Mohammed AS1,
Samina Tarannum2
1Dr. Mohammed Abdul Saleem, Assistant Professor, Department of Paediatrics, Gandhi
Medical College, Secunderabad, Telangana, India,
2Dr.
Samina Tarannum, Assistant
Professor, Department of Paediatrics, Gandhi Medical College, Secunderabad,
Telangana, India. E-mail Id: drsaleemgmc@gmail.com
Corresponding Author: Dr. Samina Tarannum, Assistant Professor, Department
of Paediatrics, Gandhi Medical College, Secunderabad, Telangana, India. E-mail
Id: drsaleemgmc@gmail.com
Abstract
Background: Perinatal asphyxia is an insult to fetus or
newborn due to lack of oxygen (hypoxia) or lack of perfusion (ischemia) to
various organ of sufficient magnitude and duration. Perinatal asphyxia is one
of the major causes of early neonatal mortality in India. Objective: To study the risk factors of birth asphyxia in children.
Design: Observational prospective
study on babies delivered in our hospital and requiring resuscitation. Duration: March 2014 to September 2014.
Setting: Department of Paediatrics,
Bhaskar Medical College. Participants: 100
babies delivered in our hospital and requiring resuscitation. Methods: All neonates who needed
resuscitation at birth were included. Maternal obstetric history was taken
which included the gravity, parity, abortions and living issues. Mother’s ANC
status was asked. Mother’s ABO Blood group and Rh type was taken. History of
maternal health conditions was asked for. History of maternal illness was also
taken. Neonatal information was entered next which birth weight, term information
and others. Results: The mean age of
mothers was 25.3 years. 54% neonates were born to primiparous mothers. Anemia
was widely prevalent in the mothers of neonates requiring resuscitation. The
maternal risk factors for newborns requiring resuscitation were PIH (22%), oligohydramnios
(14%),multiple gestation (4%), PROM (3%), diabetes mellitus (3%) and UTI (5%). One
third of neonates requiring resuscitation were born to unbooked mothers. The
fetal factors associated with resuscitation of newborns were IUGR (35%), fetal
distress (32%), prematurity (31%), MAS (10%) and mal-presentations (4%). Conclusion: The most common maternal
risk factors for newborns requiring resuscitation was PIH followed by
oligohydramnios, multiple gestation, PROM, diabetes mellitus and UTI. IUGR was
the most common fetal risk factor followed by fetal distress, prematurity, MAS
and mal-presentations.
Key words: Birth asphyxia, Children, Risk Factors, PIH,
IUGR.
Author Corrected: 20: th November 2018 Accepted for Publication: 24th November 2018
Introduction
World Health Organization defined birth asphyxia as “the failure to
initiate and sustain breathing at birth. The exact definition of birth asphyxia
is given by the ACOG (American College of Obstetricians and Gynecologists), AAP
includes existence of 3 factors: Metabolic or mixed academia (pH<7) which is
determined by umbilical cord arterial blood samples; APGAR score of this
definition is designed for use in hospital-based settings which requires evaluation
[1,2,3]. Worldwide Midwives uses APGAR score for describing the wellbeing of
new-borns at birth. Because it is a clinical indicator commonly used to
describe the new-born’s physical condition at birth. In many cases, the timing
of asphyxia cannot be established with certainty that is why the severity of asphyxia
is widely assessed by the APGAR score, at 1 and 5 min after birth [4,5].
Commonly the first 1 min after birth which is the “golden minute” the baby
should be breathing well. The ACOG stated that a low APGAR score beyond 5 min
is a suggestive criterion for an estimate of the severity of asphyxia. The
birth of a healthy new-born is one of the finest gifts of nature. The birth
process takes only few hours but it is the most hazardous period of life since
it is associated with the largest number of deaths as compared to any other
phase of life. If new-born is unable to breathe spontaneously at birth it
results birth asphyxia and causes a damaging condition of impaired blood gas
exchange and if it persists leading to progressive hypoxemia, hypercapnia with
significant metabolic acidosis and tissue oxygen debt, which can cause serious
multi organ failure and poor prognosis and high mortality stillbirth or
lifelong disability in the surviving infant commonly with a very high incidence
of 25% irreversible neurologic damage and 1.15 million develop clinical
encephalopathy such as cerebral palsy, mental retardation and epilepsy leading
to detrimental long term consequences for both child and family. Cognitive and behavioral
difficulties which lead to memory and attention deficit hyperactivity disorder
(ADHD), autism and schizophrenia. Globally birth asphyxia continues to present
a major clinical problem and one of the common and leading causes of perinatal
and neonatal mortality and morbidity especially in developing countries [6,7,8,9].
Four million babies are born with asphyxia each year. According to statistics
by WHO, in developing countries 3% of infants (3.6 million babies) suffer from
moderate to severe asphyxia, of whom 23% (840,000) die which equates to nearly
1 million neonatal deaths per year and in countries with high neonatal
mortality rates the death rate is 8 times that of countries with low NMRs and
almost the same number suffer from the associated consequences [10].
Recognition of risk factors, results in identification of high-risk deliveries
and attendance of the resuscitation team, before the baby is born. The
prognosis and severity of the symptoms of child with birth asphyxia depends on
the risk factors and management of the patient [11,12]. The objective of this
research was to study the risk factors of birth asphyxia in children requiring
resuscitation.
Place of Study: Department of Paediatrics, Bhaskar Medical
College.
Type of Study: Observational prospective study on babies
delivered in our hospital and requiring resuscitation.
Sample Collection: Maternal obstetric history was taken which
included the gravity, parity, abortions and living issues and was entered in
the GPAL format. Mother’s ANC status i.e. booked/unbooked pregnancy was asked.
Mother’s ABO Blood group and Rh type was taken. Socioeconomic status was taken
according to the Modified Kuppuswamy Scale (Annexure IV) and mothers were
graded into 5 classes. History of maternal health conditions was asked for. History
of maternal illness was also taken. Neonatal information was entered next which
birth weight, term information and others.
Sampling Methods: Sample size was calculated using the formula:
Sample size = Z1-⍺/22 p (1-p) / d2.
Inclusion Criteria: All neonates who needed resuscitation at birth
were included.
Exclusion Criteria: Neonates whose parents didn’t give consent and who
needed only initial steps of resuscitation were excluded.
Statistical Methods: The results obtained were tabulated and analyzed
using appropriate statistical programme, Statistical Package for Social
Sciences (SPSS), version 18.0 and Graph Pad Prism 5.1. The results were
compared using the Chi square test and multiple logistic regression, p value
was calculated. The results were tested at 5% level of significance.
Results
Table-1: Distribution of maternal risk
factors
|
Risk Factor |
N (%) |
|
PIH |
22(22%) |
|
Oligohydramnios |
14(14%) |
|
Polyhydramnios |
8(8%) |
|
Multiple Gestation |
4(4%) |
|
Tobacco Chewing |
2(2%) |
|
Diabetes Mellitus |
3(3%) |
|
Eclampsia |
1(1%) |
|
Bleeding Per Vaginal |
2(2%) |
|
Threatened Preterm |
1(1%) |
|
PROM |
3(3%) |
|
Maternal Fever |
1(1%) |
|
UTI |
5(5%) |
|
AS Pattern |
1(1%) |
|
Bad OBS History |
1(1%) |
The maternal risk factors for newborns
requiring resuscitation were PIH (22%), oligohydramnios (14%), multiple
gestation (4%), PROM (3%), diabetes mellitus (3%) and UTI (5%). Other risk
factors found in this study were threatened preterm labor, PROM, maternal
fever, UTI, AS pattern and bad obstetric history.
Table-2: Distribution of registration of
status of mothers
|
Registration Status |
N (%) |
|
Booked |
67(67%) |
|
Unbooked |
33(33%) |
|
Total |
100(100%) |
The above table shows that of the 100 babies
requiring resuscitation 33 were born to mothers who were unbooked.
Table-3: Distribution of neonates according
to their gender
|
Gender |
N (%) |
|
Male |
52(52%) |
|
Female |
48(48%) |
Table-4: Distribution of neonates according
to fetal risk factors
|
Risk Factor |
N (%) |
|
IUGR |
35(35%) |
|
Fetal Distress |
32(32%) |
|
Prematurity |
31(31%) |
|
MAS |
10(10%) |
|
Congenital Malformation |
7(7%) |
|
Mal-presentation |
4(4%) |
The fetal factors associated with
resuscitation of newborns were IUGR (35%), fetal distress (32%), prematurity
(31%), MAS (10%) and mal-presentations (4%).
Table-5: Distribution of neonates according
to birth weight
|
Birth Weight(Kg) |
N (%) |
|
<1Kg |
4(4%) |
|
1-1.4 Kg |
11(11%) |
|
1.5-2.4Kg |
47(47%) |
|
≥2.5Kg |
38(38%) |
|
Total |
100(100%) |
Table 5 shows that we had 62 children with
low birth weight requiring resuscitation. Of these 2 were ELBW’s and 11 were
VLBW’s.
Discussion
Perinatal asphyxia, neonatal asphyxia or birth asphyxia is the medical
condition resulting from deprivation of oxygen to a newborn infant that lasts
long enough during the birth process to cause physical harm, usually to the
brain. Hypoxic damage can occur to most of the infant's organs (heart, lungs,
liver, gut, kidneys), but brain damage is of most concern and perhaps the least
likely to quickly or completely heal. In more pronounced cases, an infant will
survive, but with damage to the brain manifested as either mental, such as
developmental delay or intellectual disability, or physical, such as
spasticity. It results most commonly from a drop in maternal blood pressure or
some other substantial interference with blood flow to the infant's brain
during delivery [13,14,15]. This can occur due to inadequate circulation or
perfusion, impaired respiratory effort, or inadequate ventilation. Perinatal
asphyxia happens in 2 to 10 per 1000 newborns that are born at term, and more
for those that are born prematurely[16,17]. WHO estimates that 4 million
neonatal deaths occur yearly due to birth asphyxia, representing 38% of deaths
of children under 5 years of age. Fatalities from perinatal asphyxia remain
high in developing countries, and continually assessing its risk factors will
help improve outcomes in these settings [18,19]. We explored how some
identified risk factors predict mortality in asphyxiated newborns, to assist
clinicians in prioritizing interventions. This was a 1-year prospective study
conducted at the Bhaskar Medical College. All newborns who met the study
criteria that were admitted to this facility in this period were enrolled and
monitored. Data collected were analysed with SPSS Version 18. A total of 100
newborns with perinatal asphyxia were enrolled into the study. According to our
study, the mean age of mothers was 25.3 years. Most of the population was from
the lower middle and upper lower socioeconomic status. 54% neonates were born
to primiparous mothers. Anemia was widely prevalent in the mothers of neonates
requiring resuscitation. The maternal risk factors for newborns requiring
resuscitation were PIH (22%), oligohydramnios (14%), multiple gestation(4%),
PROM (3%), diabetes mellitus (3%) and UTI (5%).One third of neonates requiring
resuscitation were born to unbooked mothers. The fetal factors associated with
resuscitation of newborns were IUGR (35%), fetal distress (32%), prematurity
(31%), MAS (10%) and mal-presentations (4%).
Conclusions
The most common maternal risk factors for newborns requiring
resuscitation was PIH followed by oligohydramnios, multiple gestation, PROM,
diabetes mellitus and UTI. IUGR was the most common fetal risk factor followed
by fetal distress, prematurity, MAS and mal-presentations. One third of
neonates requiring resuscitation were born to unbooked mothers.