Hypoxic ischemic encephalopathy in term newborns: risk factors and their impact on the course of acute period
Background. Hypoxic ischemic encephalopathy (HIE), despite significant advances in monitoring technology and understanding fetal and neonatal pathology, is one of the most frequent causes of cerebral palsy and other severe neurological disorders in children. Analysis of severe HIE cases shows preconceptual and antepartum risk factors in 69 % of all newborns with moderate-to-severe neonatal encephalopathy. The purpose of the study was to investigate the antenatal and intranatal risk factors for the development of hypoxic ischemic encephalopathy in term newborns and their impact on the further course of acute period of HIE. Materials and methods. Analysis of the data of 205 term newborns was conducted. The average gestational age was 39.6 ± 1.4 (37–42) weeks, the birth weight was 3573 ± 549 (2440–5300) grams. 128 babies (62.4 %) were males and 77 (37.6 %) were females. Results. 47 (22.9 %) babies were admitted to the neonatal intensive care unit (NICU) in the first 6 hours of life, 136 (66.3 %) — in the 6–24 hours of life, 19 (9.3 %) — in 24–72 hours of life and 3 infants (1.5 %) were admitted after 72 hours. Mortality ratio on the 28th day of treatment was 3 of 205 babies (1.46 %). In 82 cases (40 %), there were first labors and in 123 (60 %) — second. The ratio of cesarean sections was 42 of 205 infants (20.5 %). From 42 births by caesarean section, 17 (40.5 %) were first deliveries and 25 (59.5 %) were second (p = 0.994). A significant difference was found on the Apgar score between the two groups on 1st minute after birth (3 (2–6) points in vaginal labors vs. 5 (3–7) points after caesarean section, p = 0.013), but no difference was found on the 5th minute after birth. Also, there was no significant difference in serum lactate level (6 (3.5–10.9) and 6.6 (3.9–14.9) mmol/l, respectively, p = 0.676), but in both groups, it doubled the normal range. The duration of mechanical ventilation in children born by caesarean section, in 6 (5–8) days was significantly higher than in infants delivered by vaginal birth (5 (4–7) days, p = 0.086), the same as the duration of stay in NICU (13 (10–16) vs. 10 (8–14) days, p = 0.028). This could be explained by a greater quotient of placental abruption in the group of caesarean section (n = 6; 85 %) compared with vaginal labors (n = 1; 14.3 %) at p < 0.001. Thus, its duration was significantly higher in babies with caesarean section compared to vaginal labors (14 (13–34) vs. 6 (1.3–12.5) hours, respectively, p = 0.013). Similarly, the differences in the median [25–75%] of the time between membrane rupture and delivery in the first and second deliveries were 0.2–39 versus 0.5–39 hours (p = 0.296), which indicates abnormal deliveries. A significant difference was found between the Apgar score in newborns needed a resuscitation at birth compared to those who were not resuscitated (3 (2–5) versus 4 (2–7) points, p = 0.09), but further it was not influence the acute period of HIE, which was demonstrated by a lack of reliable difference in duration of mechanical ventilation, total days in NICU and frequency of brain leukomalacia as an unfavorable treatment outcome. Conclusions. Hypoxic ischemic encephalopathy in term newborns is a polyethiologic pathological condition, the development of which depends on both the abnormality of labor in mother and the inadequate labor management. There are no prognostically reliable maternal risk factors for the development of HIE, except for placental abruption. When deciding on the further treatment of infants, the clinical evaluation on the Sarnat scale and laboratory data confirming hypoxia-ischemia (elevated blood lactate level) are more important than the nature of labor. The Apgar score can be used to make a decision about neonatal resuscitation at birth, but cannot be used as a basis when diagnosing hypoxic ischemic encephalopathy.
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