1. Perinatal Asphyxia
Dr. Kalpana Malla
MD Pediatrics
Manipal Teaching Hospital
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2. PERINATAL ASPHYXIA
Definition
An insult to the fetus or newborn due to lack of
oxygen (hypoxia) and /or lack of perfusion
(ischemia) to various organs.
Associated with
Tissue lactic acidosis
• Hypoventilation
• Hypercapnea
2

3. PERINATAL ASPHYXIA
Incidence
1-1.5%
20% of perinatal deaths
Increased risk in IDM
Toxemic mothers
IUGR
Breech
Postmature
3

4. SEQUENCE OF EVENTS
HR…..decrease
BP…...decrease
Normal Resp...Rapid breathing….Pr.Apnea….Irreg.breathing…Sec.Apnea
Resuscitation Resuscitation
Normal Respiration Normal Respiration
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5. ETIOLOGY
90% Antepartum/ Intrapartum 10% Postpartum
FACTORS
Maternal:
- Hypertension- chronic / pre-eclampsia
- Diabetes, anemia,, malnutrition
- Hypoxia-Pulmonary/Cardiac/ - heart Ds,
Bronchial asthma
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6. FACTORS
Maternal……:
Hypotension
Intrauterine infections
Prolonged and difficult 2nd stage of labour
Placental: Infarction/fibrosis/abruption
Cord Accidents:
Prolapse / True knots / compression/Abn. vessels

7. FACTORS
Fetal:
• Infection - intrauterine
• Anemia - Feto-fetal or feto maternal
transfusion
• IUGR/ Postmaturity - Meconium aspiration
tracheal plug by blood mucus
• Cong malformations - choanal
atresia, laryngeal web,D. hernia, TEF,ICH
• Hydrops fetalis

8. PATHOPHYSIOLOGY
Diving reflex:
Shunting of blood to brain ,heart, adrenals and
away from gut, kidney, liver, spleen ,skeletal
muscle and skin
Progressive asphyxia:
Hypoxia, Hypercapnea, acidosis
Pulmonary vasoconstriction, R to L shunt
Decrease in HR, CO, BP
Cerebral edema- Petechial hemorrhage, SIADH,
Na- intracellular accumulation 8

9. TARGET ORGAN-BRAIN
HIE:PATHOPHYSIOLOGY
Hypoxia Alteration in glucose and energy
metabolism loss of autoregulation & decreased
cardiac function ischemia
Severe hypoxia and ischemia failure of oxidative
phosphorylation & ATP production
Accumulation of Na, Cl,Ca intracellular and K and
excitatory neurotransmitters extracellular
neuronal death
9

10. HIE- PATHOLOGY
1. Selective neuronal necrosis - Cerebral and
cerebellar cortex, Thalamus, brain stem
nuclei
2. Focal and multifocal cortical necrosis
3. Watershed infarct
4. Parasagittal cerebral injury
5. Periventricular leucomalacia
6. Status murmoratus.
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11. Hypoxic Ischaemic Encephalopathy
• Most important consequence of perinatal
asphyxia
• Hypoxic ischaemic insult to the brain
• 25-30% of survivors have permanent damage like
CP and MR.
• 15-20% with HIE die

12. SARNAT STAGING
Features Stage1 Stage 2 Stage3
Mild Moderate Severe
1.Level of Hyperalert Lethargic Stuperous
consciousness Irritable Obtunded Comatose
2.Neuromuscular
control.
Muscle tone N Hypotonia Flaccid
Posture N Flexion Decerebration
Reflexes   Decreased / Absent
3. Reflexes
Suck Weak Weak /Absent Absent
Moro Strong Weak Absent
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13. SARNAT STAGING
Features Stagee1 Stage 2 Stage3
Mild Moderate Severe
4.Autonomic Gen.sympathetic Gen.Parasymp Both depressed
function
Pupil Mydriasis Miosis Midposition
Resp Spont Spont Periodic,apnea
HR Tachycardia bradycardia Variable
5.Seizures None common Uncommon
6.EEG Normal abnormal abnormal
7. Duration <24hr 24hr-14day Day-weeks
8.Outcome Good Variable Death

14. SARNAT STAGING
Features Stage1(Mild) Stage 2(Moderate) Stage3(Severe)
4.Autonomic Gen.sympathetic Gen.Parasymp Both depressed
function
Pupil Mydriasis Miosis Midposition
Resp Spont Spont Periodic,apnea
HR Tachycardia bradycardia Variable
5.Seizures None common Uncommon
6.EEG Normal abnormal abnormal
7. Duration <24hr 24hr-14day Day-weeks
8.Outcome Good Variable Death

15. APGAR SCORE
APGAR Score:
8-10 No asphyxia
5-7 Mild asphyxia
3-4 Moderate asphyxia
0-2 Severe asphyxia
Virginia Apgar
0_________ 1__________ 2_____
Heart rate 0 <100 >100
Respiration 0 weak, irregular good cry
Reaction 0 slight good
Colour blue or pale body pink limbs blue all pink
Tone limp some movement active movements
limbs well flexed

16. ASSESSMENT/PRECAUTIONS
Perinatal
1.Awareness of problems and high risk
2.Fetal movement count
3.Fetal BPP
5. Monitor FHR
6.Progress of labor
7.Fetal scalp -pH
8.Presence of meconium
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17. SYSTEMIC MANIFESTATIONS
Brain(28%)- HIE, ICH, Apneic attacks, Seizures
Heart(25%)- PFC, Arrhythmia, Myocardial
damage,TR,CCF
Lungs(23%)- Meconium aspiration, Pul.hemorrhage
Pneumothorax, pneumonia
Kidney(50%)- Hematuria, ARF, ATN, RVT
GIT- NEC, Paralytic ileus
17

18. SYSTEMIC MANIFESTATIONS
• Hematologic-
DIC, Hyperbilirubinemia, sepsis
• Endocrine- SIADH, Adrenal hemorrhage
• Metabolic- hypoglycemia, hypocalcemia,
hyperbilirubinemia

19. Late effects
• Microcephaly
• MR
• Developmental delay
• Cerebral palsy
• Epilepsy
• Visual, hearing impairement
• Behavioral disturbances

21. MANAGEMENT
• Ventilation-For hypoxia and hypercapnea
• Maintain cerebral perfusion
• Correction of hypoglycemia and
hypocalcemia
• Temperature maintenance
• Control of seizure- Anticonvulsants
• Cardiac effects-Ionotropes
• Renal effects- Dopamine
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22. CLINICAL MANIFESTATIONS OF
NEUROLOGICAL SEQUELAE
• Cerebral Palsy- Spastic diplegia,
Spastic quadriplegia,
Spastic hemiplegia
Dystonic
Choreo athetotic
• Mental retardation
• Epilepsy
• Auditory, visual and language difficulties
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23. PROGNOSIS
• Overall mortality - 10-20%
• Neurological sequele - 20-45%
• Sarnat Stages
1- 100% Normal neurological outcome
2- 80% Normal neurological outcome
3- 50% deaths, 50% major neurological sequelae
• Risk for CP - 5-10%
• Subtle school problems in neurologically and
mentally normal survivors of HIE stage 1-nil,
stage 2- 18-35%
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24. Thank you
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Medical Post [ www.themedicalpost.net ]