PERINATAL ASPHYXIA

Dr.LORN TRY
Patrich,Pediatrician.DHM

Dr.LORN TRY Patrich,pediatrician,DHM

 DEFINITION
 Perinatal asphyxia as condition in the
neonate where there is the following
combination:
– An event or condition during the perinatal period
that is likely to severely reduce oxygen delivery
and lead to acidosis.
– A failure of function of at least two organs
(include lung, heart, liver, brain, kidneys, and
hematological) consistent with the effects of
acute asphyxia.

Dr.LORN TRY Patrich,pediatrician,DHM

 RISK FACTOR
 Hypertensive disease of pregnancy or preeclampsia.
 Intrauterine growth restriction
 Placental abruption
 Fetal anemia (eg rhesus incompatible)
 Post maturity
 Malpresentation
 cord compression
 transplacental anaesthetic or narcotic administration
 severe meconium aspiration
 congenital cardiac or pulmonary anomalies
 birth trauma
 intrauterine pneumonia

Dr.LORN TRY Patrich,pediatrician,DHM

 D’APGAR SCORE
 D’apgar Scoreis based on 5 vital signs :
– Heart rate
– Respiratory effort
– Present or absence of central or peripheral cyanosis
– Muscle tone
– Response to stimulation
 Each vital signs is given a score 0 or 1 or 2. A vital
sign score of 2 is normal.A score 1 mildly
abnormal .A score 0 is severity abnormal.
 Normally D’apgare score is of 7 to 10:
– 4 – 6 Moderate depression
– 0-3 severely depress vital signs and great risk of dying
unless actively resuscitated.

Dr.LORN TRY Patrich,pediatrician,DHM

 CLINICAL DIAGNOSIS
 At delivery
– Abnormal fetal heart rate
– Meconium staining of the liquor
 At birth
– Apgar score < 7 at 5 minutes
– Acidosis pH< 7
 Post natal
– Hypoxic ischemic encephalopathy
– Multiorgan system dysfonctionnement (Liver, Kedney,
heart, brain)

Dr.LORN TRY Patrich,pediatrician,DHM

 INTERVENTION
 Principle:
– Correct of hypoglycemia
– Correction of acidosis
– Treatment of seizures
– Temperature: Maintain core temperature 36-37 o- 37o .
– Respiratory status : Meconium aspiration, oxygene
– Cardiac status : Cardiac ECHO
– Fluid therapy and renal impairment:electrolytes and
creatinine should be performed.
– Gastro-intesinal-feeding: Brest milk is preferred.

Dr.LORN TRY Patrich,pediatrician,DHM

 PREDICTION OF OUTCOME
 During resuscitation
a) Apgar scores
– Although the 1 and 5 minutes Apgar scores, are
poor predictors of neonatal.
– Apgars score 0-3 at 20 minutes ,59% of survivors
died before 1 year, and 57 % of the survivors had
cerebral palsy.
b) Time to spontaneous respirations
• The overall risk of death or handicap was 72% in
the pooled seri of infants with > 30 minutes to
substained spontaneous resppiration

Dr.LORN TRY Patrich,pediatrician,DHM

PREDICTION OF OUTCOME(Count)
 Clinical assessment of encephalopathy the overall risk of
death or severe handicap in a pooled serie of infant was:
– Grade 1 : HIE 1.6%
– Grade 2 : HIE 24%
– Grade 3 : HIE 78%
 Grade of HIE
– Grade 1 : Mild encephalopathy with infant hyperalert,
and over sensitive to stimulation EEG is
normal,tarchycardia,dilated pupils.
– Grade 2 : moderate encephalopathy with the infant
displaying lethargy, hypotonie. EEG abnormal , 70% of
infants will have seizure, small pupils.
– Grade 3 : Severe encephalopathy with a stuporous
absent reflexes .The infant may have seizures and has
abnormal EEG with decreased background activity
Dr.LORN TRY Patrich,pediatrician,DHM
NEONATAL HYPOGLYCEMIA

Dr.LORN TRY Patrich,Pediatrician,DHM

Dr.LORN TRY Patrich,pediatrician,DHM

 DEFINITION
 Glycemia < 1.1 mmol/l(1mmol/l=180mg/l) in
growth retarded and preterm; < 1.7 mmol/l in term
baby :
– In at risk asymptomatic term or near term baby ( 36
weeks ) BGL should be maintained about 1.5 mmol/l
– In preterm babies ( < 35 weeks) or sick term babies
BGL should be maintained about 2.5 mmol/l.

Dr.LORN TRY Patrich,pediatrician,DHM

 RISKS FACTORS
 Infants of diabetic mothers
 Growth restricted babies
 Preterm babies
 Macrosomie babies (may have hyperinsulinism)
 Sick babies including these with:
– Pernatal asphyxia
– Rhesus diseas
– Sepsis
– Polycythaemia

Dr.LORN TRY Patrich,pediatrician,DHM

 CLINICAL DIAGNOSIS
 Irritability
 Apnea and cyanosis
 Hypotonia and poor feeding
 Convulsions

Dr.LORN TRY Patrich,pediatrician,DHM

PREVENTION and TREATMENT
 Prevention at risk infant
– Infant of all diabetic mothers
– Small for gestational age infants
– Wasted “babies”( < 3rd centil)
– Preterm babies (< 37 weeks )
– Macrosomies baby
Need attention paid to early establishement of breast
feeding .

Dr.LORN TRY Patrich,pediatrician,DHM

 WHEN SHOULD ACTIVE
INTERVENTION BE STARTED?
 Glycemia =1.5-2mmol/l
– Admit to NICU
– Continue breast, complements or tube feeds
– Commence IV 10% dextrose if BSL not maintained
about 2 mmol/l
 Glycemia = 1 – 1.5 mmol/l
– Admit to NICU
– Continue IV 10% dextrosee at 60-90mls/kg/day to
maintain normal blood glucose.

Dr.LORN TRY Patrich,pediatrician,DHM

 WHEN SHOULD ACTIVE
INTERVENTION BE STARTED?(Counti)
 Glycemia < 1 mmol/l
– Admit to NICU urgently
– Give IV bolus of 10% dextrose at 2.5mls/kg
– Ensure BSL has increased to > 1.5 mmol/l
– Contious IV 10% dextrose at 60-90 mls/Kg/day to
maintain normal blood glucose.
 Persistent severe hypoglycemia: We should interpretation
of hormone levels and take some blood for : Insulin,
Cortisol, Growth hormone. The treatment :
– Increase volume by 30 ml/kg/day.
– Increase the glucose concentration to 12.5%
– If still persisting.Start a glucagon infusion
Dr.LORN TRY Patrich,pediatrician,DHM
 RESUSCITATION

Dr.LORN TRY Patrich,pediatrician,DHM

Dr.LORN TRY Patrich,pediatrician,DHM

 INTRODUCTION
 Approximately 1-10% of in hospital delivered newborns
require resuscitation. The aim of resuscitation is to prevent
neonatal death and adverse long term neurodevelopmental
sequelae associated with asphyxia.
 Substantial physiologic changes occur in the transition
from fetal to extra uterine life including:
– Changes from fluid-filled to air filled alveolar sacs
– Reduction in pulmonary vascular bed pressure
– Reduction of intra and extra cardiac shunting
– Establishment of adequate lung volume
– Surfactant production

Dr.LORN TRY Patrich,pediatrician,DHM

Dr.LORN TRY Patrich,pediatrician,DHM
 PREPARATION
 Personnel
– At least two trained people are required for adequate
resuscitation involving ventilation and cardiac
compression.
 Check equipment
– Resuscitation equipment should be checked daily after
each usage.
– When use is anticipated at birth recheck equipment,
including : Oxygen supply, laryngoscope, bag and mask
circuit and endotracheal tubs.
 Communication: with anesthetic and obstetric staff
regarding maternal condition and therapie, fetal condition
 Environment: Prevention of heat loss, dry infant,warm
towels.

Dr.LORN TRY Patrich,pediatrician,DHM

 ASSESSMENT
 Evaluation begins immediately after birth and
continues throughout the resuscitation process
until vitals signs have normalized:
– Respiration : the newly infant should establish regular
respirations in order to maintain 30<RR < 60 bpm.
– Heart Rate : with stethoscope the HR should be > 100
bpm.
– Color: A central pink color in room air

Dr.LORN TRY Patrich,pediatrician,DHM

 MANAGEMENT
 Stimulation: Most infants respond to stimulation with
movement of extremities.
 Airway : The head should in a neutral.
 Breathing: Attend to adequate inflation and ventilation
before oxygenation .Few infants require immediate
intubation .The majority of infants can be managed with
bag and mask ventilation.
 Circulation: The majority of infants establishment of
adequate ventilation will restore circulation. Begin chest
compressions(3:1) for either:
– Absent HR or HR < 60 for 30 seconds

Dr.LORN TRY Patrich,pediatrician,DHM

Dr.LORN TRY Patrich,pediatrician,DHM
Dr.LORN TRY Patrich,pediatrician,DHM
 MEDICATION
 Route of delivery : Umbilical venous catheter
 Adrenaline : For HR < 60 for > 30 Sec despite compression
 Naloxone : 0.1 ml/kg of 0,4 mg/ml solution and contra-
indication infant of narcotic dependant mothers.
 Bicarbonate : Currently there is insufficient evidence for
routine use.
 Stopping resuscitations : If the infant has not responded
with a spontaneous circulation by 15 minutes of age.

Dr.LORN TRY Patrich,pediatrician,DHM

 Newborn Life Support

Dry &
cover
Airway

A &
Breathing

B C CC
D
D
Dr.LORN TRY Patrich,pediatrician,DHM
© RC (UK) NLS Resus 31