Perinatal asphyxia

IMPLICATIONS, TREATMENT AND MANAGEMENT

Neonatal mortality in India

l ow
a nd t
ri t y i gh
a tu we
re m irt h
P b

a tal
s e rin yxia
on P ph
c t i as
e
Inf
Perinatal asphyxia

 Asphyxia refers to a combination of hypoxia,

hypercarbia, and metabolic acidosis because of
occlusion of umbilical vessels or interference
with placental perfusion before or during, or after
birth.
 Leading cause of perinatal death and long-term
disability in survivors
 No unanimity or consensus regarding the definition
of birth asphyxia
Recent definitions

 APGAR score of < 7 at 1-min or 5-min or 10-min or later

 Gasping or no breathing at 1-min or 5-min or 10-min or later
 Time taken to establish spontaneous breathing after birth
 Umbilical cord arterial pH <7.0
 Evidences of hypoxic-ischemic encephalopathy
 Evidences of multiorgan dysfunction
Not all babies with low APGARS develop
encephalopathy

Event
Evidence
Antepartum or
intrapartum fetal Consequence
Baby not cried at birth
hypoxia-ichemia
Encephalopathy or
organ damage
Mild
Moderate
Severe
Perinatal asphyxia

 Incidence: 0.5 -8.5% in various studies

 Causes in recent times
 Maternal obstetric illnesses: GDM or hypertensive disorders
 Maternal dehydration or anaemia
 Placental abruption, cord prolapse
 Fetal growth restrictions
 Systemic illnesses
 Fetal malformations
 Polyhydramnios
 Multiple birth
Pathophysiology
Time line Cardiac
dysfunction

Recovery

Renal dysfunction
Neonatal implications

 23 % of all deaths are due to birth asphyxia

 Organs affected:
 Acute kidney injury- 50-75%
 HIE- 25%
 Myocardial damage
 Liver injury
 Gut injury
 Lung injury
Parental Implications

 When followed up
 Almost 59% of mothers and 38% of fathers develop post-traumatic stress disorder
 Financial implications
 Social implications
Perinatal  Unfavourable outcome of pregnancy is

asphyxia: 
unacceptable to families
Always reduces to inadequate care during delivery
Blame game
Parental emotions

State of uncertainty
Being thrown into a
chaos Feeling abandoned

Waiting time for knowing the

• Serious negative outcome
Ambiguous investigation No one to talk to
conversation
• Understanding that Too much hope on treatment Alone
something is wrong
• NICU environment
 Click icon to add picture

Long term
implications
Cerebral palsy: 25% of all cases of CP
neonatal HIE
Developmental delay- 25 % of all cases
Seizures
Milder cases: ADHD, learning difficulties
Prevention

 No absolute cure for asphyxia

 At-risk approach
 Being prepared for everything
Role of CTG

 Cardiotocographic monitoring or electronic Fetal monitoring

Low risk pregnancies High risk pregnancies

What constitutes a high-risk pregnancy?
What constitutes good fetal monitoring?
Criticism on intrapartum monitoring and
interventions

 Too short EFM

 Too infrequent EFM
 Wrong interpretation
Criticism on intrapartum monitoring and
interventions

 Decision to delivery time

interval
 ? 30 minutes
 Average is 26 minutes with
epidural top-up and 43
minutes with spinal
Post resuscitation
management
The importance of neonatal resusictation

 Effective and optimal management of every neonate at birth is the first step
 Basic neonatal resuscitation training should be provided to all care providers
 Advanced neonatal resuscitation training for specific provider
 IAP-NNF-NRP programme
Monitoring and deciding on intensive care

 Any child with 5 minutes APGAR of less than 4, will require intensive monitoring and
investigations
 Hemodynamic monitoring- multichannel monitoring
 Blood gases to monitor acidosis
 Urine output and renal function monitoring
 CK BB, lactate will help in identifying intensity of organ damage
 Blood sugars and elctrolytes
Basic supportive management

 Thermoneutral environment
 Intravenous fluids
 Correction of hyponatremia, hypocalcemia and hyperkalemia as and when detected
 Supportive care
 Routine antibiotics is not necessary
 Avoid bolus drug administration
 Saline bolis, plasma to correct hypotension
 Inotropic support: dopamineor dobutamine
Brain oriented
approach
 aEEG monitoring
 Seizure management
 Optimising four parameters:
 Temperature
 Sugar
 Sodium
 Oxygen and carbon dioxide
Therapeutic hypothermia- a standard of care?

 Effective in reducing morbidity associated with HIE and has

become the standard of care for HIE in developed countries
Therapeutic hypothermia

 Early application of TH preferably within 6 is likely to be

effective and improve neurodevelopmental outcome
 Implementing the same in resource-restricted settings in India is
not that easy
Practical aspects of cooling

 Duration 72 hours
 Temperature upto33.5C
 Slow rewarming over 7 hours
 Initiated within 6 hours

 Term neonates > 36 weeks

Criticool
Clinical benefits with TH

 Treat 11 babies with TH one death will be prevented

 Treat 8 babies with TH one child with neurodevelopmental disability will be prevented
 Also limits myocardial injury and renal damage
Difficulties in resource limited set up

 Lack of access to transport, large distances and costs that are required to be borne for
transport, coupled with weak communication systems and deliveries in resource poor
settings can lead to delay in care that can be offered to a sick neonate
 An increased rate of perinatal infections has also raised concern when cooling in India.
Differential diagnosis

 Inborn errors of metabolism

 Developmental and structural disorders of brain
 Neuromuscular disorders
 Neonatal sepsis
How can we make the situation better?
 1 2 3
Step 1: create a high risk Step 2: intrapartum Step 3: being prepared for
approach for pregnancies monitoring document emergency caesarian
every step and measures section
that has been taken
 41 52 63
Step 4: intrahospital or Step 5: improving Step 6: Providing
inter hospital transport parental counselling and optimal post asphyxial
hospital experience care