Perinatal asphyxia in a rural Nigerian hospital: Incidence and determinants of early outcome

Incidence and predictors of mortality among neonates admitted with perinatal asphyxia at west Oromia tertiary hospitals, Ethiopia, 2022

BACKGROUND

Perinatal asphyxia is one of the preventable and treatable causes of neonatal mortality. However, it is the fifth-largest cause of under-five mortality. Even with management advancements, it remains one of the key public health issues in underdeveloped countries, including Ethiopia. Comorbidities are also understated; therefore, adequate information regarding the incidence of death and its predictors is required.

METHODS

A four-year retrospective follow-up study was conducted from October 3 to November 2, 2022. From a total sample size, of 655, 616 data were collected by nurse through follow-up reviews charts using Kobo Toolbox software. The data was exported to STATA Version 14 for analysis. The Cox proportional hazard assumption was checked, and the model for the data was selected using Akaike Information Criteria. Finally, an adjusted hazard ratio with 95% CI was computed, and variables with a P-value < 0.05 in the multivariable analysis were taken as significant predictors of death.

RESULT

The overall incidence of mortality was 38.86/1000 (95% CI: 33.85-44.60). The median time of follow-up was 15 days (95% CI: 14-20). The proportion of deaths was 202 (32.79%, 95% CI: 29.18-36.61) among neonates with perinatal asphyxia. While the distance from health facility > 10 km is (AHR: 2.25; 95% CI: 1.60-3.17), direct oxygen (AHR: 1.83; 95% CI: 1.35-2.48), APGAR score (Appearance, Pulse, Grimace, Activity, and Respiration) < 3 at the fifth minute (AHR: 2.63; 95% CI: 1.03-6.73), prolonged rupture of membrane (AHR: 1.41; 95% CI: 1.02-1.94), and stage III hypoxic ischemic encephalopathy (AHR: 2.02; 95% CI: 1.18-3.47) were predictors of mortality among neonates with perinatal asphyxia.

CONCLUSION

According to this study's findings, high neonatal mortality due to perinatal asphyxia requires proper intervention regarding membrane rupture, APGAR score (Appearance, Pulse, Grimace, Activity, and Respiration), oxygen use, stage III hypoxic-ischemic encephalopathy, and residence distance.

Birth asphyxia related mortality in Northwest Ethiopia: A multi-centre cohort study

BACKGROUND

Birth asphyxia is the second leading cause of neonatal death in Ethiopia, next to preterm-associated infections. Understanding the causes of death in asphyxiated newborns will help to design appropriate care. This study identifies predictors of neonatal mortality in asphyxiated newborns in selected hospitals in Northwest Ethiopia.

METHODS

An institution-based prospective cohort study of 480 newborns with birth asphyxia was conducted at Debre Markos Comprehensive Specialized Hospital, Shegaw Motta District Hospital, and Injibara General Hospital. All newborns with asphyxia admitted to the neonatal critical care unit from the first of November 2018 to the first of November 2019 were included. Data were obtained prospectively from mothers using an interviewer's administered questionnaire. The Kaplan-Meier survival curve was used to estimate survival time, and Log rank test was used to compare the survival curves. Bivariable and multivariable Cox proportional hazards models were fitted to identify the independent predictors of mortality in asphyxiated newborns. Adjusted hazard Ratios (AHRs) with 95% Cis (Confidence Intervals) were used to measure the strength of association and test statistical significance.

RESULTS

The overall cumulative incidence of mortality among asphyxiated newborns was 42.29% (95% CI: 38%, 46). Asphyxiated neonates with other comorbidities (sepsis, neonatal anemia) (AHR = 2.63, 95% CI:1.69, 4.10), oxygen saturation of 50-69 (AHR = 4.62, 95% CI:2.55, 8.37), oxygen saturation of 70-89 (AHR = 2.82, 95% CI: 1.80, 4.42), severe Apgar score at one minute (AHR = 1.59, 95% CI:1.12, 2.25), neonates with Hypoxic Ischemic Encephalopathy (HIE) (AHR = 6.12, 95% CI:2.23, 16.75) were at higher risk of mortality.

CONCLUSIONS

The mortality rate among asphyxiated neonates remains high, and slightly higher than previous studies. Asphyxiated newborns with other comorbidities, severe Apgar score at one minute, who develop HIE, and low oxygen saturation were at higher risk of death. Therefore, designing appropriate interventions and prevention methods should be considered for identified variables.

Survival status and predictors of mortality among asphyxiated neonates admitted to the NICU of Dessie comprehensive specialized hospital, Amhara region, Northeast Ethiopia

INTRODUCTION

Birth asphyxia is one of the leading causes of early neonatal mortality, which causes an estimated 900,000 deaths annually. Therefore, assessing the survival status and predictors of mortality among asphyxiated neonates will be highly helpful to policymakers in designing, implementing, and evaluating programs to achieve the sustainable development goal of reducing neonatal mortality as low as 12/1,000 live births by 2030.

METHODS

A facility-based retrospective cohort study was conducted among 378 asphyxiated neonates admitted to the NICU of Dessie Comprehensive Specialized Hospital from January, 2017 -December, 2019. The data were collected from eligible records by using a structured data extraction tool from March 30 -April 21, 2020. The data were cleaned manually and entered into Epi-data version 7.1.2.0, and STATA version 16 was used for the analysis. Bivariate and Multivariate Cox proportional hazard regression analysis were performed, and significant predictors were identified using 95% confidence interval and p-value <0.05.

RESULT

A total of 378 neonates were followed for 2298 neonatal days, ranging from 1 to 28 days. The mortality incidence rate was 5.3/100 person-days-of observation (95% CI: 4.41, 6.29), and 32% (95% CI: 27.6%, 36.8%) of the study subjects died. Admission weight (AHR: 1.72; 95% CI: 1.09, 2.72), seizure (AHR: 1.52; 95% CI: 1.02, 2.27), neonates who received resuscitation (AHR: 2.11; 95% CI: 1.18, 3.80), and stage of asphyxia (moderate (AHR: 3.50; 95% CI: 1.55, 8.36), and severe (AHR: 11.55; 95% CI: 4.73, 28.25)) were significant predictors of neonatal mortality among asphyxiated neonates.

CONCLUSION

The magnitude of neonatal mortality among asphyxiated neonates in the study area was high. Admission weight, seizure, resuscitation, and stage of asphyxia were significant predictors of mortality among neonates with asphyxia. Therefore, special attention should be given to asphyxiated neonates with low admission weight and those who had seizure. Additionally, the timing, quality, and effectiveness of resuscitation might need further assessment and evaluation.

A multicenter study of incidence, risk factors and outcomes of babies with birth asphyxia in Nepal

Background

Perinatal events which result in compromised oxygen delivery to the fetus can lead to Birth Asphyxia (BA). While the incidence, risk factors and outcomes of BA have been characterized, less is known in low resource settings.

Aim

To determine the incidence of Birth Asphyxia (BA) in Nepal and to evaluate associated risk factors and outcomes of this condition.

Methods

A nested observational study was conducted in 12 hospitals of Nepal for a period of 14 months. Babies diagnosed as BA at ≥37 weeks of gestation were identified and demographics were reviewed. Data were analyzed using binary logistic regression followed by multiple logistic regression analysis.

Results

The incidence of BA in this study was 6 per 1000 term livebirths and was higher among women 35 years and above. Predictors for BA were instrumented vaginal delivery (aOR:4.4, 95% CI, 3.1–6.1), fetal distress in labour (aOR:1.9, 95% CI, 1.0–3.6), malposition (aOR:1.8, 95% CI, 1.0–3.0), birth weight less than 2500 g (aOR:2.0, 95% CI, 1.3–2.9), gestational age ≥ 42 weeks (aOR:2.0, 95% CI, 1.3–3.3) and male gender (aOR:1.6, 95% CI, 1.2–2.0). The risk of pre-discharge mortality was 43 times higher in babies with BA (aOR:42.6, 95% CI, 32.2–56.3).

Conclusion

The incidence of Birth asphyxia in Nepal higher than in more resourced setting. A range of obstetric and neonatal risk factors are associated with BA with an associated high risk of pre-discharge mortality. Interventions to improve management and decrease rates of BA could have marked impact on outcomes in low resource settings.

Trends and predictors of in-hospital mortality among babies with hypoxic ischaemic encephalopathy at a tertiary hospital in Nigeria: A retrospective cohort study

Background

Globally, approximately 9 million neonates develop perinatal asphyxia annually of which about 1.2 million die. Majority of the morbidity and mortality occur in Low and middle-income countries. However, little is known about the current trend in incidence, and the factors affecting mortality from hypoxic ischaemic encephalopathy (HIE), in Nigeria.

Objective

We assessed the trends in incidence and fatality rates and evaluated the predictors of mortality among babies admitted with HIE over five years at the Lagos University Teaching Hospital.

Methods

A temporal trend analysis and retrospective cohort study of HIE affected babies admitted to the neonatal unit of a Nigerian Teaching Hospital was conducted. The socio-demographic and clinical characteristics of the babies and their mothers were extracted from the neonatal unit records. Kaplan-Meir plots and Multivariable Cox proportional hazard ratio was used to evaluate the survival experienced using Stata version 16 (StataCorp USA) statistical software.

Results

The median age of the newborns at admission was 26.5 (10–53.5) hours and the male to female ratio was 2.1:1. About one-fifth (20.8%) and nearly half (47.8%) were admitted within 6 hours and 24 hours of life respectively, while majority (84%) of the infants were out-born. The prevalence and fatality rate of HIE in our study was 7.1% and 25.3% respectively. The annual incidence of HIE among the hospital admissions declined by 1.4% per annum while the annual fatality rate increased by 10.3% per annum from 2015 to 2019. About 15.7% died within 24 hours of admission. The hazard of death was related to the severity of HIE (p = 0.001), antenatal booking status of the mother (p = 0.01) and place of delivery (p = 0.03).

Conclusion

The case fatality rate of HIE is high and increasing at our centre and mainly driven by the pattern of admission of HIE cases among outborn babies. Thus, community level interventions including skilled birth attendants at delivery, newborn resuscitation trainings for healthcare personnel and capacity building for specialized care should be intensified to reduce the burden of HIE.

Impact of Erythropoietin in the management of Hypoxic Ischaemic Encephalopathy in resource-constrained settings: protocol for a randomized control trial

Background

Perinatal asphyxia, more appropriately known as hypoxic-ischemic encephalopathy (HIE), is a condition characterized by clinical and laboratory evidence of acute or sub-acute brain injury resulting from systemic hypoxemia and/or reduced cerebral blood flow. HIE is a common and devastating clinical condition in resource-poor countries with poor treatment outcome. This paper describes the protocol for an ongoing study that aims to evaluate the neuroprotective effects of Erythropoietin (EPO) as compared to routine care in the management of moderate to severe HIE among term infants.

Methods

This study is a double-blind randomized controlled trial that will be conducted in the neonatal wards of the Lagos University Teaching Hospital (LUTH), Lagos, Nigeria, over a two-year period after ethical approvals and consents. One hundred and twenty-eight term newborns (≥ 37 weeks gestation) diagnosed with moderate/ severe HIE at admission will be allocated by randomization to receive either EPO or normal saline. All the participants will be offered standard care according to the unit protocol for HIE. Baseline investigations and close monitoring of the babies are done until discharge. Participants are followed up for 2 years to monitor their outcome (death or neurological development) using standard instruments.

Discussion

Previous trials had shown that EPO confers neuroprotective benefits and improve neurological and behavioral outcome in infants with HIE both singly or as an adjuvant to therapeutic hypothermia. This study hypothesized that administering EPO to newborns with moderate /severe HIE can positively influence their clinical and neurological outcomes and will provide evidence to either support or disprove the usefulness of Erythropoietin as a sole agent in the treatment of HIE, especially in resource-limited environment with the highest burden of the disease.

Trial registration

The study has been registered with the Pan African Clinical trials registry on the 2nd of December 2018, with registration number PACTR201812814507775.

Prevalence of perinatal asphyxia in East and Central Africa: systematic review and meta-analysis

Background

Birth asphyxia leads to about 4 million neonatal deaths every year around the globe. But, the pooled prevalence of asphyxia was not yet collated in East and Central African countries. Hence, this systematic review and meta-analysis aimed to determine the pooled prevalence of perinatal asphyxia in Central and East Africa.

Methods

PubMed, Google Scholar, Science Direct, Africa Index Medicus, Africa Journal Online, Excerpta Medica Database, and Cochrane Library databases were searched. All necessary data were extracted using a standardized data extraction format. Data were analyzed using STATA 14 statistical software. A heterogeneity of studies was assessed using the I² statistics. Publication bias was checked by using a funnel plot and Egger's regression test. A random-effect model was computed to estimate the pooled prevalence of perinatal asphyxia.

Results

Thirteen full-text studies were included in the present meta-analysis. The pooled prevalence of perinatal asphyxia in this study was 15.9% (95%CI: 10.8, 21.0% [I² = 94.6, p = 0.000]). Regional subgroup analysis indicated that the pooled prevalence of perinatal asphyxia was 18.0 % (95%CI:11.4, 26.7% [I² = 96.00, p = 0.000]) and 9.1 % (95%CI:2.0, 16.2% [I² = 90.80, P = 0.000]) in East and Central African countries respectively. Similarly, the level of perinatal asphyxia was varied based on asphyxia measuring tools. But the trim fill analysis pointed that there was no difference in the pooled prevalence of perinatal asphyxia in this study.

Conclusion

The pooled prevalence of perinatal asphyxia was high in the current study. It had also substantial variation across the regions and measuring tools. Therefore, there is a call to reduce the high burden of this problem in the region.

Effectiveness of theophylline administration in neonates with perinatal asphyxia: a meta-analysis

AIM

To evaluate the effects of prophylactic theophylline in renal function and survival rates of asphyxiated newborns.

METHODS

Medline, Scopus, Cochrane Central Register of Controlled Trials, Clinicaltrials.gov and Google Scholar databases were systematically searched. All randomized controlled trials evaluating the efficacy of theophylline in the prevention of perinatal asphyxia were selected.

RESULTS

A total of seven studies were included with a total of 458 asphyxiated neonates. Incidence of acute kidney injury was significantly lower in neonates receiving theophylline (OR: 0.24, 95% CI: [0.16, 0.36]), while mortality rates were similar between the two groups (OR: 0.86, 95% CI: [0.46, 1.62]). Theophylline administration was associated with significantly decreased serum creatinine levels (MD: -0.57 mg/dl, 95% CI: [-0.68, -0.46]) and elevated glomerular filtration rate (MD: 13.79 ml/min/1.73 m², 95% CI: [11.91, 15.68]) in the third day of life. Theophylline also lead to lower β2-microglobulin levels, higher urine output and negative fluid balance.

CONCLUSIONS

The present findings suggest the effectiveness of theophylline in ameliorating renal function of asphyxiated neonates. Future large-scale trials should assess potential long-term adverse outcomes in clinical practice.KeynotesAsphyxia is a major cause of acute kidney injury in neonatesAcute kidney injury is associated with adverse clinical outcomes in asphyxiated neonates.Theophylline administration leads to significantly lower incidence of acute kidney injury in asphyxiated neonates.