MAYBE CAUSED BY NEONATAL ASPHYXIA

- Acute tubular necrosis : oliguria, hematuria, polyuria

- Cardiomyopathy : hypotension- Persistent pulmonary hypertension :

tachypnea, hypoxemia

OTHER MULTIORGAN SYSTEM DYSFUNCTION

- Hepatic necrosis : ↑ ammonia, jaundice,

- ↑ AST/ ALT- NEC : distention, bloody stools- Adrenal insufficiency : ↓ glucose, ↓

Na, BP ↓- Inappropiate secretion of ADH :

oliguria, ↓ Na

MANAGEMENT OF HIE

1. Prevention in the best management2. Timing is very crucial and a few minute of delay

can lead to death or life long suffering from handicap

3. Maintain oxygenation and acid base balance4. Start mechanical ventilation if necessary5. Monitor and maintain body temperature6. Correct 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. Administerb 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

if 40 mg/kb is reached10. No other theraoeutic interventions have been

proven helpful ie. Corticosteroids, prophylactic phenobarbital, furosemite, manitol, etc

TERIMAKASIH