Dr Maksudur Rahman MBBS, DCH, FCPS (Paed)), MD (Neonatology) - PowerPoint PPT Presentation

Dr Maksudur Rahman MBBS, DCH, FCPS (Paed)), MD (Neonatology) Assistant Professor Neonatology Department. Bangladesh Institute of Child Heatlh & Dhaka Shishu (Children) Hospital

Correlation of cardiac impairment with the severity of hypoxic ischemic encephalopathy and its immediate outcome.

Perinatal asphyxia is an insult to fetus or newborn due to a lack of oxygen (hypoxia) and /or a lack of perfusion(ischemia) to various organs which will manifest as difficulty in establishing spontaneous respiration evident by delayed cry after birth. .

 Immediate morbidity and mortality of perinatal asphyxia is due to multiorgan dysfunction .  The incidence of myocardial dysfunction in perinatal asphyxia ranges from 29 to 62%.

 Respiratory distress, congestive cardiac failure, cardiogenic shock and systolic murmur(Tricuspid regurgitation and Mitral regurgitation ) are common feature related to cardiac impairment.

 Cardiac troponin-I is more sensitive and specific than other cardiac enzymes.  Echocardiographic changes in perinatal asphyxia are pulmonary hypertension, RV- hypokinesia , LV hypokinesia, Mitral regurgitation, RV/LV dilatation.

 Assessment of the cardiac impairment in asphyxiated neonates may help to understand severity of perinatal asphyxia and predict its outcome.

 To find out the cardiac function impairment in perinatal asphyxia in order to understand its relation with the outcome.

Specific Objectives A ) To asses cardiac function Clinically  Serum Troponin- I  2-D Color Doppler  Echocardiography.

B)To correlate cardiac impairment with  Stages of HIE  Mortality  Hospital stay Of Asphyxiated neonates

• Study d dy design- Cross sectional study • Study p dy period- January 2012-december 2012 • Pl Plac ace o of study- Neonatal ward of Dhaka Shishu hospital • Study p dy popu pulation- Neonate admitted in Dhaka Shishu hospital • Samp ample S Siz ize -60 • Sampl pling M Methods ds-Purposive.

Inclusion criteria : Admitted neonates Age = 0-72 hours , Gestational age=35-42 weeks and along with following • H/o failure to breathe spontaneously immediately after birth and/or • H/o delayed /no cry after birth and/or  H/o requirement of resuscitation and/or  APGAR score ( at 5minute <5),when available.

Exclusion criteria -  Major congenital anomaly .  Clinical features consistent with congenital infection .  Neonate with Sepsis ,meconium aspiration syndrome  Congenital heart disease .

 Hypoxic-ischemic encephalopathy was categorized clinically according to modified sarnat & sarnat stages (without EEG).  Serum cardiac troponin-I, echocardiography  Newborn was thoroughly examined with special attention to heart rate, blood pressure, capillary refill time at admission and during hospital stay and was monitored upto discharge or death.

 All data were recorded systematically in preformed data collection form.  Statistical analyses of the results was done by using a computer with SPSS-17 program.  The results were presented in tables , diagram & graphs.  Statistical tests X 2 ,Odds ratio ,Multiple logistic regression analysis for significance of difference were done.

 Total Cases-60  Male= 36 (60)% Female= 24 (40%)  Full term- 44 (74%) Preterm- 16 (26%)

Figure-1: Distribution of newborns according to severity of encephalopathy N=60 N=60 35(58.3%) 35 30 13(21.7%) 12(20%) 25 20 15 10 5 HI HIE-I I H HIE-II II HIE-III III 0 Thirteen (21.7%) newborns were in group –I, 35(58.3%) in Group-II and rest 12(20%) in group-III.

Clin Clinica ical l Number er(N (N) Percent ntage(% e(%) feat atures Convulsion 43 71.7% Respiratory 32 53.3% distress Comatose/ 11 18.3% stuporous Pallor 17 28.3%

Fig Figure-2: 2:Percentage of Raised S troponin- I in Perinatal Asphyxia 53.3% 42.7% 60 50 40 30 20 10 0 Troponin-I Troponin-I raised normal

Table-2: Echocardiography changes(n=60) Echocardiography number percentage Changes Pulmonary hypertension 16 26.6% Tricuspid 27 45% regurgitation(TR) Ventricular dysfunction 19 31.7% RV/RA dilatation 18 30% LA/LV dilatation 5 8.3%

cardiac impairment 28(47 32(53 absent %) %) cardiac impairment present

20(57%) 35 cardiac 30 impairment 25 present 1(8%) 20 11(91%) cardiac 15 15(43 12(92 impairment 10 %) absent % 5 1(9%) 0 1 2 3

HIE-I HIE- HIE- Chi P II III Value value 1 20 11 18.17 .0001 Cardiac P A impairment 13 15 1

31.4 0% 69.6 0% 100% cure 33.40 Gro roup-I 66.60 De… Gro roup-II % % Group-III Gro III Above figure shows that mortality of study newborns and were found 11 among 35 (31.4%) in group-II,8 among 12( 66.6%) in group- III and none in group-I .

Mortality 14(44% cure 18(56% death )

Cardiac impairment & Mortality Factors Death No Death OR P value ( X 2 test) (95% CI) Cardiac 18 14 impairment 30.60 .00001 No cardiac 1 27 (3.70- impairment 253.21) •OR=Odd Ratio>1=Significant risk factor. •Level of significant=p < 0.05.

Cardiac impairment & prolong hospital stay ≤10 days) OR (95% CI) Factors >10 days) P value ( X 2 test) Cardiac 15 17 impairment 7.35 .004 No cardiac (1.85-29.35 ) impairment 3 25 •OR=Odd Ratio>1=Significant risk factor. •Level of significant=p < 0.05.

Conclusion: Cardiac impairment directly correlates with the outcome of perinatal asphyxia and is a significant risk factor for morbidity and mortality. Simultaneously other organ impairments also contribute to severity of morbidity and mortality in perinatal asphyxia.

 Small sample size  Single centre study  Financial constraint.

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̈ Table-3: Percentage of organ involvement in Perinatal asphyxia Organs Number Percentage CNS 60 100% Respiratory 35 58.3% cardiac 32 53.3% Hepatic 12 20% Renal 20 33.3%

Tabl ble-8 : Multiple logistic regression of organ impairment for mortality Organ Sig. Exp(B) Cardiac impairment .184 10.404 Respiratory impairment .734 1.846 Renal impairment .459 1.740 Hepatic impairment .025 6.601 *Exp(B) represents the ratio change in the odds of the event of interest for one unite change in the predictor Sig.=level of significant <.05

 Troponin I I : Raised ≥0.183µg/l  Card rdiac imp c impair irment:  1)Clinical feature of cardiac involvement  (Tachycardia/bradycardia and CRT>3Sec/ hypotension/systolic murmur ) with or without  2) S.Troponin- I >0.183µg/l. with or without  3) Echocardiographic finding (pulmonary hypertension , RV-hypokinesia LV hypokinesia, Tricuspid regurgitation,Mitral regurgitation and RV/LV dilatation). 10,12,21