Risk Of Hypoxic-ischemic Encephalopathy Research Articles

Epidural Analgesia During Labor and Neonatal Hypoxic-Ischemic Encephalopathy

Epidural analgesia is used by approximately 70% of birthing persons in the US to alleviate labor pain and is a common cause of elevated temperature in the birthing parent during labor, which, in turn, is associated with adverse neonatal outcomes such as hypoxic-ischemic encephalopathy (HIE). To determine whether epidural analgesia is associated with increased risk of HIE after adjusting for the birthing person's maximal temperature before epidural placement and for the propensity to get an epidural. This retrospective, population-based cohort study was conducted at 15 Kaiser Permanente Northern California hospitals. Participants included singleton neonates born at 35 weeks' or later gestational age between 2012 and 2019. Elective cesarean deliveries and deliveries within 2 hours of hospital admission were excluded. Data analysis was performed from November 2022 to June 2024. The primary exposure was epidural analgesia during labor. The primary outcome was HIE, defined as the presence of both neonatal acidosis (ie, pH <7 or base deficit ≥10) and encephalopathy. The presence and timing of epidural analgesia and demographic, pregnancy, and labor characteristics were extracted from electronic medical records. A propensity score for receiving epidural analgesia was created including demographic variables and comorbidities predating epidural placement. Logistic regression was used to evaluate the association between epidural analgesia and HIE, adjusting for maximal birthing parent's temperature before epidural placement and the propensity for receiving an epidural. Among 233 056 infants born at 35 weeks' or later gestational age by vaginal or unplanned cesarean delivery after at least 2 hours of in-hospital labor, 177 603 (76%) were exposed to epidural analgesia and 439 (0.19%) had HIE. On unadjusted analysis, epidural analgesia was associated with an increased risk of maximal temperature greater than 38 °C during labor (risk ratio [RR], 8.58; 95% CI, 8.06-9.14). Each degree increase in maximal temperature during labor was associated with nearly triple the odds of HIE (odds ratio [OR], 2.82; 95% CI, 2.51-3.17). However, there was no significant association between epidural analgesia and the risk of HIE either on crude (RR, 1.21; 95% CI, 0.96-1.53) or adjusted (adjusted OR, 0.93; 95% CI, 0.73-1.17) analyses. In this cohort study including more than 230 000 parent-infant dyads, epidural analgesia was associated with increased maximal temperature during labor, a known risk factor for HIE. However, epidural analgesia was not associated with increased odds of HIE.

Risk factors for neonatal hypoxic ischemic encephalopathy and therapeutic hypothermia: a matched case-control study

BackgroundPeripartum asphyxia is one of the main causes of neonatal morbidity and mortality. In moderate and severe cases of asphyxia, a condition called hypoxic-ischemic encephalopathy (HIE) and associated permanent neurological morbidities may follow. Due to the multifactorial etiology of asphyxia, it may be difficult prevent, but in term neonates, therapeutic cooling can be used to prevent or reduce permanent brain damage. The aim of this study was to assess the significance of different antenatal and delivery related risk factors for moderate and severe HIE and the need for therapeutic hypothermia.MethodsWe conducted a retrospective matched case-control study in Helsinki University area hospitals during 2013–2017. Newborn singletons with moderate or severe HIE and the need for therapeutic hypothermia were included. They were identified from the hospital database using ICD-codes P91.00, P91.01 and P91.02. For every newborn with the need for therapeutic hypothermia the consecutive term singleton newborn matched by gender, fetal presentation, delivery hospital, and the mode of delivery was selected as a control. Odds ratios (OR) between obstetric and delivery risk factors and the development of HIE were calculated.ResultsEighty-eight cases with matched controls met the inclusion criteria during the study period. Maternal and infant characteristics among cases and controls were similar, but smoking was more common among cases (aOR 1.46, CI 1.14–1.64, p = 0.003). The incidence of preeclampsia, diabetes and intrauterine growth restriction in groups was equal. Induction of labour (aOR 3.08, CI 1.18–8.05, p = 0.02) and obstetric emergencies (aOR 3.51, CI 1.28–9.60, p = 0.015) were more common in the case group. No difference was detected in the duration of the second stage of labour or the delivery analgesia.ConclusionsSmoking, induction of labour and any obstetric emergency, especially shoulder dystocia, increase the risk for HIE and need for therapeutic hypothermia. The decisions upon induction of labour need to be carefully weighed, since maternal smoking and obstetric emergencies can hardly be controlled by the clinician.

Association between decreased cord blood inter-alpha inhibitor levels and neonatal encephalopathy at birth

BackgroundInter-alpha inhibitor proteins (IAIPs) are structurally related proteins found in the systemic circulation with immunomodulatory anti-inflammatory properties. Reduced levels are found in inflammatory related conditions including sepsis and necrotizing enterocolitis, and in neonatal rodents after exposure to hypoxia ischemia. In the current study, cord blood IAIP levels were measured in neonates with and without exposure to hypoxic-ischemic encephalopathy (HIE). MethodsThis is a prospective cohort study including infants born ≥36 weeks over a one-year period. Term pregnancies were divided into two groups: a “reference control” (uncomplicated term deliveries), and “moderate to severe HIE” (qualifying for therapeutic hypothermia). IAIPs were quantified using a sensitive ELISA on the cord blood samples. ResultsThe study included 57 newborns: Reference control group (n = 13) and moderate/severe HIE group (n = 44). Measurement of IAIP cord blood concentrations in moderate to severe HIE group [278.2 (138.0, 366.0) μg/ml] revealed significantly lower IAIP concentrations compared with the control group [418.6 (384.5, 445.0) μg/ml] (p = 0.002). ConclusionsThese findings suggest a potential role for IAIPs as indicators of neonates at risk for HIE. IAIP levels could have diagnostic implications in the management of HIE. Future research is required to explore the relationship between HIE and IAIPs as biomarkers for disease severity. Category of studyTranslational.

Umbilical artery eucapnic pH to assess fetal well-being

Umbilical artery gas results help obstetricians assess fetal well-being during labor and guide screening decisions on eligibility for therapeutic hypothermia (ie, whole-body or head cooling). The accuracy of results, especially for the base deficit on arterial cord gas analysis, in predicting brain injury is questioned. A novel biomarker specifically calculated for fetal acid-base physiology and response to asphyxia-neonatal eucapnic pH as a marker of neonatal metabolic acidosis-has the potential to be an accurate predictor of hypoxic-ischemic encephalopathy. We aimed to compare false-negative rates of hypoxic-ischemic encephalopathy for umbilical artery pH, base deficit, and neonatal eucapnic pH in assessing fetal acid-base balance as a marker of fetal well-being and predicting acute brain injury. This is a retrospective single-center cohort study of newborns ≥ 35 weeks of gestation diagnosed with hypoxic-ischemic encephalopathy. We compared false-negative rates for any grade of hypoxic-ischemic encephalopathy using unilateral paired chi-square statistical analysis based on cutoff values for umbilical artery pH ≤7.00, base deficit ≥16 mmol/L, base deficit ≥12 mmol/L and neonatal eucapnic pH ≤7.14. We performed an analysis of variance between umbilical artery pH, base deficit, and neonatal eucapnic pH for each hypoxic-ischemic encephalopathy grade. We included 113 newborns. False-negative rate for hypoxic-ischemic encephalopathy was significantly higher for base deficit <16 mmol/L (n=78/113; 69.0%) than <12 mmol/L (n=46/113; 40.7%), pH >7.00 (n=41/113; 36.3%), or neonatal eucpanic pH >7.14 (n=35/113; 31.0%) (P<.0001). All true-positive cases were identified using only umbilical artery pH and neonatal eucapnic pH. Base deficit ≥16 or ≥12 mmol/L did not add any value in identifying newborns with hypoxic-ischemic encephalopathy when using umbilical artery pH and neonatal eucapnic pH. No association emerged between any marker and hypoxic-ischemic encephalopathy severity grading. Our findings support the accuracy of neonatal eucapnic pH to assess fetal well-being during labor and to improve predictive performance for acute brain injury. Neonatal eucpanic pH, in addition to umbilical artery pH, may be a viable alternative in identifying newborns at risk for hypoxic-ischemic encephalopathy.

Magnesium sulfate and risk of hypoxic-ischemic encephalopathy in a high-risk cohort

Hypoxic-ischemic encephalopathy contributes to morbidity and mortality among neonates ≥36 weeks of gestation. Evidence of preventative antenatal treatment is limited. Magnesium sulfate has neuroprotective properties among preterm fetuses. Hypertensive disorders of pregnancy are a risk factor for hypoxic-ischemic encephalopathy, and magnesium sulfate is recommended for maternal seizure prophylaxis among patients with preeclampsia with severe features. (1) Determine trends in the incidence of hypertensive disorders of pregnancy, antenatal magnesium sulfate, and hypoxic-ischemic encephalopathy; (2) evaluate the association between hypertensive disorders of pregnancy and hypoxic-ischemic encephalopathy; and (3) evaluate if, among patients with hypertensive disorders of pregnancy, the odds of hypoxic-ischemic encephalopathy is mitigated by receipt of antenatal magnesium sulfate. We analyzed a prospective cohort of live births ≥36 weeks of gestation between 2012 and 2018 within the California Perinatal Quality Care Collaborative registry, linked with the California Department of Health Care Access and Information files. We used Cochran-Armitage tests to assess trends in hypertensive disorders, encephalopathy diagnoses, and magnesium sulfate utilization and compared demographic factors between patients with or without hypertensive disorders of pregnancy or treatment with magnesium sulfate. Hierarchical logistic regression models were built to explore if hypertensive disorders of pregnancy were associated with any severity and moderate/severe hypoxic-ischemic encephalopathy. Separate hierarchical logistic regression models were built among those with hypertensive disorders of pregnancy to evaluate the association of magnesium sulfate with hypoxic-ischemic encephalopathy. Among 44,314 unique infants, the diagnosis of hypoxic-ischemic encephalopathy, maternal hypertensive disorders of pregnancy, and the use of magnesium sulfate increased over time. Compared with patients with hypertensive disorders of pregnancy alone, patients with hypertensive disorders treated with magnesium sulfate represented a high-risk population. They were more likely to be publicly insured, born between 36 and 38 weeks of gestation, be small for gestational age, have lower Apgar scores, require a higher level of resuscitation at delivery, have prolonged rupture of membranes, experience preterm labor and fetal distress, and undergo operative delivery (all P<.002). Hypertensive disorders of pregnancy were associated with hypoxic-ischemic encephalopathy (adjusted odds ratio, 1.26 [95% confidence interval, 1.13-1.40]; P<.001) and specifically moderate/severe hypoxic-ischemic encephalopathy (adjusted odds ratio, 1.26 [95% confidence interval, 1.11-1.42]; P<.001). Among patients with hypertensive disorders of pregnancy, treatment with magnesium sulfate was associated with 29% reduction in the odds of neonatal hypoxic-ischemic encephalopathy (adjusted odds ratio, 0.71 [95% confidence interval, 0.52-0.97]; P=.03) and a 37% reduction in the odds of moderate/severe neonatal hypoxic-ischemic encephalopathy (adjusted odds ratio, 0.63 [95% confidence interval, 0.42-0.94]; P=.03). Hypertensive disorders of pregnancy are associated with hypoxic-ischemic encephalopathy and, specifically, moderate/severe disease. Among people with hypertensive disorders, receipt of antenatal magnesium sulfate is associated with a significant reduction in the odds of hypoxic-ischemic encephalopathy and moderate/severe disease in a neonatal cohort admitted to neonatal intensive care unit at ≥36 weeks of gestation. The findings of this observational study cannot prove causality and are intended to generate hypotheses for future clinical trials on magnesium sulfate in term infants.

The association between plasma IgG N-glycosylation and neonatal hypoxic-ischemic encephalopathy: a case-control study.

Hypoxic-ischemic encephalopathy (HIE) is one of severe neonatal brain injuries, resulting from inflammation and the immune response after perinatal hypoxia and ischemia. IgG N-glycosylation plays a crucial role in various inflammatory diseases through mediating the balance between anti-inflammatory and pro-inflammatory responses. This study aimed to explore the effect of IgG N-glycosylation on the development of HIE. This case-control study included 53 HIE patients and 57 control neonates. An ultrahigh-performance liquid chromatography (UPLC) method was used to determine the features of the plasma IgG N-glycans, by which 24 initial glycan peaks (GPs) were quantified. Multivariate logistic regression was used to examine the association between initial glycans and HIE, by which the significant parameters were used to develop a diagnostic model. Though receiver operating characteristic (ROC) curves, area under the curve (AUC) and 95% confidence interval (CI) were calculated to assess the performance of the diagnostic model. There were significant differences in 11 initial glycans between the patient and control groups. The levels of fucosylated and galactosylated glycans were significantly lower in HIE patients than in control individuals, while sialylated glycans were higher in HIE patients (p < 0.05). A prediction model was developed using three initial IgG N-glycans and fetal distress, low birth weight, and globulin. The ROC analysis showed that this model was able to discriminate between HIE patients and healthy individuals [AUC = 0.798, 95% CI: (0.716-0.880)]. IgG N-glycosylation may play a role in the pathogenesis of HIE. Plasma IgG N-glycans are potential noninvasive biomarkers for screening individuals at high risk of HIE.

Standardizing neonatal hypoxic ischemic encephalopathy evaluation and documentation practices.

Infants at risk for hypoxic ischemic encephalopathy (HIE) require a time sensitive evaluation and decision-making regarding treatment with therapeutic hypothermia (TH). Prior to this project, there was no standardized approach to evaluating these infants locally. Included infants were "at risk for HIE," defined as meeting the "patient characteristics" and "biochemical criteria" per the institutional HIE pathway. Our primary outcome was documentation of an HIE therapeutic hypothermia evaluation (HIETHE) within the first six hours of life which included: (1) recognition of at-risk status, (2) an encephalopathy exam, and (3) a decision regarding TH. Plan-Do-Study-Act cycles included novel clinical decision support. From October 2020 to May 2023, among infants at-risk for HIE, the average percentage with an HIETHE documented improved from 47% to 82%. We standardized the approach to infants at risk for HIE and improved the presence of a complete and timely evaluation regarding TH eligibility.

Eucapnic pH coupled with arterial cord pH improves hypoxic-ischemic encephalopathy prediction.

To consider the classical use of "pH < 7.0 and/or a base deficiency ≥12 mmol/L" as markers of the risk of neonatal hypoxic-ischemic encephalopathy (HIE), recalling various criticisms of the use of these markers in favor of that of neonatal eucapnic pH, which appears to be a better marker of this risk. Fifty-five cases of acidemia with pH < 7.00 were collected from a cohort from the Nice University Hospital with eight cases of HIE. We compared the receiver operating characteristics curves established from the positive likelihood ratio (+LR) for each case of: umbilical cord artery pH (pHa), neonatal eucapnic pH (pH euc-n) in isolation (not matched to pHa), and matched pHa to its own pH euc-n. The areas under the curve (AUC) are identical for pHa and pH euc-n, but AUC for the matched pair pHa-pH euc-n appears superior but non-significant because of the small number in our cohort. However, using the bootstrap method, the partial AUC for a sensitivity greater than 75% indicates the significant superiority (P < 0.01) of the matched pair pHa-pH euc-n approach. The originality of this study lies in the use of two methodologic approaches: (1) standardized partial analysis of the AUCs of the pHa curve and that of pHa matched to its own pH euc-n, and (2) bootstrap statistical technique, that allowed us to conclude (P < 0.01) that the combined use of pH measured at the cord coupled with its eucapnic correction is better for diagnosing metabolic acidosis and best predicting the risk of HIE.

Trends of Neonatal Hypoxic-Ischemic Encephalopathy Prevalence and Associated Risk Factors in the United States, 2010 to 2018

ABSTRACT Neonatal hypoxic ischemic encephalopathy (HIE) is one of the most common causes of neonatal morbidity and mortality worldwide. It has an overall mortality rate ranging from 15% to 25%, with up to 50% of survivors developing long-term neurological disabilities. Therapeutic hypothermia (TH) has been the only effective treatment for moderate to severe HIE in neonates ≥35 weeks of gestation. Infants with mild HIE previously had been excluded from studies, but a recent study reported approximately 16% developed a disability at 18 to 22 months of age. Despite treatment, up to 29% of neonates with HIE still develop adverse outcomes. To decrease the prevalence of neonatal HIE, prevention is key and a better understanding of associated maternal, perinatal, and neonatal risk factors is needed. The aim of this study was to assess trends of HIE prevalence and use of TH, mortality, and clinical neonatal outcomes. This was a cross-sectional analysis using National Inpatient Sample data sets from 2010 to 2018. Included were newborn infants diagnosed with HIE or asphyxia, who were ≥35 weeks of gestation and had a birth weight ≥2500 g. Excluded were those with congenital heart disease, congenital central nervous system anomalies, congenital lung anomalies, congenital abdominal wall defects, gastroschisis or omphalocele, multiple congenital anomalies, common syndromes, and chromosomal disorders. Of the 32,180,617 infants included in the analysis, 31,249,100 were term infants (&gt;35 weeks). The prevalence of all degrees of HIE for term infants was approximately 0.1%. There was a modest increase from 0.093% during the years 2010 and 2012 up to 0.097% during 2016 and 2018. Approximately 21% of cases were managed with TH. More infants with moderate HIE received TH than those with severe HIE (29.9% vs 19.9%; P &lt; 0.01). Fewer infants with mild or unspecified HIE received TH than those with severe HIE (17.7% and 17.3%, respectively; P &lt; 0.01). From 2010 to 2018, the use of TH increased overall and within each grade of HIE (P &lt; 0.01). The mortality rate was higher in term infants with all degrees of asphyxia than the general population (10.8% vs 0.06%; P &lt; 0.01). Over time, the mortality rate in term infants decreased from 12.3% in 2010 to 8.3% in 2018 (P &lt; 0.01). The analysis included 931,517 were late preterm infants (35–36 weeks of gestation). The combined prevalence for all grades of HIE was 0.23% and did not change significantly over the years. Approximately 21% of late preterm infants were managed with TH. More infants with moderate HIE received TH than those with severe HIE (26.9% vs 20.1%). Fewer infants with mild HIE received TH (13.2%), and no significant difference was observed in infants with unspecified HIE compared with those with severe HIE (18.7% vs 20.1%). The use of TH increased has increased in late preterm infants over the years. The strongest factors associated with HIE were placental infarction or insufficiency, placental abruption, and cord prolapse. Female infant sex, maternal Hispanic ethnicity, and maternal Asian race were associated with lower risk of HIE. In conclusion, HIE prevalence remained essentially the same at 1 per 1000 live births. Use of TH increased, and mortality decreased over time. The strongest factors associated with HIE were placental factors.

Maternal and Fetal Risk Factors for Neonatal Hypoxic-Ischemic Encephalopathy: A Retrospective Study.

Neonatal hypoxic-ischemic encephalopathy (HIE) leads to different degree of neurological sequelae. The incidence of HIE is relatively high, and the risk factors associated with HIE are still controversial. It is necessary to identify the risk factors associated with HIE. A total of 258 neonates (110 HIE patients and 148 controls) were enrolled in this study. The characteristics of pregnant women and fetuses during pregnancy and delivery were compared between HIE patients and controls, and the risk factors of HIE were analyzed. The proportions of premature infants, low-birth-weight infants and the levels of 1-minute Apgar score, 5-minute Apgar score in HIE group were significantly lower than those in control group, while the proportion of amniotic fluid contamination in the HIE group was significantly higher than those of the controls. When HIE was taken as the end point of 1-minute Apgar score, and 5-minute Apgar score, the cut-off value of 1-minute Apgar score was 3, and 5-minute Apgar score was 7 by receiver operating characteristic (ROC) curve analysis. The results of multivariate logistic regression analysis showed that low birth weight (<2.5 kg) (OR 1.780, 95% CI: 0.124-25.463, P=0.016), amniotic fluid contamination (OR 3.223, 95% CI: 1.049-9.901, P=0.041), low 1-minute Apgar score (≤3) (OR 92.425, 95% CI: 15.522-550.343, P<0.001), and low 5-minute Apgar score (≤7) (OR 12.641, 95% CI: 2.894-55.227, P=0.001) may increase risk of HIE. In addition, amniotic fluid contamination, low 1-minute Apgar score (≤3), and low 5-minute Apgar score (≤7) may increase risk of HIE among newborns born to women without previous childbearing history, but not in newborns born to women with previous childbearing history. Low birth weight (<2.5 kg), amniotic fluid contamination, low 1-minute Apgar score (≤3), and 5-minute Apgar score (≤7) may increase risk of HIE.

Risk factors for hypoxic-ischemic encephalopathy or neonatal death in placental abruption

ObjectiveTo identify risk factors for moderate or severe hypoxic-ischemic encephalopathy (HIE), or neonatal death in clinical placental abruption. Material and methodsA nested case-control study within a cohort of singleton pregnancies complicated by placental abruption with a live born infant at two academic reference centers in France, from 2006 to 2019. Cases were patients who gave birth to an infant with moderate or severe HIE or death within 28 days (HIE/death group), and controls were patients whose infant did not have any of these outcomes (no-HIE group). Independent risk factors were identified by logistic regression. Binary decision tree discriminant (CART) analysis was performed to define high-risk subgroups of HIE or death. ResultsAmong 152 patients, the infants of 44 (29%) had HIE or death. Out-of-hospital placental abruption and fetal bradycardia at admission were more frequent in cases than in controls: 39 (89%) vs 61 (56%), p < .01 and 24 (59%) vs 19 (18%), p < .01, respectively. In multivariate analysis, out-of-hospital placental abruption (aOR, 7.05; 95% CI, 1.94-25.66) and bradycardia at admission (aOR, 8.60; 95% CI, 2.51-29.42) were independently associated with an increased risk of HIE or death. The combination of out-of-hospital placental abruption and bradycardia was the highest risk situation associated with HIE or death (67%). The decision-to-delivery interval was 15 [12-20] minutes among cases. ConclusionOut-of-hospital placental abruption combined with bradycardia at admission was associated with a major risk of moderate or severe HIE or death. An optimal decision-to-delivery interval does not guarantee the absence of an adverse neonatal outcome.

ROLE OF URINARY URIC ACID AND CREATININE RATIO IN DIAGNOSIS OF PERINATAL ASPHYXIA

Background: Perinatal asphyxia is a common neonatal condition and contributes signicantly to neonatal morbidity and mortality. There is a need to identify neonates with asphyxia who will be at risk for hypoxic ischemic encephalopathy (HIE) and multi-organ dysfunction. Objectives: To evaluate prospectively the value of measuring urinary UA/ Cr ratio in early spot urine samples in diagnosing perinatal asphyxia and to assess the relationship between the urinary UA/Cr ratio and the severity of HIE. Methods: The study was conducted in babies born at K V G medical college and Hospital, Sullia from October 2018 to May 2020. The urine sample from 55 asphyxiated neonates comprising cases and 55 comprising controls constituted the material for the study. Results: Urinary uric acid/creatinine ratios were found to be higher in asphyxiated infants (2.58 ± 0.94) when compared to those in control group (0.87 ± 0.17). The cut-off UUA/Cr value of 1.03 has 92.72% sensitivity with a specicity of 76.36% and has a positive predictive value of 79.68% with a negative predictive value of 91.30%. Conclusion: UUA/Cr concentration increase after birth asphyxia and is non-invasive, sensitive and costeffective method for assessment of asphyxia and its outcome.

Outcomes of Nonvigorous Neonates Born through Meconium-Stained Amniotic Fluid after a Practice Change to No Routine Endotracheal Suctioning from a Developing Country.

The International Liaison Committee on Resuscitation (ILCOR) 2015 gave a weak recommendation based on low certainty of evidence against routine endotracheal (ET) suctioning in non-vigorous (NV) neonates born through meconium-stained amniotic fluid (MSAF) and suggested for immediate resuscitation without direct laryngoscopy. A need for ongoing surveillance post policy change has been stressed upon. This study compared the outcomes of NV MSAF neonates before and after implementation of the ILCOR 2015 recommendation. This was a prospective cohort study of term NV MSAF neonates who underwent immediate resuscitation without ET suctioning (no ET group, July 2018 to June 2019, n = 276) compared with historical control who underwent routine ET suction (ET group, July 2015 to June 2016, n = 271). Baseline characteristics revealed statistically significant higher proportion of male gender and small for gestational age neonates in the prospective cohort. There was no significant difference in the incidence of primary outcome of meconium aspiration syndrome (MAS) between the groups (no ET group: 27.2% vs ET group: 25.1%; p = 0.57). NV MSAF neonates with hypoxic ischemic encephalopathy (HIE) was significantly lesser in the prospective cohort (no ET group: 19.2% vs ET group: 27.3%; p = 0.03). Incidence of air leaks and need for any respiratory support significantly increased after policy change. In NV MSAF neonates with MAS, need for mechanical ventilation (MV) (no ET group: 24% vs ET group: 39.7%; p = 0.04) and mortality (no ET group: 18.7% vs ET group: 33.8%; p = 0.04) were significantly lesser. Current study from a developing country indicates that immediate resuscitation and no routine ET suctioning of NV MSAF may not be associated with increased risk of MAS and may be associated with decreased risk of HIE. Increased requirement of any respiratory support and air leak post policy change needs further deliberation. Decreased risk of MV and mortality among those with MAS was observed. · Not performing ET suction in NV MSAF infants is not associated with increase in the incidence of MAS.. · Initiating immediate resuscitation without ET suctioning was associated with decreased risk of HIE but increased receipt of any respiratory support and air leak.. · Large multicentric trial is required to generate robust evidence..

Maternal &amp; fetal risk factors for hypoxic-ischemic encephalopathy (HIE) in newborns

Introduction- Perinatal hypoxia leading to hypoxic-ischemic encephalopathy (HIE) is a leading cause of neonatal and under 5 mortality across the world and in India. There are wide regional and social variations in the risk factors associated with HIE and this study was conducted to assess the maternal &amp; fetal risk factors in newborns with moderate to severe HIE. Methodology- This was a case-control study at the SNCU of MKCG Medical College and Hospital in southern Odisha where 100 cases of HIE and 100 matched controls were recruited over a period of 2 years. Data on maternal, antenatal, intrapartum, and post-delivery risk factors were collected from medical records and history taking using a pre-defined proforma. Comparative bivariate analysis was done to assess the strength of association of these risk factors between the two groups. Results- The incidence of HIE is more in 20-30 years age group, however, risk of HIE is significant in &lt;20 years age group. Maternal anemia is a significant risk factor but Bad Obstetric History (BOH) has only clinical correlation. There is no statistical significance for antepartum hemorrhage (APH), pregnancy-induced hypertension (PIH) or gestational diabetes mellitus (GDM) in cases of HIE.

A study of urinary uric acid to creatinine ratio as a biochemical marker of perinatal asphyxia

Background: Perinatal asphyxia remains an important cause of neonatal mortality, morbidity and sequelae especially in developing countries. Prevalence of perinatal asphyxia is 1 to 6 per 1000 live births while incidence of hypoxic-ischemic injury is 0.3 to 2 per 1000 term infants. There was a need to identify neonates with asphyxia at risk for hypoxic ischemic encephalopathy and multi-organ dysfunction using simple bedside tests. The objectives of the study were to evaluate the efficacy of uric acid to creatinine (UA/Cr) ratio in early spot urine samples as a diagnostic tool for perinatal asphyxia and to assess the relationship between urinary UA/Cr ratio and severity of HIE.Methods: This study was conducted on 49 neonates having asphyxia (cases) and 49 neonates without asphyxia (controls) born at a tertiary care hospital over 12 months. Spot urine samples were collected within 24 hours of life and sent for analysis. A UA/Cr ratio of &gt;2.51 was taken as cut-off value.Results: The urinary UA/Cr ratio was found to be higher in asphyxiated infants (2.88±1.01) as compared to the control group (1.72±0.7, p&lt;0.001). UUA/Cr ratio was significantly higher in infants with HIE stage 3 (3.65±1.4) as compared to infants with HIE stage 2 (2.62±0.76) and HIE stage 1 (2.71±0.4) (p&lt;0.009). The cut-off UUA/Cr value of &gt;2.51 has 71.43% sensitivity and 93.88% specificity.Conclusions: The UUA/Cr ratio is a simple and reliable screening test for early diagnosis and assessment of perinatal asphyxia.

Does magnesium sulfate for hypertensive disease reduce the risk of neonatal hypoxic ischemic encephalopathy?

Maternal hypertension (HTN) is a known risk factor for neonatal hypoxic ischemic encephalopathy (HIE). We hypothesize that the use of magnesium for maternal seizure prophylaxis in HTN will reduce the risk of HIE in an at-risk population.

Standardized Evaluation of Cord Gases in Neonates at Risk for Hypoxic Ischemic Encephalopathy.

Umbilical-cord acidemia may indicate perinatal asphyxia and places a neonate at increased risk for hypoxic ischemic encephalopathy (HIE). Our specific aim was to develop a standardized clinical care pathway, ensuring timely identification and evaluation of neonates with umbilical-cord acidemia at risk for HIE. A standardized clinical care pathway to screen inborn neonates ≥36 weeks with abnormal cord blood gases (a pH of ≤7.0 or base deficit of ≥10) for HIE was implemented in January 2016. Abnormal cord blood gases resulted in a direct notification from the laboratory to an on-call physician. Evaluation included a modified Sarnat examination, postnatal blood gas, and standardized documentation. The percentage of neonates in which physician notification, documented Sarnat examination, and postnatal blood gas occurred was examined for 6 months before and 35 months after implementation. Of 203 neonates with abnormal cord gases in the post-quality improvement (QI) period, physician notification occurred in 92%. In the post-QI period, 94% had a documented Sarnat examination, and 94% had postnatal blood gas, compared with 16% and 11%, respectively, of 87 neonates in the pre-QI period. In the post-QI period, of those evaluated, >96% were documented within 4 hours of birth. In the post-QI period, 15 (7.4%) neonates were cooled; 13 were in the NICU at time of identification, but 2 were identified in the newborn nursery and redirected to the NICU for cooling. A standardized screening pathway in neonates with umbilical-cord acidemia led to timely identification and evaluation of neonates at risk for HIE.

Temporal Evolution of Intrapartum Fetal Heart Rate Features.

Our research goal is to improve the intrapartum identification of tracings associated with severe acidosis at birth and subsequent hypoxic-ischemic encephalopathy so that timely interventions could avoid such complications without causing excessive unnecessary interventions in births with normal outcomes. The present study examines the evolution of fetal heart rate (FHR) features over the course of labor. We analyzed FHR signals collected in the last 6 hours before delivery in 21,853 births with normal neonatal outcomes and in 163 that developed hypoxic-ischemic encephalopathy (HIE) from 15 hospitals of Kaiser Permanente Northern California. We divided these six hours into 18 nonoverlapping 20-minute epochs. The power spectral density of each epoch was divided into three bands: low frequency (LF, 30-150 mHz), movement frequency (MF, 150-500 mHz), and high frequency (HF, 500-1000 mHz). We also estimated the LF/(MF+HF) ratio, the mean and standard deviation of the FHR signal, the approximate entropy (ApEn), and the deceleration capacity (DC). In our results, ApEn, the standard deviation, and DC showed a promising ability to detect risk of HIE as early as 120 minutes before birth, which gives enough leading time for timely interventions.

Hypoxic ischemic encephalopathy in offspring of immigrant women in Sweden: A population-based cohort study.

One in four women giving birth in Sweden is foreign-born. Immigrant status has been suggested as a risk factor for adverse perinatal outcomes. It is not known if infants to foreign-born women have an increased risk of severe birth asphyxia, or which factors might mediate such association. A population-based cohort study of 726730live births at 36weeks of gestation or more in Sweden in 2009-2015. The exposure was maternal country of birth, grouped according to the World Bank country classification: low-, lower-middle, upper-middle, and high-income economies. The main outcome was neonatal hypoxic ischemic encephalopathy (HIE). The outcome was estimated by severity and classified as non-hypothermia-treated HIE, representing mainly mild cases, and hypothermia-treated HIE, representing moderate to severe cases. A secondary outcome was low Apgar score at 5minutes, defined as <7 or <4. Odds ratios with 95% CI were calculated, using Swedish-born women as the reference. Structural equation modeling was used to investigate potential mediation of known antepartum risk factors. A total of 854 infants were diagnosed with HIE and 398 received therapeutic hypothermia. Offspring of mothers born in low-income countries had the highest incidences of HIE and low Apgar score, with an incidence of therapeutic hypothermia of 1.1 per 1000. Compared with offspring of Swedish-born mothers, these neonates had an almost two-fold increased risk of HIE, with or without hypothermia treatment (odds ratio 1.7; 95% CI 1.2-2.7 and odds ratio 1.7; 95% CI 1.2-2.6, respectively), and a 2- to 3-fold increased risk of low Apgar score. The structural equation model analysis indicated an exclusive direct effect of country of birth on HIE. Factors reflecting socio-economic status mediated a small proportion of the risk of Apgar score <7 at 5minutes. Offspring of women born in low-income countries had associations with severe birth asphyxia, with increased risk of both HIE and low Apgar score at 5minutes. The associations seemed only to be marginally mediated by other antepartum factors. The associations are complex and further studies are needed to find explanatory and potentially preventable factors.

Decision to Incision and Risk for Fetal Acidemia, Low Apgar Scores, and Hypoxic Ischemic Encephalopathy.

This study aimed to assess risk for fetal acidemia, low Apgar scores, and hypoxic ischemic encephalopathy based on decision-to-incision time interval in the setting of emergency cesarean delivery. This unplanned secondary analysis of the Maternal-Fetal Medicine Units prospective observational cesarean registry dataset evaluated risk for hypoxic ischemic encephalopathy, umbilical cord pH ≤7.0, and Apgar score ≤4 at 5 minutes based on decision-to-incision time for emergency cesarean deliveries. Cesarean occurring for nonreassuring fetal heart rate monitoring, bleeding previa, nonreassuring antepartum testing, placental abruption, or cord prolapse was classified as emergent. Decision-to-incision time was categorized as <10 minutes, 10 to <20 minutes, 20 to <30 minutes, 30 to <50 minutes, or ≥50 minutes. As secondary outcomes umbilical cord pH ≤7.1, umbilical artery pH ≤7.0, and Apgar score ≤5 at 5 minutes were analyzed. Of 5,784 women included in the primary analysis, 12.4% had a decision-to-incision interval ≤10 minutes, 20.2% 11 to 20 minutes, 14.9% 21 to 30 minutes, 18.2% 31 to 50 minutes, and 16.5% >50 minutes. Risk for umbilical cord pH ≤7.0 was highest at ≤10 and 11 to 20 minutes (10.2 and 7.9%, respectively), and lowest at 21 to 30 minutes (3.9%), 31 to 50 minutes (3.9%), and >50 minutes (3.5%) (p < 0.01). Risk for Apgar scores ≤4 at 5 minutes was also higher with decision-to-incision intervals ≤10 and 11 to 20 minutes (4.3 and 4.4%, respectively) compared with intervals of 21 to 30 minutes (1.7%), 31 to 50 minutes (2.1%), and >50 minutes (2.0%) (p < 0.01). Hypoxic ischemic encephalopathy occurred in 1.5 and 1.0% of women with decision-to-incision intervals of ≤10 and 11 to 20 minutes compared with 0.3 and 0.5% for women with decision-to-incision intervals of 21 to 30 minutes and 31 to 50 minutes (p = 0.04). Risk for secondary outcomes was also higher with shorter decision-to-incision intervals. Shorter decision-to-incision times were associated with increased risk for adverse outcomes in the setting of emergency cesarean. · Shorter intervals likely occur with higher risk cases.. · Shorter intervals were associated with higher neonatal risk.. · Shorter intervals were associated with low cord pH..