SlideShare una empresa de Scribd logo
1 de 39
Descargar para leer sin conexión
1
EARLY NEONATAL DISEASES
RELATED TO ASPHYXIA
BY
DR. AYODELE, NOSRULLAH S
FMC, BIRNIN KEBBI
OUTLINE
 INTRODUCTION/OVERVIEW
 EPIDEMIOLOGY
 PREDISPOSING FACTORS
 AETIOPATHOGENESIS
 CLINICAL MANIFESTATION
 COMPLICATIONS
 NEUROLOGICAL COMPLICATIONS
 RENAL COMPLICATIONS
 PREVENTION
 SUMMARY
 CONCLUSION
 REFERENCES 2
INTRODUCTION
 Birth asphyxia can be defined as a clinical condition
characterised by inability/failure to initiate or sustain
spontaneous regular respiration leading to varying
degree of hypoxic and ischaemic injuries to body tissues
and organs.
 Historically categorized into two grades
 asphyxia livida (blue asphyxia) - blue appearance of the
newborn. Muscle tone is good and the infant is responsive to
stimuli
 asphyxia pallida (white/pale asphyxia) more severe, baby is
pale, flaccid and unresponsive to stimuli
3
INTRODUCTION
 Currently, birth asphyxia is graded into 3 categories
(mild, moderate and severe) using the APGAR SCORE 1
 According to the American College of Obstetricians and
Gynecologists and the American Academy of Pediatrics, a
neonate is labelled to be asphyxiated if the following
conditions are satisfied:
 Umbilical cord arterial pH <7
 Apgar score of 0–3 for longer than 5 min
 Neonatal neurological manifestations (e.g. seizures, coma or hypotonia);
and
 Multisystem organ dysfunction, e.g. cardiovascular, gastrointestinal,
haematological, pulmonary or renal system
4
INTRODUCTION
 Currently, birth asphyxia is graded into 3 categories
(mild, moderate and severe) as proposed by Sanart and
Sanart 2
 This grading depends mainly on the severity of the
clinical symptoms and signs
 Birth asphyxia can be caused by events in the
antepartum, the intrapartum or the postpartum periods
or combinations of all three.
 A recent review suggests that asphyxia is probably
primarily antepartum in 50% of cases, intrapartum in
40% and postpartum in the remaining 10% of cases 1
5
INTRODUCTION
 In developing countries intrapartum causes account for
a larger proportion of cases
 Poverty, ignorance, absence of standard health facilities
and trained birth attendants are impediments to the
management of birth asphyxia in Nigeria, and most
developing countries
6
EPIDEMIOLOGY
 According to the World Health Organization (WHO),
between 4 and 9 million newborns develop birth
asphyxia each year. 1
 About 1.2 million (23-30%) die and at least the same
number develop severe consequences, such as epilepsy,
cerebral palsy and developmental delay1
 Less than 0.1% of newborn infant deaths occur in
industrialized countries due improvements in primary
and obstetric care
7
PREDISPOSING FACTORS
 Any factors which interfere with the circulation
between maternal and fetal blood exchange (leading
to hypoxia) could result in the happens of perinatal
asphyxia.
 These factors can be maternal factor, fetal factor,
delivery factor or combination.
8
PREDISPOSING FACTORS
9
Maternal Fetal Delivery
Hypotension Multiple gestation Cord accidents
Hypertension Congenital
malformation
PROM
Diabetes Malpresentation Prolonged labour
Anaemia Preterm/prematurity Obstructed labour
Smoking Post maturity Meconium aspiration
Nephritis IUGR Oxytocin excess
Heart disease Chorioamnionitis
Extreme of age Abruptio placentae
Pre/eclampsia Placenta praevia
Drugs
AETIOPATHOGENESIS
 Interference with blood flow to the brain due to systemic
hypotension and a failure of autoregulation of cerebral blood
flow
 The initial circulatory response of the fetus is increased
shunting through the ductus venosus, ductus arteriosus, and
foramen ovale, with transient maintenance of perfusion of the
brain, heart, and adrenals in preference to the lungs, liver,
kidneys, and intestine (driving reflex).
 Persistence hypoxia produce ischaemia, a major factor in the
causation of brain damage.
 Ischaemia then causes neuronal and oligodendroglia damage
via excitoxicity of free radicals
10
AETIOPATHOGENESIS
11
Interference to cerebral blood flow
(hypotension, failure of autoregulation)
Hypoxia
Ischemia to the brain
Generation of free radicals
Reduced energy production (ATP)+ anaerobic glycolysis, lactic acidosis
Glutamate release + receptors (excitotoxic)
Change in membrane function (accumulation of Na+, NO in cells and release of Ca2+)
Cellular damage + oedema
(by affectation of mitochondrial function)
CLINICAL PRESENTATION
 Acidaemia, leading to an abnormal heart rate or rhythm
 Pallor
 Cyanosis
 Decreased tones and reflexes
 Poor or absent cry
 Gasping or poor respiratory effort
 Hypotonia
 Hyporeflexia
 Meconium stained liquor
 Ocular manifestation (fixed dilated pupils, nystagmus)
 Stupor
 Comma
12
INVESTIGATIONS
 No confirmatory test to diagnose asphyxia
 Investigations are done to assess the severity of brain injury
and to monitor the functional status of systemic organs.
 FBC
 Septic culture
 Urinalysis (ketones, ammonia)
 E/U/Cr
 Ultrasound scan
 CT – diffuse hypoattenuation
 MRI
 Electroencephalogram (EEG)
13
EARLY COMPLICATIONS
LATE COMPLICATIONS
 Developmental delay

Cerebral palsy

Mental retardation

Microcephaly

Behavioral abnormalities

Seizure disorders (epilepsy)
15
HYPOXIC-ISCHAEMIC
ENCEPHALOPATHY
 It is a clinical condition characterized by generalized
neurologic dysfunction emanating from hypoxic injury to
the rain tisssue
 It is an important cause of permanent damage to CNS
tissues that may result in neonatal death or manifest
later as cerebral palsy or developmental delay.4
 There are 3 clinical stages as proposed by Sarnat into
mild(HIE I), moderate (HIE II) and severe (HIE III) 2
16
CLINICAL PRESENTATION
Neonatal asphyxia
CLINICAL PRESENTATION
 Long term Sequelae
 Cognitive delay
 Cerebral palsy,
 Dystonia
 Seizure disorder
 Ataxia,
 Bulbar or pseudo-bulbar palsy.
19
MANAGEMENT
MANAGEMENT
 Supportive therapy
 Initially NPO
 Oxygen via face mask of nasal catheter
 Assisted ventilation when required
 Correction of hypoglycaemia
 Correction of electrolyte derangement and acidosis
 Fluid restriction to prevent cerebral oedema
 ? Prophylactic antibiotics
21
MANAGEMENT
 Control seizure with anticonvulsants
 1st – phenbarbitone (loading 20mg/kg slowly, maintain with
5-10mg/kg/day in 2 divided doses
 If seizure persists add phenytoin (20mg/kg loading dose)
 Diazepam (0.1-0.2mg/kg) 6 hrly
 lorazepam (0.1 mg/kg)
22
MANAGEMENT
 Reduction of cerebral injury by induced hypothermia
 Whole body (systemic) or selective cerebral therapeutic
hypothermia reduces mortality or major neurodevelopmental
impairment in term and near-term infants.
 Decreases the rate of apoptosis and suppresses production
of neurotoxic mediators e.g. extracellular glutamate, free
radicals, nitric oxide, and lactate
 Reduces mortality and neurodevelopmental impairment if
instituted within 6 hrs
23
MANAGEMENT
 Isolated cerebral cooling or systemic induced servo
controlled hypothermia to a core (rectal) temperature of
33.5°C (92.3°F)
 It works by prevention of cerebral reperfusion injury by
 reduction of brain metabolism,
 suppression of inflammatory cascade,
 decreased free radical formation
 cerebral vasoconstriction thereby reducing cerebral oedema
 Agents used include antipyretics, fans, cold fluids, water filled
blanket, ice packs or cooling caps
24
MANAGEMENT
 Commence feeding as soon as clinical condition
improves
 Complications of induced hypothermia include
 thrombocytopenia (usually without bleeding)
 reduced heart rate, and
 subcutaneous fat necrosis
 overcooling
25
MANAGEMENT
 Subsequent management include
 Counselling the parents on possible developmental problems
 Management of feeding difficultiy (may need NG tube for a long
period or gastrostomy in severe case)
 Physiotherapy for limitation of disability
 Speech and language therapy (SALT)
26
RENAL COMPLICATIONS
 The kidneys are very sensitive to oxygen deprivation,
 Renal insufficiency may occur within 24 hours of a
hypoxic ischaemic episode
 If prolonged, may lead to irreversible cortical necrosis
 Early recognition of renal failure is important in babies
with HIE to facilitate appropriate fluid and electrolyte
management
 Diagnosis of renal failure is difficult in neonates as
many of the established clinical and biochemical
parameters are unreliable in this age group 6
27
RENAL COMPLICATIONS
 May be in form of acute tubular necrosis, renal vein
thrombosis and renal failure
 Acute renal failure (ARF) occurs when there is a
sudden decrease in renal function accompanied by
abnormal retention of nitrogenous wastes and serum
creatinine level rises above 1.5mg/ dL. 8
 ARF is the commonest and carries a poor prognosis
and may even result in permanent renal damage in
up to 40% of survivors
 The type of ARF following asphyxia is either pre-renal
or intrinsic renal (ATN)
28
CLINICAL PRESENTATION
 History and clinical features of asphyxia
 Non-voiding of urine within 24 hours
29
INVESTIGATIONS
 Serum biochemistry
 electrolytes, urea, creatinine, calcium, phosphate
 Urinalysis and microscopy
 haematuria , haemoglobinuria, myoglobinuria, proteinuria
 Blood
 haemoglobin (evidence of polycythaemia)
 platelet count
 pH
 base deficit or bicarbonate
 Urine biochemistry
 Creatinine, sodium, osmolality,
30
INVESTIGATIONS
 Ultrasound (selected cases):
 abnormalities of renal structural or parenchyma
 renal tracts including bladder size
 Doppler assessment of renal vasculature
31
MANAGEMENT
 Management of pre-renal failure:
 Fluid challenge with Normal Saline or Hartmann’s Solution
20mL/kg over 1 hour.
 If there is no response, intravenous 2mg to 4mg/kg of
Frusemide is given.
 Management of persistent/intrinsic failure include:
 Twice daily recording of body weight
 Fluid restriction to insensible fluid loss (20 to 30mL/kg or
400ml/m2/day) and previous day urinary output.
 This may be given as 5% or 10% Dextrose infusion or
expressed breast milk via naso-gastric tube. 8
32
MANAGEMENT
 Monitor serum electrolytes, BUN and Creatinine at
least daily.
 Severe hyperkalaemia is managed with
 IV Salbutamol,
 IV 10% Calcium gluconate,
 IV 8.4% Sodium Bicarbonate
 and IV Soluble insulin 0.1IU/kg with 0.5g/kg Dextrose.
 Peritoneal dialysis as a form of Renal Replacement
Therapy is indicated by life-threatening electrolytes
derangements or fluid overload.
33
PREVENTION
 This entails prevention of birth asphyxia and
prevention of its complications when it occurs
 Follows the five levels of prevention
1. Health education (primary)- educate the masses about it
2. Specific protection(primary)- identify risks in pregnancy and
institute preventive measures
3. Early diagnosis and treatment (secondary) – identify and
treat asphyxia promptly
4. Limitation of disability (tertiary) - physiotherapy
5. Rehabilitation (tertiary) – integration of the baby and the
mother into the community
34
SUMMARY
 Birth asphyxia results from inadequate oxygen supply to
the organs causing varying degrees of ischaemic injury
depending on severity
 Virtually all organs of the body are affected, worst on
the brain, kidneys, heart
 The effect can be immediate and may resolve with
appropriate management
 Long term sequalae may follow which include cerebral
palsy, seizure disorders, ental retardation and behavioral
abnormalities
 Oxygen therapy, fluid, calorie and electrolyte
management and thermal control are key in the
management
35
CONCLUSION
 Perinatal asphyxia remains a leading cause of infant
morbidity and mortality especially in the developing
world.
 Prompt diagnosis and appropriate management
instituted early in the disease course will help to
avert death and also give a better outcome both in
the immediate period and later in life.
36
REFERENCES
1. Ezeogu, Joseph. Birth Asphyxia in Nigeria; A Review.. Trop J Med Sc
and Health Research. Birth Asphyxia in Nigeria; A Review. Emechebe
GO, Ezeogu J, Odinaka KK. Trop J Med Sc and Health Research
2016:5; 6-11. 6-11.
2. Sarnat HB, Sarnat MS. Neonatal Encephalopathy Following Fetal
Distress: A Clinical and Electroencephalographic Study. Arch Neurol.
1976;33(10): 696-705.
3. Rainaldi MA, Perlman JM. Pathophysiology of birth asphyxia. Clinics
in perinatology. 2016 Sep 1;43(3):409-22.
4. Kliegman, Robert, Richard E. Behrman, and Waldo E. Nelson. Nelson
textbook of pediatrics. 20th edition (2016).
5. Mark Luscombe John C Andrzejowski. Clinical applications of induced
hypothermia. Continuing Education in Anaesthesia Critical Care &
Pain, Volume 6, Issue 1, 1 February 2006, Pages 23–27,
https://doi.org/10.1093/bjaceaccp/mki064 37
REFERENCES
6. Gupta BD, Sharma P, Bagla J, Parakh M, Soni JP. Renal failure in
asphyxiated neonates. Indian pediatrics. 2005 Sep 1;42(9):928.
7. Medani SA, Kheir AEM, Mohamed MB. Acute kidney injury in
asphyxiated neonates admitted to a tertiary neonatal unit in
Sudan. Sudan J Paediatr 2014; 14(2):29 - 34.
8. Ogunlesi TA, Adekanmbi F. Evaluating and managing neonatal
acute renal failure in a resource-poor setting. The Indian Journal of
Pediatrics. 2009 Mar 1;76(3):293-6.
9. Moghal NE, Embleton ND. Management of acute renal failure in the
newborn. In Seminars in Fetal and Neonatal Medicine 2006 Jun 1
(Vol. 11, No. 3, pp. 207-213). Elsevier.
38
39
THANK YOU
FOR LISTENING

Más contenido relacionado

La actualidad más candente

Perinatal asphyxia
Perinatal asphyxiaPerinatal asphyxia
Perinatal asphyxiaVarsha Shah
 
Neonatal jaundice - 2017
Neonatal jaundice   - 2017Neonatal jaundice   - 2017
Neonatal jaundice - 2017Sayed Ahmed
 
Hypertension in pregnancy
Hypertension in pregnancyHypertension in pregnancy
Hypertension in pregnancyRashna Sharmin
 
Nephrotic syndrome in children
Nephrotic syndrome in childrenNephrotic syndrome in children
Nephrotic syndrome in childrenShriyans Jain
 
Asphyxia neonatorum
Asphyxia neonatorumAsphyxia neonatorum
Asphyxia neonatorumVarsha Shah
 
Antepartum haemorrhage
Antepartum haemorrhageAntepartum haemorrhage
Antepartum haemorrhageHui Pheng Neoh
 
Birth injuries
Birth injuriesBirth injuries
Birth injuriesAruna Ap
 
Breech presentation
 Breech presentation Breech presentation
Breech presentationobgymgmcri
 
bronchiolitis in paediatrics
bronchiolitis in paediatricsbronchiolitis in paediatrics
bronchiolitis in paediatricsmeducationdotnet
 
Management of lbw low birthweight babies
Management of lbw low birthweight babiesManagement of lbw low birthweight babies
Management of lbw low birthweight babiesVarsha Shah
 
Respiratory distress syndrome
Respiratory distress syndromeRespiratory distress syndrome
Respiratory distress syndromeNisha Ghimire
 
Meconium aspiration syndrome
Meconium aspiration syndromeMeconium aspiration syndrome
Meconium aspiration syndromeLALIT KARKI
 

La actualidad más candente (20)

Puerperal sepsis
Puerperal sepsisPuerperal sepsis
Puerperal sepsis
 
Hypothermia in newborn
Hypothermia in newbornHypothermia in newborn
Hypothermia in newborn
 
Perinatal asphyxia
Perinatal asphyxiaPerinatal asphyxia
Perinatal asphyxia
 
Aph
AphAph
Aph
 
Neonatal jaundice - 2017
Neonatal jaundice   - 2017Neonatal jaundice   - 2017
Neonatal jaundice - 2017
 
Hypertension in pregnancy
Hypertension in pregnancyHypertension in pregnancy
Hypertension in pregnancy
 
Meningitis In Children
Meningitis  In ChildrenMeningitis  In Children
Meningitis In Children
 
Nephrotic syndrome in children
Nephrotic syndrome in childrenNephrotic syndrome in children
Nephrotic syndrome in children
 
Asphyxia neonatorum
Asphyxia neonatorumAsphyxia neonatorum
Asphyxia neonatorum
 
Antepartum haemorrhage
Antepartum haemorrhageAntepartum haemorrhage
Antepartum haemorrhage
 
Birth injuries
Birth injuriesBirth injuries
Birth injuries
 
Oligohydramnios
OligohydramniosOligohydramnios
Oligohydramnios
 
Preterm
PretermPreterm
Preterm
 
Breech presentation
 Breech presentation Breech presentation
Breech presentation
 
bronchiolitis in paediatrics
bronchiolitis in paediatricsbronchiolitis in paediatrics
bronchiolitis in paediatrics
 
Management of lbw low birthweight babies
Management of lbw low birthweight babiesManagement of lbw low birthweight babies
Management of lbw low birthweight babies
 
Respiratory distress syndrome
Respiratory distress syndromeRespiratory distress syndrome
Respiratory distress syndrome
 
Postpartum hemorrhage
Postpartum hemorrhage Postpartum hemorrhage
Postpartum hemorrhage
 
Meconium aspiration syndrome
Meconium aspiration syndromeMeconium aspiration syndrome
Meconium aspiration syndrome
 
Low birth weight
Low birth weightLow birth weight
Low birth weight
 

Similar a Neonatal asphyxia

Similar a Neonatal asphyxia (20)

Birth asphyxia
Birth asphyxiaBirth asphyxia
Birth asphyxia
 
Asphyxia
AsphyxiaAsphyxia
Asphyxia
 
1. asphyxia.PPT
1. asphyxia.PPT1. asphyxia.PPT
1. asphyxia.PPT
 
Management of Asphyxia
Management of AsphyxiaManagement of Asphyxia
Management of Asphyxia
 
Hypoxic Ischemic Encephalopathy
Hypoxic Ischemic EncephalopathyHypoxic Ischemic Encephalopathy
Hypoxic Ischemic Encephalopathy
 
12. Curs Asfixia
12. Curs Asfixia12. Curs Asfixia
12. Curs Asfixia
 
Perinatalasphyxia
PerinatalasphyxiaPerinatalasphyxia
Perinatalasphyxia
 
asphyxia.PPT
asphyxia.PPTasphyxia.PPT
asphyxia.PPT
 
Perinatal asphyxia
Perinatal asphyxiaPerinatal asphyxia
Perinatal asphyxia
 
Hie ppt
Hie pptHie ppt
Hie ppt
 
Hie ppt
Hie pptHie ppt
Hie ppt
 
Neonatal seziure
Neonatal seziureNeonatal seziure
Neonatal seziure
 
asphyxia neonatorum.pptx
asphyxia neonatorum.pptxasphyxia neonatorum.pptx
asphyxia neonatorum.pptx
 
Birth asphyxia
Birth asphyxiaBirth asphyxia
Birth asphyxia
 
BA.pptx
BA.pptxBA.pptx
BA.pptx
 
Copy of PERINATAL_ASPHYXIA.pptx
Copy of PERINATAL_ASPHYXIA.pptxCopy of PERINATAL_ASPHYXIA.pptx
Copy of PERINATAL_ASPHYXIA.pptx
 
Asphyxia Neonetrium.pptx for the obstretics
Asphyxia Neonetrium.pptx for the obstreticsAsphyxia Neonetrium.pptx for the obstretics
Asphyxia Neonetrium.pptx for the obstretics
 
Hie
HieHie
Hie
 
缺氧缺血性脑病(英文)2009
缺氧缺血性脑病(英文)2009缺氧缺血性脑病(英文)2009
缺氧缺血性脑病(英文)2009
 
birthasphyxia-220522183549-29b3fd18 (1).pdf
birthasphyxia-220522183549-29b3fd18 (1).pdfbirthasphyxia-220522183549-29b3fd18 (1).pdf
birthasphyxia-220522183549-29b3fd18 (1).pdf
 

Más de Nosrullah Ayodele

Más de Nosrullah Ayodele (10)

Polycystic ovarian syndrome
Polycystic ovarian syndromePolycystic ovarian syndrome
Polycystic ovarian syndrome
 
Cervical cancer
Cervical cancerCervical cancer
Cervical cancer
 
Gestational trophoblastic diseases
Gestational trophoblastic diseasesGestational trophoblastic diseases
Gestational trophoblastic diseases
 
Neonatal resuscitation
Neonatal resuscitationNeonatal resuscitation
Neonatal resuscitation
 
Physiology of transition
Physiology of transitionPhysiology of transition
Physiology of transition
 
Newborn feeding
Newborn feedingNewborn feeding
Newborn feeding
 
Neonatal jaundice
Neonatal jaundiceNeonatal jaundice
Neonatal jaundice
 
Neonatal infections
Neonatal infectionsNeonatal infections
Neonatal infections
 
Neonatal assessment
Neonatal assessmentNeonatal assessment
Neonatal assessment
 
High risk infants
High risk infantsHigh risk infants
High risk infants
 

Último

CPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing studentCPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing studentsaileshpanda05
 
Basic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptxBasic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptxkomalt2001
 
Using Data Visualization in Public Health Communications
Using Data Visualization in Public Health CommunicationsUsing Data Visualization in Public Health Communications
Using Data Visualization in Public Health Communicationskatiequigley33
 
"Radical excision of DIE in subferile women with deep infiltrating endometrio...
"Radical excision of DIE in subferile women with deep infiltrating endometrio..."Radical excision of DIE in subferile women with deep infiltrating endometrio...
"Radical excision of DIE in subferile women with deep infiltrating endometrio...Sujoy Dasgupta
 
Understanding AIDS:a roadmap to well ess
Understanding AIDS:a roadmap to well essUnderstanding AIDS:a roadmap to well ess
Understanding AIDS:a roadmap to well essAbhishekKumar524514
 
blood bank management system project report
blood bank management system project reportblood bank management system project report
blood bank management system project reportNARMADAPETROLEUMGAS
 
A presentation on Thermal gravimetry analysis (TGA)
A presentation on Thermal gravimetry analysis (TGA)A presentation on Thermal gravimetry analysis (TGA)
A presentation on Thermal gravimetry analysis (TGA)1922Jaygohel
 
PAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdf
PAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdfPAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdf
PAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdfDolisha Warbi
 
Arthroscopic Surgery in Indore : A Minimally Invasive Guide to Joint Health
Arthroscopic Surgery in Indore : A Minimally Invasive Guide to Joint HealthArthroscopic Surgery in Indore : A Minimally Invasive Guide to Joint Health
Arthroscopic Surgery in Indore : A Minimally Invasive Guide to Joint HealthGokuldas Hospital
 
MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.whalesdesign
 
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdfSGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdfHongBiThi1
 
Generative AI in Health Care a scoping review and a persoanl experience.
Generative AI in Health Care a scoping review and a persoanl experience.Generative AI in Health Care a scoping review and a persoanl experience.
Generative AI in Health Care a scoping review and a persoanl experience.Vaikunthan Rajaratnam
 
ayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologypptayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologypptPradnya Wadekar
 
Female Reproductive Physiology Before Pregnancy
Female Reproductive Physiology Before PregnancyFemale Reproductive Physiology Before Pregnancy
Female Reproductive Physiology Before PregnancyMedicoseAcademics
 
AUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functionsAUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functionsMedicoseAcademics
 
DNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptx
DNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptxDNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptx
DNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptxMAsifAhmad
 
Cure of patients which terminally ill.pdf
Cure of patients which terminally ill.pdfCure of patients which terminally ill.pdf
Cure of patients which terminally ill.pdfrg0000009
 

Último (20)

CPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing studentCPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing student
 
Basic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptxBasic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptx
 
Using Data Visualization in Public Health Communications
Using Data Visualization in Public Health CommunicationsUsing Data Visualization in Public Health Communications
Using Data Visualization in Public Health Communications
 
"Radical excision of DIE in subferile women with deep infiltrating endometrio...
"Radical excision of DIE in subferile women with deep infiltrating endometrio..."Radical excision of DIE in subferile women with deep infiltrating endometrio...
"Radical excision of DIE in subferile women with deep infiltrating endometrio...
 
Understanding AIDS:a roadmap to well ess
Understanding AIDS:a roadmap to well essUnderstanding AIDS:a roadmap to well ess
Understanding AIDS:a roadmap to well ess
 
Rheumatoid arthritis Part 1, case based approach with application of the late...
Rheumatoid arthritis Part 1, case based approach with application of the late...Rheumatoid arthritis Part 1, case based approach with application of the late...
Rheumatoid arthritis Part 1, case based approach with application of the late...
 
blood bank management system project report
blood bank management system project reportblood bank management system project report
blood bank management system project report
 
A presentation on Thermal gravimetry analysis (TGA)
A presentation on Thermal gravimetry analysis (TGA)A presentation on Thermal gravimetry analysis (TGA)
A presentation on Thermal gravimetry analysis (TGA)
 
PAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdf
PAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdfPAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdf
PAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdf
 
Arthroscopic Surgery in Indore : A Minimally Invasive Guide to Joint Health
Arthroscopic Surgery in Indore : A Minimally Invasive Guide to Joint HealthArthroscopic Surgery in Indore : A Minimally Invasive Guide to Joint Health
Arthroscopic Surgery in Indore : A Minimally Invasive Guide to Joint Health
 
MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.
 
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdfSGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
 
Generative AI in Health Care a scoping review and a persoanl experience.
Generative AI in Health Care a scoping review and a persoanl experience.Generative AI in Health Care a scoping review and a persoanl experience.
Generative AI in Health Care a scoping review and a persoanl experience.
 
ayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologypptayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologyppt
 
Female Reproductive Physiology Before Pregnancy
Female Reproductive Physiology Before PregnancyFemale Reproductive Physiology Before Pregnancy
Female Reproductive Physiology Before Pregnancy
 
AUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functionsAUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functions
 
Biologic therapy ice breaking in rheumatology, Case based approach with appli...
Biologic therapy ice breaking in rheumatology, Case based approach with appli...Biologic therapy ice breaking in rheumatology, Case based approach with appli...
Biologic therapy ice breaking in rheumatology, Case based approach with appli...
 
DNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptx
DNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptxDNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptx
DNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptx
 
Cure of patients which terminally ill.pdf
Cure of patients which terminally ill.pdfCure of patients which terminally ill.pdf
Cure of patients which terminally ill.pdf
 
GOUT UPDATE AHMED YEHIA 2024, case based approach with application of the lat...
GOUT UPDATE AHMED YEHIA 2024, case based approach with application of the lat...GOUT UPDATE AHMED YEHIA 2024, case based approach with application of the lat...
GOUT UPDATE AHMED YEHIA 2024, case based approach with application of the lat...
 

Neonatal asphyxia

  • 1. 1 EARLY NEONATAL DISEASES RELATED TO ASPHYXIA BY DR. AYODELE, NOSRULLAH S FMC, BIRNIN KEBBI
  • 2. OUTLINE  INTRODUCTION/OVERVIEW  EPIDEMIOLOGY  PREDISPOSING FACTORS  AETIOPATHOGENESIS  CLINICAL MANIFESTATION  COMPLICATIONS  NEUROLOGICAL COMPLICATIONS  RENAL COMPLICATIONS  PREVENTION  SUMMARY  CONCLUSION  REFERENCES 2
  • 3. INTRODUCTION  Birth asphyxia can be defined as a clinical condition characterised by inability/failure to initiate or sustain spontaneous regular respiration leading to varying degree of hypoxic and ischaemic injuries to body tissues and organs.  Historically categorized into two grades  asphyxia livida (blue asphyxia) - blue appearance of the newborn. Muscle tone is good and the infant is responsive to stimuli  asphyxia pallida (white/pale asphyxia) more severe, baby is pale, flaccid and unresponsive to stimuli 3
  • 4. INTRODUCTION  Currently, birth asphyxia is graded into 3 categories (mild, moderate and severe) using the APGAR SCORE 1  According to the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics, a neonate is labelled to be asphyxiated if the following conditions are satisfied:  Umbilical cord arterial pH <7  Apgar score of 0–3 for longer than 5 min  Neonatal neurological manifestations (e.g. seizures, coma or hypotonia); and  Multisystem organ dysfunction, e.g. cardiovascular, gastrointestinal, haematological, pulmonary or renal system 4
  • 5. INTRODUCTION  Currently, birth asphyxia is graded into 3 categories (mild, moderate and severe) as proposed by Sanart and Sanart 2  This grading depends mainly on the severity of the clinical symptoms and signs  Birth asphyxia can be caused by events in the antepartum, the intrapartum or the postpartum periods or combinations of all three.  A recent review suggests that asphyxia is probably primarily antepartum in 50% of cases, intrapartum in 40% and postpartum in the remaining 10% of cases 1 5
  • 6. INTRODUCTION  In developing countries intrapartum causes account for a larger proportion of cases  Poverty, ignorance, absence of standard health facilities and trained birth attendants are impediments to the management of birth asphyxia in Nigeria, and most developing countries 6
  • 7. EPIDEMIOLOGY  According to the World Health Organization (WHO), between 4 and 9 million newborns develop birth asphyxia each year. 1  About 1.2 million (23-30%) die and at least the same number develop severe consequences, such as epilepsy, cerebral palsy and developmental delay1  Less than 0.1% of newborn infant deaths occur in industrialized countries due improvements in primary and obstetric care 7
  • 8. PREDISPOSING FACTORS  Any factors which interfere with the circulation between maternal and fetal blood exchange (leading to hypoxia) could result in the happens of perinatal asphyxia.  These factors can be maternal factor, fetal factor, delivery factor or combination. 8
  • 9. PREDISPOSING FACTORS 9 Maternal Fetal Delivery Hypotension Multiple gestation Cord accidents Hypertension Congenital malformation PROM Diabetes Malpresentation Prolonged labour Anaemia Preterm/prematurity Obstructed labour Smoking Post maturity Meconium aspiration Nephritis IUGR Oxytocin excess Heart disease Chorioamnionitis Extreme of age Abruptio placentae Pre/eclampsia Placenta praevia Drugs
  • 10. AETIOPATHOGENESIS  Interference with blood flow to the brain due to systemic hypotension and a failure of autoregulation of cerebral blood flow  The initial circulatory response of the fetus is increased shunting through the ductus venosus, ductus arteriosus, and foramen ovale, with transient maintenance of perfusion of the brain, heart, and adrenals in preference to the lungs, liver, kidneys, and intestine (driving reflex).  Persistence hypoxia produce ischaemia, a major factor in the causation of brain damage.  Ischaemia then causes neuronal and oligodendroglia damage via excitoxicity of free radicals 10
  • 11. AETIOPATHOGENESIS 11 Interference to cerebral blood flow (hypotension, failure of autoregulation) Hypoxia Ischemia to the brain Generation of free radicals Reduced energy production (ATP)+ anaerobic glycolysis, lactic acidosis Glutamate release + receptors (excitotoxic) Change in membrane function (accumulation of Na+, NO in cells and release of Ca2+) Cellular damage + oedema (by affectation of mitochondrial function)
  • 12. CLINICAL PRESENTATION  Acidaemia, leading to an abnormal heart rate or rhythm  Pallor  Cyanosis  Decreased tones and reflexes  Poor or absent cry  Gasping or poor respiratory effort  Hypotonia  Hyporeflexia  Meconium stained liquor  Ocular manifestation (fixed dilated pupils, nystagmus)  Stupor  Comma 12
  • 13. INVESTIGATIONS  No confirmatory test to diagnose asphyxia  Investigations are done to assess the severity of brain injury and to monitor the functional status of systemic organs.  FBC  Septic culture  Urinalysis (ketones, ammonia)  E/U/Cr  Ultrasound scan  CT – diffuse hypoattenuation  MRI  Electroencephalogram (EEG) 13
  • 15. LATE COMPLICATIONS  Developmental delay  Cerebral palsy  Mental retardation  Microcephaly  Behavioral abnormalities  Seizure disorders (epilepsy) 15
  • 16. HYPOXIC-ISCHAEMIC ENCEPHALOPATHY  It is a clinical condition characterized by generalized neurologic dysfunction emanating from hypoxic injury to the rain tisssue  It is an important cause of permanent damage to CNS tissues that may result in neonatal death or manifest later as cerebral palsy or developmental delay.4  There are 3 clinical stages as proposed by Sarnat into mild(HIE I), moderate (HIE II) and severe (HIE III) 2 16
  • 19. CLINICAL PRESENTATION  Long term Sequelae  Cognitive delay  Cerebral palsy,  Dystonia  Seizure disorder  Ataxia,  Bulbar or pseudo-bulbar palsy. 19
  • 21. MANAGEMENT  Supportive therapy  Initially NPO  Oxygen via face mask of nasal catheter  Assisted ventilation when required  Correction of hypoglycaemia  Correction of electrolyte derangement and acidosis  Fluid restriction to prevent cerebral oedema  ? Prophylactic antibiotics 21
  • 22. MANAGEMENT  Control seizure with anticonvulsants  1st – phenbarbitone (loading 20mg/kg slowly, maintain with 5-10mg/kg/day in 2 divided doses  If seizure persists add phenytoin (20mg/kg loading dose)  Diazepam (0.1-0.2mg/kg) 6 hrly  lorazepam (0.1 mg/kg) 22
  • 23. MANAGEMENT  Reduction of cerebral injury by induced hypothermia  Whole body (systemic) or selective cerebral therapeutic hypothermia reduces mortality or major neurodevelopmental impairment in term and near-term infants.  Decreases the rate of apoptosis and suppresses production of neurotoxic mediators e.g. extracellular glutamate, free radicals, nitric oxide, and lactate  Reduces mortality and neurodevelopmental impairment if instituted within 6 hrs 23
  • 24. MANAGEMENT  Isolated cerebral cooling or systemic induced servo controlled hypothermia to a core (rectal) temperature of 33.5°C (92.3°F)  It works by prevention of cerebral reperfusion injury by  reduction of brain metabolism,  suppression of inflammatory cascade,  decreased free radical formation  cerebral vasoconstriction thereby reducing cerebral oedema  Agents used include antipyretics, fans, cold fluids, water filled blanket, ice packs or cooling caps 24
  • 25. MANAGEMENT  Commence feeding as soon as clinical condition improves  Complications of induced hypothermia include  thrombocytopenia (usually without bleeding)  reduced heart rate, and  subcutaneous fat necrosis  overcooling 25
  • 26. MANAGEMENT  Subsequent management include  Counselling the parents on possible developmental problems  Management of feeding difficultiy (may need NG tube for a long period or gastrostomy in severe case)  Physiotherapy for limitation of disability  Speech and language therapy (SALT) 26
  • 27. RENAL COMPLICATIONS  The kidneys are very sensitive to oxygen deprivation,  Renal insufficiency may occur within 24 hours of a hypoxic ischaemic episode  If prolonged, may lead to irreversible cortical necrosis  Early recognition of renal failure is important in babies with HIE to facilitate appropriate fluid and electrolyte management  Diagnosis of renal failure is difficult in neonates as many of the established clinical and biochemical parameters are unreliable in this age group 6 27
  • 28. RENAL COMPLICATIONS  May be in form of acute tubular necrosis, renal vein thrombosis and renal failure  Acute renal failure (ARF) occurs when there is a sudden decrease in renal function accompanied by abnormal retention of nitrogenous wastes and serum creatinine level rises above 1.5mg/ dL. 8  ARF is the commonest and carries a poor prognosis and may even result in permanent renal damage in up to 40% of survivors  The type of ARF following asphyxia is either pre-renal or intrinsic renal (ATN) 28
  • 29. CLINICAL PRESENTATION  History and clinical features of asphyxia  Non-voiding of urine within 24 hours 29
  • 30. INVESTIGATIONS  Serum biochemistry  electrolytes, urea, creatinine, calcium, phosphate  Urinalysis and microscopy  haematuria , haemoglobinuria, myoglobinuria, proteinuria  Blood  haemoglobin (evidence of polycythaemia)  platelet count  pH  base deficit or bicarbonate  Urine biochemistry  Creatinine, sodium, osmolality, 30
  • 31. INVESTIGATIONS  Ultrasound (selected cases):  abnormalities of renal structural or parenchyma  renal tracts including bladder size  Doppler assessment of renal vasculature 31
  • 32. MANAGEMENT  Management of pre-renal failure:  Fluid challenge with Normal Saline or Hartmann’s Solution 20mL/kg over 1 hour.  If there is no response, intravenous 2mg to 4mg/kg of Frusemide is given.  Management of persistent/intrinsic failure include:  Twice daily recording of body weight  Fluid restriction to insensible fluid loss (20 to 30mL/kg or 400ml/m2/day) and previous day urinary output.  This may be given as 5% or 10% Dextrose infusion or expressed breast milk via naso-gastric tube. 8 32
  • 33. MANAGEMENT  Monitor serum electrolytes, BUN and Creatinine at least daily.  Severe hyperkalaemia is managed with  IV Salbutamol,  IV 10% Calcium gluconate,  IV 8.4% Sodium Bicarbonate  and IV Soluble insulin 0.1IU/kg with 0.5g/kg Dextrose.  Peritoneal dialysis as a form of Renal Replacement Therapy is indicated by life-threatening electrolytes derangements or fluid overload. 33
  • 34. PREVENTION  This entails prevention of birth asphyxia and prevention of its complications when it occurs  Follows the five levels of prevention 1. Health education (primary)- educate the masses about it 2. Specific protection(primary)- identify risks in pregnancy and institute preventive measures 3. Early diagnosis and treatment (secondary) – identify and treat asphyxia promptly 4. Limitation of disability (tertiary) - physiotherapy 5. Rehabilitation (tertiary) – integration of the baby and the mother into the community 34
  • 35. SUMMARY  Birth asphyxia results from inadequate oxygen supply to the organs causing varying degrees of ischaemic injury depending on severity  Virtually all organs of the body are affected, worst on the brain, kidneys, heart  The effect can be immediate and may resolve with appropriate management  Long term sequalae may follow which include cerebral palsy, seizure disorders, ental retardation and behavioral abnormalities  Oxygen therapy, fluid, calorie and electrolyte management and thermal control are key in the management 35
  • 36. CONCLUSION  Perinatal asphyxia remains a leading cause of infant morbidity and mortality especially in the developing world.  Prompt diagnosis and appropriate management instituted early in the disease course will help to avert death and also give a better outcome both in the immediate period and later in life. 36
  • 37. REFERENCES 1. Ezeogu, Joseph. Birth Asphyxia in Nigeria; A Review.. Trop J Med Sc and Health Research. Birth Asphyxia in Nigeria; A Review. Emechebe GO, Ezeogu J, Odinaka KK. Trop J Med Sc and Health Research 2016:5; 6-11. 6-11. 2. Sarnat HB, Sarnat MS. Neonatal Encephalopathy Following Fetal Distress: A Clinical and Electroencephalographic Study. Arch Neurol. 1976;33(10): 696-705. 3. Rainaldi MA, Perlman JM. Pathophysiology of birth asphyxia. Clinics in perinatology. 2016 Sep 1;43(3):409-22. 4. Kliegman, Robert, Richard E. Behrman, and Waldo E. Nelson. Nelson textbook of pediatrics. 20th edition (2016). 5. Mark Luscombe John C Andrzejowski. Clinical applications of induced hypothermia. Continuing Education in Anaesthesia Critical Care & Pain, Volume 6, Issue 1, 1 February 2006, Pages 23–27, https://doi.org/10.1093/bjaceaccp/mki064 37
  • 38. REFERENCES 6. Gupta BD, Sharma P, Bagla J, Parakh M, Soni JP. Renal failure in asphyxiated neonates. Indian pediatrics. 2005 Sep 1;42(9):928. 7. Medani SA, Kheir AEM, Mohamed MB. Acute kidney injury in asphyxiated neonates admitted to a tertiary neonatal unit in Sudan. Sudan J Paediatr 2014; 14(2):29 - 34. 8. Ogunlesi TA, Adekanmbi F. Evaluating and managing neonatal acute renal failure in a resource-poor setting. The Indian Journal of Pediatrics. 2009 Mar 1;76(3):293-6. 9. Moghal NE, Embleton ND. Management of acute renal failure in the newborn. In Seminars in Fetal and Neonatal Medicine 2006 Jun 1 (Vol. 11, No. 3, pp. 207-213). Elsevier. 38