Outcome Significance of Perinatal Versus Postnatal Fetal Depression, a Comparative Study

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Outcome Significance of Perinatal Versus Postnatal Fetal Depression, Dr. Abstract Background: Hypoxic-ischemic encephalopathy HIE, causing significant mortality and longterm morbidity as a perinatal depression
Outcome Significance of Perinatal Versus Postnatal Fetal Depression, Dr. Abstract Background: Hypoxic-ischemic encephalopathy HIE, causing significant mortality and longterm morbidity as a perinatal depression with cord ph 7.00, Apgar score 3 at 5 minutes of age with multiple organ involvement.another form of depression when newborn s was born fine then insult seriously within the first seven days of life. Objective: Compare the outcome of perinatal to those with postnatal fetal depression. Materials and Method Retrospective study of infants admitted at birth or within the first 7 days of life to neonatal or pediatric intensive care and followed over 18months in the women's and Hamad teaching hospitals, Doha, Qatar. Results: Forty four cases in the study 22 in each group, mean gestational age 36.8wks for group 1with perinatal HIE compared to 38.8wks for group 2 postnatal HIE(P value 0.04), Apgar score significantly different, all cases in group1 required resuscitation compared to 8 cases in group 2 (P value 0.00). Conclusion: The outcome of cases of postnatal HIE was much better than that of Perinatal HIE. Preterm depressed babies present earlier and more severe than term babies. Abbreviations: NICU neonatal intensive care unit, PICU pediatric intensive care unit, HIE hypoxic ischemic encephalopathy, GA gestational age, ND normal delivery, AND assisted normal delivery,cs caesarian section. Pediatrics Department, Diyala University Medical College,Diyala, Iraq. Introduction Hypoxic-ischemic encephalopathy (HIE), remains a serious condition, causing significant mortality and long-term morbidity [1, 2, 3]. In spite of major advances in monitoring technology and knowledge of fetal and neonatal pathologies perinatal asphyxia remains a major concern [4]. HIE is characterized by clinical and laboratory evidence of acute or sub acute brain injury due to asphyxia (i.e., hypoxia, acidosis) [1]. Most often, the underlying cause remains unknown [5]. The exact time of brain injury often remains uncertain, and an abnormal brain (e.g. growth failure, impaired development) might be an underlying risk factor [6]. The American Academy of Pediatrics (AAP) and the American College of Obstetrics and Gynecology (ACOG) published guidelines to assist in the diagnosis of severe HIE for the designation of perinatal asphyxia including Profound metabolic or mixed acidemia (ph 7.00) in an umbilical artery blood sample, an Apgar score of 0-3 for at least 5 minutes Diyala Journal of Medicine 11 Vol. 1, Number 1, 2011 and neonatal neurologic squeal (e.g seizures, coma, hypotonia)or multiple organ involvement (e.g of the kidney, lungs, liver, heart or intestines) for typical perinatal HIE [1,7]. Another presented like hypoxic ischemic brain insult may arise after delivery when the newborn s condition antenatal was fine and at birth initially stable with Apgar score more than 3 at 5 minute of age, PH more than 7.0 of arterial cord blood gas but for other undiagnosed, not identified pathologies he or she later on developed a major life threatening insult within the first 7 days of life required resuscitation and admission to intensive care [8]. Material and Methods The study was a retrospective chart review of the records including delivery room charts recording umbilical cord blood gas of newborn infants admitted to the neonatal or pediatric intensive care units at birth or during the first 7 days of life and followed over 18 months from may 2007 to November 2008 in the women's and Hamad General teaching hospitals, Doha, Qatar to compare the outcome of perinatal/typical hypoxic ischemic encephalopathy with those who developed postnatal/atypical hypoxic ischemic encephalopathy during the first 7 days of life. Inclusion Criteria In the first group, any newborn baby admitted to the neonatal intensive care unite with a suspicion of perinatal depression and/or primary diagnosis of birth asphyxia or hypoxic ischemic encephalopathy was included while in the second group any neonate admitted to pediatric intensive care with neonatal seizures or apneas, lethargy, focal or general neurological findings. Both groups were followed through their charts over 18 months of age. Exclusion Criteria Any newborn delivered with multiple congenital anomalies incompatible with life or perinatal team decision for no code or no resuscitation were excluded from the study. Results Forty four cases were included in the study 22 in each group. Group 1 with perinatal HIE compared to group 2 of postnatal HIE, The mean gestational age was 36.8wks for group 1 while it was 38.8wks for group2 (P value 0.040). Apgar score were significantly lower in group1 compared to group2 (figure no.1), all cases in group1 required cardiopulmonary resuscitation ( CPR) and assisted ventilation compared to 8 (36%)in group 2 (P value0.00),2 (9%) of group1 had intracranial hemorrhage compared to 1 (4.5%) in group 2 (9%) (P 0.99),3(37.5%) in group 1 had cerebral palsy while no cases had it in group 2 (P0.23),11 (61%) of group 1 had seizures 5 (27.8%) of them discharged on anticonvulsants while 5(27.8%) of group 2 had seizures(p value 0.12) 4 of them discharged on anticonvulsants. Diyala Journal of Medicine 12 Vol. 1, Number 1, 2011 Table 1: Demographic data of the studied group with their significant difference. VARIABLES No. 22 cases No. 22 cases P Value GA* 36.8 ** 38.8 ** 0.04 Apgar score at 1 min Apgar score at 5 min Apgar score at 10 min Mode of delivery# ND 3(13%) CS 18(78%) AND 2(9%) ND 12(55%) CS 7(32%) AND 3(13%) CPR* &Ventilation 22 (100%) 7(32%) Delayed mile stone 8(36%) 1(4.5%) Death 11(50%) 1(4.5%) *GA Gestational age **, # Mode of delivery ND normal delivery, CS caesarian section, AND assisted normal delivery (ventouse or forceps delivery) CPR cardiopulmonary resuscitation. Table 2: Demographic data with non-significant difference. VARIABLES 22 cases 22 cases P Value Age on discharge 16** 13.85** 0.06 Cord PH Days in hospital 19.5 ** 9.5 ** 0.06 ** AScore 1 min. AScore 5 min AScore 10 min Graph 1: showing the mean Apgar score comparative values. Diyala Journal of Medicine 13 Vol. 1, Number 1, 2011 Weeks Outcome Significance of Perinatal Versus Postnatal Fetal Depression, GA Graph 2: showing the mean gestation age difference values. Statistical analysis The data were analyzed using the Statistical Program for Social Sciences (SPSS 16.0).Chi square and fisher exact test were used when appropriate to compare the outcome data in both groups of insults. The differences were considered statistically significant at a P value Discussion Although the cases of group 1 were delivered prematurely in a mean compared to group 2(36.8wksVS 38.8 wks) and most cases of this group were delivered by caesarian section urgently as shown in the table no.1 despite of that the Apgar score was significantly low, In many institutions, the decision to obtain cord gases is made by the provider attending the birth. In settings where obtaining cord gases is feasible, Gibbs et al. suggest that cord gases should be obtained after delivery of an infant with risk factors for neonatal encephalopathy[8]. The decision to obtain cord gases must be weighed by the individual clinician against the potential benefits to delayed cord clamping,particularly in the preterm infant (higher hematocrit and hemoglobin levels, increased blood pressure, and increased blood volume, fewer days of oxygen and ventilation, and decreased need for transfusions).[9] Examination of the placenta can be helpful in establishing nonhypoxic and/or antepartum causes of neonatal encephalopathy and/or cerebral palsy. In addition to a thorough gross examination of the placenta at the time of delivery, a microscopic examination of the placenta by a pathologist should be considered in cases where there are antepartum risk factors for neonatal encephalopathy or cerebral palsy. Requirement of resuscitation and assisted ventilation, number of cerebral palsy cases and deaths among group1 remain significantly high which means that might be the monitoring of the delivery or decision timing for early delivery and caesarian section still need to be done tightly and properly or the resuscitation at birth might be Diyala Journal of Medicine 14 Vol. 1, Number 1, 2011 not done in proper time or by unskilled personnel and still antenatal close monitoring and follow up with high index for perinatal depression suspicion and the early notification to a well trained perinatology team of such cases to be on board all the time. Maternal perception of fetal movements (FM) is a universally implemented selfscreening, administered and interpreted individually by all pregnant women, with or without guidance from health care professionals showed Improved quality of management of FM and uniform information to improve the value of the existing selfscreening of fetal activity was associated with a reduction in stillbirth rates, the concerns that such a quality improvement intervention would increase interventions and iatrogenic injuries, it is likely that the added cost of ultrasound was compensated by reduced use of admissions for induction and repeated follow up consultations[10], still further research is required to identify optimal methods for detecting important reductions in FM to be an effective screening tool for adverse pregnancy outcomes [11]. At present, there is no evidence that any absolute definition of reduced fetal movements is of greater value than maternal subjective perception of reduced fetal movements in the detection of intrauterine fetal death or fetal compromise. Further investigation is required to determine an effective method of identifying patients with reduced fetal movements and to determine the best subsequent management [12]. Examination of the placenta can be helpful in establishing nonhypoxic and/or antepartum causes of neonatal encephalopathy and/or cerebral palsy. In addition to a thorough gross examination of the placenta at the time of delivery, a microscopic examination of the placenta by a pathologist should be considered in cases where there are antepartum risk factors for neonatal encephalopathy or cerebral palsy. From the study we found some cases in the second group despite of being given acceptable Apgar score at birth (more than 3 at 5 minutes of age), they still at risk of developing serious life threatening events in early neonatal life This can be explained by inaccurate calculation of Apgar score by the attending staff or they had a serious problem which is not necessarily presented at birth. After delivery observation for 24hrs for low risk deliveries and 48hrs observation for high risk deliveries (preterm more than 35-37weeks,small for date, maternal chronic illness and any baby with antenatally detected problems) are highly recommended. Recommendations It is highly recommended that all antenatal high suspicion of fetal depression to be monitored and treated early and highly skilled staff to be on board from the beginning. We speculate and recommend that lower threshold for caesarian section and tight fetal monitoring might help to reduce the incidence of HIE. Pretem delivery is all the time a high-risk delivery so we recommend that such delivery should be notified, followed and controlled by a full skilled perinatology team (obstetrician and neonatologist). Conclusion The outcome of cases of Atypical/Postnatal HIE was much better than that of typical/. The preterm babies perinataly depressed will present soon after birth while depressed term babies might present later. Diyala Journal of Medicine 15 Vol. 1, Number 1, 2011 References [1] American Academy of Pediatrics: Relation between perinatal factors and neurological outcome. (2008) In: Guidelines for Perinatal Care.sixth edition. [2] Patel J, Edwards AD(1997): Prediction of outcome after perinatal asphyxia. Curr Opin Pediatr Apr; 9(2): [3] Simon NP(1999): Long-term neurodevelopmental outcome of asphyxiated newborns. Clin Perinatal Sep; 26(3): [4] Vannucci RC, Perlman JM(1999): Interventions for perinatal hypoxic-ischemic encephalopathy. Pediatrics Dec 1997; 100(6): [5] Yves Garnier Arne Jensen(2003), perinatal brain damage from pathophysiology to prevention. Johannes Middelanis, Richard Berger European Journal of Obstetrics & Gynecology and Reproductive Biology, 110 S70 S79. [6] Mark Scher, perinatal asphyxia: Timing and mechanisms of injury in neonatal encephalopathy. Current Neurology and Neuroscience, April, 2001, [7] Sarnat HB, Sarnat MS(1976): Neonatal encephalopathy following fetal distress: A clinical and electroencphalographic study. Archives of Neurology;, 33: [8] Gibbs RS et al.( 2004) Suggestions for practice to accompany neonatal encephalopathy and cerebral palsy. Obstet Gynecol.; 103: [9] Mercer JS(2001). Current best evidence: A review of the literature on umbilical cord clamping. J Midwifery Womens Health;46: [10] Julie Victoria Holm Tveit et al (2009), Reduction of late stillbirth with the introduction of fetal movement information and guidelines a clinical quality improvement, BMC Pregnancy Childbirth. ; 9: 32. [11] Frøen JF(2004). A kick from within fetal movement counting and the cancelled progress in antenatal care. J Perinat Med. ;32: Doi: /JPM. [12] Heazell AE, Frøen JF.(2008), Methods of fetal movement counting and the detection of fetal compromise, J Obstet Gynaecol. ; 28(2): Diyala Journal of Medicine 16 Vol. 1, Number 1, 2011
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