1. 1 Guslihan Dasa Tjipta Division of Perinatology Department of Child Health Medical School University of Sumatera Utara

2. 2 Definition Perinatal asphyxia is a n insult to the fetus/newborn, due to: Lack of oxygen (hypoxia) and/or Lack of oxygen (hypoxia) and/or Lack of perfusion (ischemia) to various organ, and may be associated with Lack of perfusion (ischemia) to various organ, and may be associated with Lack of ventilation (hypercapnia). Lack of ventilation (hypercapnia).

3. 3 Definition Essential characteristics: American Academy of Pediatrics (AAP) and the American College Of Obstetricians and Gynecologists (ACOG): 1. Profound metabolic or mixed acidemia (pH < 7) 2. Apgar score of 0-3 for >5 min 3. Neurologic manifestations: seizures, hypotonia, coma, or hypoxic ischemic encephalopathy (HIE) 4. Evidence of multiorgan system dysfunction in the immediate neonatal periode.

4. 4 Incidence 1.0-1.5% of total live birth : 1.0-1.5% of total live birth : <36 wk : 9% <36 wk : 9% >36 wk : 0.5% >36 wk : 0.5% ~20% of perinatal death ~20% of perinatal death

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6. 6 Apgar score (1952) A scoring system to help assessing a neonate’s transition after birth A scoring system to help assessing a neonate’s transition after birth Conceived to report on the state of the newborn and effectiveness of resuscitation. Conceived to report on the state of the newborn and effectiveness of resuscitation. Poor tool for assessing asphyxia Poor tool for assessing asphyxia

7. 7 APGAR SCORING Sign012 Appearance(color) Blue or pale Pink body with blue extr Completely pink Puls (heart rate) AbsentSlow (<100 bpm) >100 bpm Grimace (reflex irritability) No response Grimace Cough or sneeze Activity (muscle tone) Limp Some flexion Active movement RespirationsAbsent Slow, irregular Good, crying

8. 8 Organ effects of asphyxia CNS CNS Lung Lung Cardiovascular system Cardiovascular system Renal system Renal system Gastrointestinal tract Gastrointestinal tract Blood Blood

9. 9 Consequences of Asphyxia CNS Cerebral hemorrhage Cerebral hemorrhage Cerebral edema Cerebral edema Hypoxic-ischemic encephalopathy Hypoxic-ischemic encephalopathy Seizures Seizures

10. 10 Pathogenesis Intrauterine asphyxia ↓ Fetal ↓pO2, ↑pCO2, ↓pH, ↓BP ↓ Intracellular edema ↓ ↑ Cerebral tissue pressure ↓ Focal ↓ Cerebral blood flow ↓ Generalized brain swelling ↓ ↑ Intracranial pressure ↓ Generalized ↓ cerebral blood flow ↓ Brain necrosis Intrauterine asphyxia ↓ Fetal ↓pO2, ↑pCO2, ↓pH, ↓BP Loss of vascular autoregulation ↓ ↓Cerebral blood flow Brain Necrosis Brain swelling

11. 11 Consequences of Asphyxia Lung Delayed onset of respiration Delayed onset of respiration Respiratory distress syndrome from surfactant deficiency or dysfunction Respiratory distress syndrome from surfactant deficiency or dysfunction Pulmonary hemorrhage Pulmonary hemorrhage Persistent pulmonary hypertention Persistent pulmonary hypertention

12. 12 Consequences of Asphyxia Cardiovascular system Shock Shock Hypotention Hypotention Myocardial necrosis Myocardial necrosis Congestive heart failure Congestive heart failure Ventricular dysfunction Ventricular dysfunction

13. 13 Consequences of Asphyxia Renal system Oliguria-anuria Oliguria-anuria Acute tubular or cortical necrosis Acute tubular or cortical necrosis Renal failure Renal failure

14. 14 Consequences of Asphyxia Gastrointestinal system Paralytic ileus or delayed (5-7 days) necrotizing enterocolitis. Paralytic ileus or delayed (5-7 days) necrotizing enterocolitis.

15. 15 Consequences of Asphyxia Blood Disseminated intravascular coagulation Disseminated intravascular coagulation Thrombocytopenia can result from shortened platelet survival Thrombocytopenia can result from shortened platelet survival Bone Marrow recovers over time Bone Marrow recovers over time

16. 16 Consequences of Asphyxia Metabolic Acidosis Acidosis Hypoglicemia (hyperinsulinism) Hypoglicemia (hyperinsulinism) Hypocalcemia Hypocalcemia Hyponatremia/ Syndrome of inappropriate antidiuretic hormone secretion (SIADH) Hyponatremia/ Syndrome of inappropriate antidiuretic hormone secretion (SIADH)

17. 17 Management Optimal management is prevention: identify the fetus being subjected Optimal management is prevention: identify the fetus being subjected Immediate resuscitation: maintenance of adequate ventilation, oxygenation, perfusion. Immediate resuscitation: maintenance of adequate ventilation, oxygenation, perfusion. Correct metabolic acidosis: Correct metabolic acidosis: Volume expander: to sustain tissue perfusion Volume expander: to sustain tissue perfusion NS or Ringers Lactate NS or Ringers Lactate O neg if (+) evidence of blood loss O neg if (+) evidence of blood loss Albumin: not recommended Albumin: not recommended Na Bicarbonate Na Bicarbonate Only with adequate ventilation and circulation Only with adequate ventilation and circulation Only when CPR is prolonged and the infant remains unresponsiveness Only when CPR is prolonged and the infant remains unresponsiveness 1-2 mEq/kg of a 0.5 mEq/L slow IV 1-2 mEq/kg of a 0.5 mEq/L slow IV Temperature: Avoid perinatal hyperthermia Temperature: Avoid perinatal hyperthermia

18. 18 Management Maintain a normal serum glucosa level (75-100 mg/dL) to provide adequate substrate for brain metabolism. Avoid hyperglycemia to prevent hyperosmolality and a possible increase in brain lactate levels Maintain a normal serum glucosa level (75-100 mg/dL) to provide adequate substrate for brain metabolism. Avoid hyperglycemia to prevent hyperosmolality and a possible increase in brain lactate levels Controle of seizures: phenobarbital is the drug of choice. Controle of seizures: phenobarbital is the drug of choice. Prevention of cerebral edema: fluid restriction (eg. 60 ml/kg) Prevention of cerebral edema: fluid restriction (eg. 60 ml/kg)

19. 19 Neonatal Resuscitation

20. 20 Primary Apnea no respiration decreasing heart rate BP maintained responds to stimulus Secondary Apnea no respiration heart rate very low BP low No response to stimulation Primary versus Secondary Apnea

21. 21 Signs of a Compromised Newborn l Cyanosis l Bradycardia l Low blood pressure l Depressed respiratory effort l Poor muscle tone © 2000 AAP/AHA

22. 22 Preparation for Resuscitation Personnel and Equipment l Trained person to initiate resuscitation at every delivery l Recruit additional personnel, for more complex delivery l Prepare necessary equipment –Turn on radiant warmer –Check resuscitation equipment l Team concept © 2000 AAP/AHA

23. 23 Evaluating the Newborn Immediately after birth, the following questions must be asked: © 2000 AAP/AHA

24. 24 © 2000 AAP/AHA Evaluation Decision Action

25. 25 Initial Steps © 2000 AAP/AHA

26. 26 Provide Warmth Prevent heat loss by Placing newborn under radiant warmer Placing newborn under radiant warmer Drying thoroughly Drying thoroughly Removing wet towel Removing wet towel © 2000 AAP/AHA

27. 27 Preventing Heat Loss Premature newborns Special problems Special problems – Thin skin – Decreased subcutaneous tissue – Large surface area Additional steps Additional steps – Raise environment temperature – Cover with clear plastic sheeting © 2000 AAP/AHA

28. 28 Opening the Airway Open the airway by Positioning on back or side Positioning on back or side Slightly extending neck Slightly extending neck “Sniffing” position “Sniffing” position Aligning posterior pharynx, larynx and trachea Aligning posterior pharynx, larynx and trachea © 2000 AAP/AHA

29. 29 Suction mouth first, then nose Clear Airway: No Meconium Present © 2000 AAP/AHA

30. 30 If meconium present and newborn is vigorous If: respiratory effort is strong respiratory effort is strong muscle tone is good muscle tone is good Heart rate > 100/ min Heart rate > 100/ minThen: Use bulb syringe or large bore catheter Use bulb syringe or large bore catheter to clear mouth and nose to clear mouth and nose

31. 31 Meconium present and newborn NOT vigorous Tracheal suction Administer oxygen Administer oxygen Insert laryngoscope, use 12F or 14F suction catheter to clear mouth Insert laryngoscope, use 12F or 14F suction catheter to clear mouth Insert endotracheal tube Insert endotracheal tube Attach endotracheal tube to suction source Attach endotracheal tube to suction source Apply suction as tube is withdrawn Apply suction as tube is withdrawn Repeat as necessary Repeat as necessary © 2000 AAP/AHA

32. 32 Management of Meconium © 2000 AAP/AHA

33. 33 Dry, Stimulate to Breathe, Reposition © 2000 AAP/AHA

34. 34 Tactile Stimulation © 2000 AAP/AHA Potentially Hazardous Stimulation  shaking  slapping the back  squeezing the rib cage  hot and cold compresses  dilating anal sphincter

35. 35 Resuscitation Flow Diagram © 2000 AAP/AHA

36. 36 Post - Resuscitation Care © 2000 AAP/AHA

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