Padayachee anoxia symptoms

Background. Perinatal asphyxia is a significant cause

Of death and disability.

Objective. To determine the outcomes

(survival to discharge and morbidity after discharge) of

Neonates with perinatal asphyxia at charlotte maxeke

Johannesburg academic hospital (CMJAH).

Methods. This was a descriptive

Retrospective study. We reviewed information obtained from the

Computerised neonatal database on neonates born at CMJAH or

Admitted there within 24 hours of birth between 1 january 2006

And 31 december 2011, with a birth weight of 1 800 g and a

5-minute apgar score 6.

Results. Four hundred and fifty

Infants were included in the study; 185 (41.1%) were females,

The mean birth weight (± standard deviation) was 3 034.8±484.9

anoxia symptoms

G, and the mean gestational age was 39.1±2.2 weeks. Most of the

Infants were born at CMJAH (391/450, 86.9%) and by normal

Vaginal delivery (270/450, 60.0%). The overall survival rate was

86.7% (390/450). Forty-two infants were admitted to the

Intensive care unit (ICU). The ICU survival rate was 88.1%

(37/42). Significant predictors of survival were place of birth

( p=0.006), mode of delivery ( p=0.007) and bag-mask ventilation at

Birth ( p=0.040). Duration of

Hospital stay ( p=0.000) was

Significantly longer in survivors than in non-survivors (6.5±6.6

Days v. 2.8±9.8 days). The remaining factors, namely gender,

Antenatal care, chest compressions, diagnosis of meconium

Aspiration syndrome or persistant pulmonary hypertension, did

anoxia symptoms

Not differ significantly between the two groups. The rate of

Perinatal asphyxia (5-minute apgar score 6) was 4.7/1 000

Live births, and there was evidence of hypoxic ischaemic

Encephalopathy (HIE) in 3.6/1 000 live births. Of the 390 babies

Discharged from CMJAH, 113 (29.0%) had follow-up records to a

Mean corrected age of 5.9±5.0 months. The majority (90/113,

79.6%) had normal development.

Conclusions. ( i)

The high overall survival and survival after ICU admission

Provides a benchmark for further care; ( ii)

Obtaining adequate data for long-term follow-up was not possible

With the existing resources – surrogate early markers of outcome

And/or more resources to ensure accurate follow-up are needed;

And ( iii) the high incidence of HIE

anoxia symptoms

Suggests that a therapeutic hypothermia service, including a

Long-term follow-up component, would be beneficial.

S afr J CH 2013;7(3):89-94.


Over 9 million children die each year during the perinatal and

Neonatal periods, and nearly all of these deaths occur in

Developing countries. 1 perinatal asphyxia is a

Serious clinical problem globally. Every year approximately 4

Million babies are born asphyxiated; this results in 1 million

Deaths and an equal number of serious neurological consequences

Ranging from cerebral palsy and mental retardation to epilepsy. 2 perinatal

Asphyxia is a major factor contributing to perinatal and

Neonatal mortality, which is an indicator of the social,

Educational and economic standards of a community.Anoxia symptoms

Perinatal asphyxia is defined as any perinatal

Insult resulting in suffocation with anoxia and increased carbon

Dioxide. 2

Severe fetal hypoxia or ischaemia can manifest in the newborn as

Encephalopathy, and may result in neonatal death or permanent

Motor and mental disability. 2

Taking into account that neonatal deaths

Account for almost 40% of deaths of children under 5, it is

Apparent that millennium developmental goal 4 (aiming at a

Two-thirds reduction in under-5 mortality by the year 2015 from

A baseline in 1990) can only be met by substantially reducing

Neonatal deaths. Perinatal asphyxia is the fifth largest cause

Of under-5 deaths (8.5%) after pneumonia, diarrhoea, neonatal

Infections and complications of preterm birth. 2

anoxia symptoms

The death of an infant as a result of

Perinatal asphyxia is devastating and frequently avoidable. In

Developed countries with well-functioning health services these

Deaths are rare and ways to prevent them are widely understood

And applied. However, a perinatal audit using the perinatal

Problem identification programme (PIPP) (www.Ppip.Co.Za) has

Identified perinatal asphyxia as a common and important cause of

Death in south africa. 3 at chris hani barawagnath

Hospital in gauteng, 20% of all neonatal deaths are due to

Asphyxia. 4

A group of 25 term asphyxiated infants admitted to the

Johannesburg hospital neonatal unit was studied between

September 1980 and march 1982. This study showed a mortality

Rate of 20%, 16% of children were disabled at the 2-year

anoxia symptoms

Assessment, and 20% were lost to follow-up. 5 in a

Follow-up retrospective study of 109 term infants with moderate

To severe perinatal asphyxia, prognosis was often poor,

Particularly in patients with seizures, cardiopulmonary signs of

Asphyxia and multi-organ dysfunction. 6

The fundamental goal of establishing perinatal

Audits in areas with high perinatal mortality rates is to reduce

The number of perinatal deaths through improvement in the

Quality of care. Several studies have shown a strong association

Between the establishment of an effective audit process and

Improvement of the quality of maternal health services and

Perinatal mortality rates. 3 currently there are limited

Data on perinatal mortality rates, and although available

anoxia symptoms

Figures are very high, they are likely to underestimate the


The major difficulty in collecting accurate

Epidemiological data is lack of a common definition of the

Diagnostic criteria of perinatal asphyxia. 2 the umbilical artery ph that defines

Asphyxia of a sufficient degree to cause brain injury is

Unknown. Although the most widely accepted definition is a ph of

1 800 g and their 5-minute apgar score

72 hours), was considered. The neonatal unit submits

Mortality data to the PIPP database ( http://www.Pipp.Co.Za ).

Final PIPP diagnosis was reviewed for all deaths.

On discharge of a patient, the

Parents/caretakers are given an appointment to visit our routine

Post-discharge neonatal follow-up clinic (NNFU), which is

anoxia symptoms

Staffed by paediatricians, medical officers, occupational

Therapists, physiotherapists and speech therapists. Defaulters

Are contacted once in writing, no further attempt being made to

Ensure follow-up. Follow-up visits are recorded and stored in

The clinic files. NNFU records were reviewed and the findings

Noted by the attending doctor and the multidisciplinary team

Were recorded. Outcomes at follow-up were recorded as normal

Neurological development (age-appropriate milestones achieved,

Normal vision and hearing), cerebral palsy and developmental

Delay, microcephaly, cortical blindness, hearing loss or

Seizures. The outcome at the last clinic attendance was noted

For each patient. Statistical analysis

anoxia symptoms

Data were entered onto an MS-excel spreadsheet and then

Imported to the statistical software SPSS version 20 for

Analysis using standard statistical methods. The analysis of

Patient demographics and baseline outcome variables was

Summarised using descriptive study methods and expressed as

Means (± standard deviations (sds)) or medians (ranges) for

Continuous variables and frequencies and percentages for

Categorical variables. Survivors and non-survivors were

Compared. Categorical data were compared using chi-square

Analysis and continuous data using unpaired t-tests (as the distribution was

Normal). Ethics approval

The study was approved by the committee for research on human

Subjects of the university of witwatersrand (clearance

anoxia symptoms

Certificate number M120447). Results

A total of 470 babies were eligible for inclusion into

The study; however, 7 were excluded because there were no

Clinical data available at all, and 13 owing to major

Congenital abnormalities. The final sample therefore consisted

Of a total of 450 babies, 185 females (41.1%) and 260 males

(57.8%). The mean ±SD maternal age

Was 25.6±6.1 years and mean parity was 1 (interquartile range

1 – 9). Birth weights ranged from 1 800 to 4 596 g (mean ±SD

3 034.8±484.9 g), and the mean ±SD

Gestational age was 39.1±2.2 weeks. Clinical and demographic

Characteristics are set out in table 1.

The majority of the babies were born at CMJAH

(391/450, 86.9%) and by normal vaginal delivery (270/450,

anoxia symptoms

60.0%). Problems in pregnancy were documented in 228/450 cases

(50.7%) (table 2), fetal distress being the most common (91/450,


A total of 346 babies (76.9%) had evidence of HIE, but only 158

(45.7%) of these had a grade of HIE recorded the rate of

Perinatal asphyxia (5-minute apgar score 6) was 4.68/1 000

Live births, and there was evidence of HIE in 3.6/1 000 live

Births. ICU admissions

Forty-two babies were admitted to the ICU, 15 females and 27

Males. Of these 15 (35.7%) had MAS, 9 (21.4%) had hyaline

Membrane disease (HMD) and 3 (7.1%) had PPHN. The ICU survival

Rate was 88.1% (37/42). Two of the babies received cerebral

Cooling after perinatal asphyxia. They were monitored in the

Neonatal ICU and both survived.Anoxia symptoms mortality

The overall survival rate was 86.7% (390/450). The causes of

Death according to the PIPP classification were as follows:

Perinatal asphyxia 53/60 (88.3%), meconium aspiration and

Perinatal asphyxia 3/60 (5.0%), HMD 1/60 (1.7%), group B

Streptococcal infection 2/60 (3.3%) and hypovolaemic shock 1/60

(1.7%). Significantly, more babies who died compared with those

Who survived had evidence of HIE (table 3).

Comparison between survivors and


Various factors were compared between the babies who survived

And those who died (tables 3 and 4). Place of birth ( p=0.006), mode of delivery ( p=0.007) and bag-mask ventilation at

Birth ( p=0.040) were all

Significantly associated with survival. The duration of stay ( p=0.000) was significantly longer in

anoxia symptoms

Survivors. The remaining factors, namely gender, antenatal care,

Chest compressions, diagnosis of meconium aspiration syndrome

And persistent pulmonary hypertension of the newborn, did not

Differ significantly between the two groups.


Of the 390 babies discharged from CMJAH, 113 (29.0%) had

Follow-up records to a mean ±SD corrected age of

5.9±5.0 months. The majority (90/113, 79.6%) had normal

Development. Details of the disabilities are shown in table 5.


This review shows that perinatal asphyxia remains a common

Problem at CMJAH, with approximately 6 admissions every month.

In-hospital mortality was low (60/450, 13.3%), with the burden

Anticipated to be in the disabled survivors. Our rates of

anoxia symptoms

Perinatal asphyxia and HIE were similar to those found by horn et al. 12

The 5-minute apgar score is a poor indication

Of cerebral injury. In this study, 103 babies (22.9%) had no

Evidence of HIE, although 347 (77.1%) had signs of neurological

Compromise recorded. Attending staff do not routinely allocate a

Grade of HIE, and only 158 babies had a grade recorded. This is

A very important omission, as it is a difficult thing to decide

Retrospectively. Possible reasons for the lack of proper grading

Or a detailed neurological examination may be related to

Challenges in a busy resource-constrained setting, lack of

Continuity of care (as different healthcare workers review

Patients daily), or healthcare workers not having been

anoxia symptoms

Adequately trained on the criteria to examine for and the

Grading to allocate.

There are few population-based studies of HIE

In sub-saharan africa, and the published criteria that are used

To define and grade HIE are too variable for meaningful

Comparisons between studies and populations. Horn et al. 12 discuss the difficulties in

Consensus definitions and criteria of HIE. The data show that

There is a wide variation in the incidence and grade of HIE,

Depending on which criteria are used. A more refined method of

Classifying perinatal asphyxia than the 5-minute apgar score is

Required, possibly the TOBY 14 or coolcap 17 definitions;

However, these require special investigations. There is a need

To encourage staff to assign an HIE grade accurately.Anoxia symptoms the need

For resuscitation at birth predicted outcome and could be

Included in the definition of perinatal asphyxia in

Resource-poor settings, where there is no means of arterial

Blood gas measurement or aeeg available.

Our busy resource-constrained setting, where

Only 74.2% of infants born with a 5-minute apgar score 6

Receive bag-mask resuscitation, presents major challenges.

Before a cooling programme is imple­mented, it is essential to

Ensure adequate neonatal resuscitation and strict HIE grading of

All asphyxiated neonates.

Our follow-up rate is unacceptably low at only

29.0% (113/390), and it was disappointing that the 2 babies who

Had received cerebral cooling were not brought for follow-up.

Failure to attend for follow-up may be due to socio-economic

anoxia symptoms

Factors and the low level of education of our patients’

Parents/guardians. It is possible that some asphyxiated babies

Died after discharge, or that disabled children are kept at home

Without access to healthcare. It is therefore not possible to

Report rates of post-discharge disability or mortality

Accurately. Of the 113 patients with follow-up data, 24 (21.2%)

Had disability.

The study results show that predictors of

Survival were mode of delivery, place of birth and resuscitation

At birth. Elective caesarean section was associated with

Improved outcomes. Unexpectedly, all babies with vaginal breech

Deliveries survived. A study has shown that in fetal breech

Presentation, neonatal outcome was better with planned caesarean

anoxia symptoms

Section than vaginal breech delivery. 18 in contrast, a study from

Europe showed that neonatal outcome after planned vaginal breech

Delivery did not differ from outcome after elective caesarean

Section. 19

However, we do not know whether our breech deliveries were

Planned. All the babies BBA survived. It is possible that more

Severely asphyxiated babies died at home or were dead on arrival

At the hospital, but data relating to that information were

Beyond the scope of this study. Duration of hospital stay was

Shorter for babies who died than for those who survived,

Indicating that their condition was very severe and resulted in

Early death. Study limitations

This was a retrospective study that relied on data from

anoxia symptoms

Attending staff, with possible inaccuracies and loss of data.

This study describes the incidence of perinatal asphyxia as

Defined by a 5-minute apgar score 6, and there are

Insufficient data to comment on the incidence of moderate to

Severe HIE or on morbidity after discharge. Lack of a clear

Definition of HIE was a further limitation. A prospective

Follow-up study of babies who sustain perinatal asphyxia is

Warranted. Conclusion

The study confirms that perinatal asphyxia remains a

Significant problem at CMJAH. The high overall survival and

Survival after ICU admission provide a benchmark for further

Care. There is a need to obtain adequate data for long-term

Follow-up, as this was not possible with the existing resources.Anoxia symptoms

Further research is required to establish consensus definitions

That can be used for meaningful population studies and

Benchmarking of HIE. More resources to ensure accurate follow-up

Are needed, and the high incidence of HIE suggests that a

Therapeutic hypothermia service including a long-term follow-up

Component would be beneficial. References