Up-Regulation of Nfat5 mRNA and Fzd4 mRNA as a Marker of Poor Outcome in Neonatal Hypoxic-Ischemic Encephalopathy

OBJECTIVE

To evaluate umbilical cord messenger RNA (mRNA) expression as biomarkers for the grade of hypoxic-ischemic encephalopathy (HIE) and long-term neurodevelopment outcome.

STUDY DESIGN

Infants were recruited from the BiHiVE1 study, Ireland (2009-2011), and the BiHiVE2 study, Ireland, and Sweden (2013-2015). Infants with HIE were assigned modified Sarnat scores at 24 hours and followed at 18-36 months. mRNA expression from cord blood was measured using quantitative real-time polymerase chain reaction.

RESULTS

We studied 124 infants (controls, n = 37; perinatal asphyxia, n = 43; and HIE, n = 44). Fzd4 mRNA increased in severe HIE (median relative quantification, 2.98; IQR, 2.23-3.68) vs mild HIE (0.88; IQR, 0.46-1.37; P = .004), and in severe HIE vs moderate HIE (1.06; IQR, 0.81-1.20; P = .003). Fzd4 mRNA also increased in infants eligible for therapeutic hypothermia (1.20; IQR, 0.92-2.37) vs those who were ineligible for therapeutic hypothermia group (0.81; IQR, 0.46-1.53; P = .017). Neurodevelopmental outcome was analyzed for 56 infants. Nfat5 mRNA increased in infants with severely abnormal (1.26; IQR, 1.17-1.39) vs normal outcomes (0.97; IQR, 0.83-1.24; P = .036), and also in infants with severely abnormal vs mildly abnormal outcomes (0.96; IQR, 0.80-1.06; P = .013). Fzd4 mRNA increased in infants with severely abnormal (2.51; IQR, 1.60-3.56) vs normal outcomes (0.74; IQR, 0.48-1.49; P = .004) and in infants with severely abnormal vs mildly abnormal outcomes (0.97; IQR, 0.75-1.34; P = .026).

CONCLUSIONS

Increased Fzd4 mRNA expression was observed in cord blood of infants with severe HIE; Nfat5 mRNA and Fzd4 mRNA expression were increased in infants with severely abnormal long-term outcomes. These mRNA may augment current measures as early objective markers of HIE severity at delivery.

Relationship between serum insulin and point-of-admission blood glucose of ill neonates at a tertiary health facility in Nigeria

Introduction

Optimal glucose metabolism is important in neonatal survival especially in the first days of life. Insulin play a significant role in maintaining blood glucose homeostasis. This study set out to determine the serum insulin levels of ill neonates as related to their point-of-admission blood glucose estimation at the Wesley Guild Hospital, Ilesa, Nigeria.

Methods

Three hundred babies took part in the study. Blood glucose and serum insulin levels were assayed at admission using Accu-Chek Active glucometer^(R) and Accu-Ɔ-Bind ELISA Microwells^(R) respectively. Hyperglycaemia was defined as blood glucose ≥7mmol/L and hypoglycaemia as blood glucose <2.2mmol/L.

Results

The median (IQR) age of the babies was 10.0 (0.5 - 70.0) hours with male to female ratio of 1.5:1. Seventy-four (24.7%) were preterms and 35 (11.7%) were small-for-gestational age. The mean (SD) blood glucose level of the babies was 4.1(2.1) mmol/L with a range of 0.6-13.4mmol/L. Hyperglycaemia and hypoglycaemia were observed in 18(6.0%) and 40(13.3%) babies respectively. The median (IQR) serum insulin level was 9.8(3.0-35.3) μIU/ml. There was weak positive correlation between serum insulin and blood glucose levels of the babies (r = 0.197, p = 0.001). Birth asphyxia was associated with lower serum insulin, while probable sepsis with relatively higher levels.

Conclusion

Serum insulin level increases with increasing blood glucose in ill Nigerian babies at presentation to the hospital. Babies with asphyxia and sepsis particularly tend to have abnormal serum insulin at admission. Hyperinsulinaemia in ill babies may connote a compensatory mechanism to normalise abnormal blood glucose rather than playing significant role in its aetio-pathogenesis.

Lactate acidosis and cardiac output during initial therapeutic cooling in asphyxiated newborn infants

Aim

We hypothesized that compromised cardiac output in asphyxiated infants may influence on the rate of disappearance of lactate due to insufficient perfusion.

Methods

The study was a prospective, observational study, where infants with perinatal asphyxia who met the criteria for therapeutic hypothermia were included. Cardiac output, stroke volume and heart rate were measured by electrical velocimetry in 15 newborn infants with perinatal asphyxia during the first six hours of active therapeutic hypothermia. Results from routine blood samples were collected retrospectively. Cardiac parameters were also measured in 10 healthy, term infants after caesarian section. Cardiac parameters were compared between the asphyxiated group and the control group prior to and during hypothermia. Rate of disappearance of lactate was correlated to cardiac output in the asphyxiated infants.

Results

Cardiac output was stable in the healthy infants from 0.5 to 6 hours postnatally. The infants with perinatal asphyxia had lower cardiac output prior to and during therapeutic hypothermia compared to the control group. Rate of disappearance of lactate was not related to cardiac output.

Conclusion

An association between disappearance of lactate acidosis and low cardiac output was not confirmed. A low rate of disappearance of lactate may rather be an indicator of organ injury due to asphyxia.

Pharmacokinetics of morphine in encephalopathic neonates treated with therapeutic hypothermia

OBJECTIVE

Morphine is a commonly used drug in encephalopathic neonates treated with therapeutic hypothermia after perinatal asphyxia. Pharmacokinetics and optimal dosing of morphine in this population are largely unknown. The objective of this study was to describe pharmacokinetics of morphine and its metabolites morphine-3-glucuronide and morphine-6-glucuronide in encephalopathic neonates treated with therapeutic hypothermia and to develop pharmacokinetics based dosing guidelines for this population.

STUDY DESIGN

Term and near-term encephalopathic neonates treated with therapeutic hypothermia and receiving morphine were included in two multicenter cohort studies between 2008-2010 (SHIVER) and 2010-2014 (PharmaCool). Data were collected during hypothermia and rewarming, including blood samples for quantification of morphine and its metabolites. Parental informed consent was obtained for all participants.

RESULTS

244 patients (GA mean (sd) 39.8 (1.6) weeks, BW mean (sd) 3,428 (613) g, male 61.5%) were included. Morphine clearance was reduced under hypothermia (33.5°C) by 6.89%/°C (95% CI 5.37%/°C- 8.41%/°C, p<0.001) and metabolite clearance by 4.91%/°C (95% CI 3.53%/°C- 6.22%/°C, p<0.001) compared to normothermia (36.5°C). Simulations showed that a loading dose of 50 μg/kg followed by continuous infusion of 5 μg/kg/h resulted in morphine plasma concentrations in the desired range (between 10 and 40 μg/L) during hypothermia.

CONCLUSIONS

Clearance of morphine and its metabolites in neonates is affected by therapeutic hypothermia. The regimen suggested by the simulations will be sufficient in the majority of patients. However, due to the large interpatient variability a higher dose might be necessary in individual patients to achieve the desired effect.

TRIAL REGISTRATION

www.trialregister.nl NTR2529.

Comparison of plasma electrolytes of perinatally asphyxiated and normal term babies

OBJECTIVES

The objective of this study is to document and compare plasma electrolytes of asphyxiated newborns of different degree within 48 hours of life.

STUDY DISIGN

A comparative cross-sectional study was conducted in the newborn special care unit at the University of Nigeria Teaching Hospital (UNTH), Enugu, South-East Nigeria. Sodium, potassium, bicarbonate and ionized calcium levels were estimated in the plasma samples of neonates with perinatal asphyxia of different degree and healthy newborns (control group) within 48 hours of birth.

MAIN OUTCOME MEASURES

The plasma sodium, potassium, bicarbonate and ionized calcium levels were estimated in both, the study subjects and controls.

RESULTS

Mean plasma sodium level was significantly lower (134.93±5.24 mmol/l vs 141.90±3.36 mmol/l; P < 0.05), mean plasma bicarbonate level was significantly lower (16.98±3.99 mmol/l vs 18.54±2.36 mmol/l; P < 0.05), and mean plasma ionized calcium level was significantly lower (1.10±0.14 mmol/l vs 1.25 0.11 mmol/l; P < 0.05) in subjects compared to controls while mean plasma potassium was significantly higher (5.07±0.93 mmol/l vs 4.65±0.51 mmol/l P < 0.05) in subjects compare to controls.

CONCLUSION

The tendency to have hyponatremia, hyperkalemia, acidosis and hypocalcemia is very high among the study subjects which underscores the need for great vigilance in electrolyte monitoring when managing an asphyxiated baby.

Comparison of Serum Electrolytes Abnormality and Renal Function Status in Asphyxiated and Normal Baby in a Tertiary Level Hospital

Complication of perinatal asphyxia is a major cause of neonatal mortality & morbidity in developing countries. This comparative cross sectional study was conducted in Mymensingh Medical College Hospital, Mymensingh, Bangladesh from May 2012 to September 2012 to determine electrolytes & renal function status in perinatal asphyxia & their impact on outcome. Thirty term normal birth weight babies with perinatal asphyxia in neonatal ward were included as a case group and thirty term normal birth weight neonates of same gestational age, without perinatal asphyxia in the department of Gynae & Obs were enrolled as a control group. Necessary information was collected by clinical examination; investigation and close follow up according to predetermined plan. There was no significant different in sex distribution, number of Antenatal care (ANC), number of gravidum of mother and mode of delivery between two groups. Among perinatal Asphyxia group most common risk factor was prolonged labor. Electrolyte abnormalities were documented (16) 53.3% cases. Among 16 electrolyte abnormalities isolated hyponatremia was found in 6(37.5%) cases, hyponatremia with hyperkalaemia 1(6.25%) case, hyponatremia with hypokalaemia in 1(6.25%) case, isolated hypokalaemia in 3(18.75%) cases and isolated hyperkalaemia in 5(31.25%) cases. None case had hypernatremia. On the other hand in control group Hypokalaemia was 3(10%) cases Hyperkalaemia 1(33.33%) case and none had Hyponatraemia. Among total cases 6 (20%) had renal impairment. Serum creatinine level was higher in case group. Twenty percent (20%) case initial value >1.5mg/dl, 20% 1.2-1.5mg/dl and17% had 0.3-0.8mg/dl. On the other hand in control group 83 % had 0.3-0.8 mg/dl & none hade above 1.1 mg/dl. Among case group 8 were died (27%). There was no death in control group. Among 8 neonatal death cases 3(37.5%) had normal electrolytes, isolated hyponatraemia were in 2(25%) cases, hyponatraemia with Hyperkalaemia in 1(6.25%) case and Isolated Hyperkalaemia in 2(25%) cases. Among those death 3(37.5%) had renal impairment. Case fatality was significantly associated with renal failure 50%, isolated Hyponatraemia 33.33%, Isolated hyperkalaemia 40%, Hyperkalaemia with Hyponatremia 100%. Hospital stay was also prolonged among alive case with abnormal electrolytes. So, we can conclude that electrolyte & renal impairments are significantly associated with morbidity & mortality of perinatal Asphyxia.

Serum Levels of Cardiac Troponin I in Asphyxiated Neonates Predict Mortality

BACKGROUND

Cardiac troponin I (cTnI) is a well-established marker for detecting myocardial ischemic damage in neonates with hypoxic-ischemic encephalopathy. However, the predictive value of cTnI in assessing mortality in neonatal asphyxia remains obscure. This retrospective study aims to analyze the relationship between cTnI levels in blood serum with gestational age, birth weight, gender, delivery type, electrocardiography, echocardiography, Apgar scores, length of hospital stay, and mortality in asphyxiated neonates.

METHODS

This study included 164 full-term neonates with evidence of asphyxia. Myocardial markers, electrocardiography, and echocardiography were assessed in the first 24 hours after birth in neonates with asphyxia. The length of hospital stay and short-term outcome were assessed.

RESULTS

There were no statistically significant correlations found between cTnI concentrations and traditional markers of asphyxia, length of hospitalization or mode of delivery. However, high cTnI levels were significant predictors of mortality in neonates with birth asphyxia.

CONCLUSIONS

This study highlights the significance of monitoring cardiac injury in asphyxiated neonates. Serum cTnI levels measured at 24 hours after birth are likely to have significant predictive value for assessing mortality in neonates with birth asphyxia.

Serum copeptin and neuron specific enolase are markers of neonatal distress and long-term neurodevelopmental outcome

The objective of this study was to evaluate the early changes in serial serum levels of copeptin and neuron-specific enolase (NSE) in neonates diagnosed with birth asphyxia, and to determine whether these biomarkers measured in the first 168 hours after birth are predictive of long-term neurodevelopmental outcome. Copeptin and NSE levels were measured from serum samples collected 6, 12, 24, 48, 72, and 168 hours after birth from 75 term neonates diagnosed with hypoxic-ischemic encephalopathy (HIE) and treated with therapeutic hypothermia for 72 hours. In addition, serum copeptin levels after birth were measured from 10 HIE diagnosed neonates, who were randomized to the normothermic arm of the TOBY cohort. All neonates underwent neurodevelopmental assessment using the Bayley Scales of Infant and Toddler Development-II at two years of age. Copeptin levels were highest at 6 hours after birth and steadily decreased, whereas the highest NSE levels were measured at 24 hours after birth. The biomarker levels correlated with blood-gas parameters (base excess, pH and lactate) at 6 and 12 hours after birth. Copeptin and NSE levels in the early postnatal period were significantly higher in neonates with poor outcome compared to those with favorable outcome at two years of age. Furthermore, in the TOBY cohort, copeptin levels were significantly lower in hypothermic compared to normothermic neonates. To conclude, copeptin and NSE measured in the early postnatal period are potential prognostic biomarkers of long-term neurodevelopmental outcome in term neonates diagnosed with HIE and treated with therapeutic hypothermia.

A comparison of blood and cerebrospinal fluid cytokines (IL-1β, IL-6, IL-18, TNF-α) in neonates with perinatal hypoxia

Perinatal hypoxia-ischemia is a specific and important pathological event in neonatal care practice. The data on relationship between the concentrations of cytokines in blood and cerebrospinal fluid (CSF) and perinatal brain injury are scarce. The aim of this study is to evaluate changes in interleukin (IL-1β, IL-6, and IL-18) and tumor necrosis factor alpha (TNF-α) levels in newborns with perinatal hypoxia (PNH). CSF and serum samples of 35 term and near-term (35-40 weeks) newborns with PNH, at the age of 3-96 hours, were analyzed using enzyme-linked immunosorbent assay. Control group consisted of 25 non-asphyxic/non-hypoxic infants of the same age sampled for clinically suspected perinatal meningitis, but proven negative and healthy otherwise. The cytokine values in CSF and serum samples were determined in relation to initial hypoxic-ischemic encephalopathy (HIE) staged according the Sarnat/Sarnat method, and compared with neurological outcome at 12 months of age estimated using Amiel-Tison procedure. The concentrations of IL-6 and TNF-α in serum of PNH patients were significantly higher compared to control group (p = 0.0407 and p = 0.023, respectively). No significant difference between average values of cytokines in relation to the stage of HIE was observed. Significantly higher levels of IL-6 and IL-18 corresponded to a mildly abnormal neurological outcome, while higher levels of IL-6 and TNF-α corresponded to a severely abnormal neurological outcome, at 12 months of age. Elevated serum levels of IL-6 and TNF-α better corresponded with hypoxia/ischemia compared to CSF values, within 96 hours of birth. Also, higher serum levels of IL-6, TNF-α, and IL-18 corresponded better with abnormal neurological outcome at 12 months of age, compared to CSF values.

Analysis of Consequences of Birth Asphyxia in Infants: A Regional Study in Southern Punjab, Pakistan

OBJECTIVE

To evaluate the biochemical consequences and platelet counts of birth asphyxia in neonates.

STUDY DESIGN

Cohort study.

PLACE AND DURATION OF STUDY

Department of Child Health, Nishter Medical College and Hospital, Multan, from September to November 2015.

METHODOLOGY

The data of 50 (50%) asphyxiated neonates and 50 (50%) non-asphyxiated neonates, with age range less than 1 month, was collected from Children Ward of Nishtar Hospital, Multan, Pakistan. Data on platelet count in blood, kidney function tests (creatinine, urea), liver function tests (bilirubin, alanine aminotransferase (ALT), aspartate aminotransferase (AST)) and cardiac enzyme test (lactate dehydrogenase (LDH)) were analysed by paired sample t-test by SPSS software. Sociodemographic data of those neonate's mothers was also collected.

RESULTS

In asphyxiated neonates LDH, ALT, AST, creatinine, bilirubin, urea levels were higher than healthy infants, while the platelet count was smaller in asphyxiated neonates than healthy infants.

CONCLUSION

There was a higher rate of alteration in platelet count, levels of LDH, AST, ALT, urea creatinine and bilirubin in asphyxiated infants. These alterations may be correlated with damage of vital organ of asphyxiated neonates.

Role of Serum Level of Neurometals; Copper, Zinc and Magnesium in Neonates with Hypoxic Ischemic Encephalopathy

BACKGROUND

Perinatal HIE is associated with high morbidity and mortality rates worldwide, despite the improvements in perinatal care. The aim of this study was to evaluate the role Cu, Zn, and Mg+2 neurometals in the development of neonatal hypoxic ischemic encephalopathy.

METHODS

This study included two groups: group 1 (study group): Thirty full term, and diagnosed as having hypoxic ischemic encephalopathy. Group 2 (control group): Thirty full term healthy neonates. All the neonates included in the study were subjected to full history taking and complete clinical and neuromuscular examinations. Laboratory investigations were done in both groups and included complete blood picture, renal functions test, ESR, serum zinc, copper, magnesium, sodium, potassium, and calcium levels.

RESULTS

There were high serum zinc and copper levels in the patient group compared to the control group. However, there was low serum magnesium, calcium, and sodium levels in the patient group compared to the control group. There was a significant difference regarding Apgar score at 1 minute and 5 minutes between patient and control groups. The mean ESR values in patient group at the first hour and second hour were higher in the patient than the control group.

CONCLUSIONS

Neonates with perinatal asphyxia have significantly higher levels of serum zinc and copper and lower serum magnesium, calcium, and potassium levels compared to healthy non asphyxiated neonates. Copper, zinc, and magnesium may play an important role in the development of neonatal hypoxic ischemic encephalopathy; however, further studies are needed to support our findings.

The Role of Plasma and Urine Metabolomics in Identifying New Biomarkers in Severe Newborn Asphyxia: A Study of Asphyxiated Newborn Pigs following Cardiopulmonary Resuscitation

BACKGROUND

Optimizing resuscitation is important to prevent morbidity and mortality from perinatal asphyxia. The metabolism of cells and tissues is severely disturbed during asphyxia and resuscitation, and metabolomic analyses provide a snapshot of many small molecular weight metabolites in body fluids or tissues. In this study metabolomics profiles were studied in newborn pigs that were asphyxiated and resuscitated using different protocols to identify biomarkers for subject characterization, intervention effects and possibly prognosis.

METHODS

A total of 125 newborn Noroc pigs were anesthetized, mechanically ventilated and inflicted progressive asphyxia until asystole. Pigs were randomized to resuscitation with a FiO2 0.21 or 1.0, different duration of ventilation before initiation of chest compressions (CC), and different CC to ventilation ratios. Plasma and urine samples were obtained at baseline, and 2 h and 4 h after return of spontaneous circulation (ROSC, heart rate > = 100 bpm). Metabolomics profiles of the samples were analyzed by nuclear magnetic resonance spectroscopy.

RESULTS

Plasma and urine showed severe metabolic alterations consistent with hypoxia and acidosis 2 h and 4 h after ROSC. Baseline plasma hypoxanthine and lipoprotein concentrations were inversely correlated to the duration of hypoxia sustained before asystole occurred, but there was no evidence for a differential metabolic response to the different resuscitation protocols or in terms of survival.

CONCLUSIONS

Metabolic profiles of asphyxiated newborn pigs showed severe metabolic alterations. Consistent with previously published reports, we found no evidence of differences between established and alternative resuscitation protocols. Lactate and pyruvate may have a prognostic value, but have to be independently confirmed.

Preliminary case control study to establish the correlation between novel peroxidation biomarkers in cord serum and the severity of hypoxic ischemic encephalopathy

BACKGROUND

Hypoxic-ischemic encephalopathy (HIE) has deleterious neurological consequences. To identify patients at risk of neuronal damage deserving implementation of neuroprotective strategies clinicians have relied on prenatal sentinel events, postnatal clinical assessment (Apgar score), and blood gas analysis. This feasibility study aimed to assess if lipid peroxidation byproducts associated with neuronal damage correlated with cord blood metabolic acidemia in patients with HIE.

POPULATION AND METHODS

This is a case/control study in which cases were newborn infants with severe acidemia (pH<7.00; base excess ≥12mmol/L) while control babies exhibited normal gases (pH=7.20-7.40; base excess=-4 to +4mmol/L) in the first cord blood analysis performed immediately after birth. Concomitantly, lipid peroxidation byproducts were determined using ultra performance liquid chromatography coupled to mass spectrometry in the same cord blood sample.

RESULTS

A total of 19 controls and 20 cases were recruited. No differences in gestational characteristics were present. However, cases exhibited profound metabolic alterations as compared to controls (Cases vs.

CONTROL

pH=6.90±0.1 vs. 7.33±0.03; base excess=-15±3 vs. -1±2mmol/L), 85% were admitted to the NICU, and 50% developed symptoms of HIE. 8-iso-15(R)-PGF2α (P=0.01) and total isoprostanes (P=0.045) presented statistically significant differences between cases and control groups and correlated with level of HIE.

CONCLUSIONS

The 8-iso-15(R)-PGF2α and isoprostanes reflecting oxidative damage are significantly increased in severe postnatal acidemia. Follow up studies with adequate power are necessary to confirm if these biomarkers measured in cord blood serum could be predictive of neonatal encephalopathy.

Effect of creatine monohydrate supplementation on relative serum level of IL-6 and IL-18 following neonatal hypoxia ischemia in male albino mouse

IL-6 has been reported to have neuroprotective effects against cerebral ischemia while IL-8 is a pro inflammatory cytokine structurally related to interleukin-1 family. In the present study, we tried to determine whether 2% Creatine monohydrate supplementation for variable duration influence the IL-6 and 18 concentrations in the serum of male albino mouse following right common carotid artery ligation and hypoxia (8% oxygen) for 25 minutes. Our result revealed that serum concentration of IL6 (P=0.0001) as well as IL-18 (P=0.003) were significantly higher in mice supplemented with creatine monohydrate for 15 weeks than in male albino mice on normal rodent diet following hypoxic ischemic insult indicating that long term creatine monohydrate supplementation up regulates the IL-6 and IL-18 concentrations triggering the neuroinflammatory and neuroprotective responses.

Impact of asphyxia on red blood cell folate concentration levels in newborns

OBJECTIVES

To determine whether red blood cell (RBC) folate concentration levels are correlated with the occurrence of neonatal asphyxia and to study the effects of gestational age, gender, and mode of delivery on RBC folate concentration levels in newborns.

BACKGROUND

Asphyxia is one of the frequent causes of morbidity and mortality of newborns. Severe perinatal asphyxia can arise due to many factors.

METHODS

In a prospective study, the RBC folate concentrations were determined on day 1 of life in the whole group (n=181) of full-term (n=121) and preterm (n=60) newborns. Immunochemical analysis for the determination of folate in erythrocytes was performed.

RESULTS

RBC folate concentration levels in asphyxiated newborns (n=16) were significantly decreased (median 974 ng/ml; p=0.023) in comparison with healthy newborns. On the other hand, the RBC folate concentration levels were significantly increased in preterm newborns (median 1,212 ng/ml; p=0.01) in comparison with full-term newborns (median 1,098 ng/ml). Higher RBC folate concentration levels were found in newborns which had been delivered by Caesarean section (median 1,188 ng/ml; p=0.02) compared to those born vaginally (median 1,098 ng/ml).

CONCLUSION

Our results confirmed a significant decrease in RBC folate concentration in asphyxiated newborns on their first day of life (Fig. 4, Ref. 36).

Angiogenesis dysregulation in term asphyxiated newborns treated with hypothermia

BACKGROUND

Neonatal encephalopathy following birth asphyxia is a major predictor of long-term neurological impairment. Therapeutic hypothermia is currently the standard of care to prevent brain injury in asphyxiated newborns but is not protective in all cases. More robust and versatile treatment options are needed. Angiogenesis is a demonstrated therapeutic target in adult stroke. However, no systematic study examines the expression of angiogenesis-related markers following birth asphyxia in human newborns.

OBJECTIVE

This study aimed to evaluate the expression of angiogenesis-related protein markers in asphyxiated newborns developing and not developing brain injury compared to healthy control newborns.

DESIGN/METHODS

Twelve asphyxiated newborns treated with hypothermia were prospectively enrolled; six developed eventual brain injury and six did not. Four healthy control newborns were also included. We used Rules-Based Medicine multi-analyte profiling and protein array technologies to study the plasma concentration of 49 angiogenesis-related proteins. Mean protein concentrations were compared between each group of newborns.

RESULTS

Compared to healthy newborns, asphyxiated newborns not developing brain injury showed up-regulation of pro-angiogenic proteins, including fatty acid binding protein-4, glucose-6-phosphate isomerase, neuropilin-1, and receptor tyrosine-protein kinase erbB-3; this up-regulation was not evident in asphyxiated newborns eventually developing brain injury. Also, asphyxiated newborns developing brain injury showed a decreased expression of anti-angiogenic proteins, including insulin-growth factor binding proteins -1, -4, and -6, compared to healthy newborns.

CONCLUSIONS

These findings suggest that angiogenesis pathways are dysregulated following birth asphyxia and are putatively involved in brain injury pathology and recovery.

Inflammatory mediators as predictors of outcome in perinatal asphyxia

OBJECTIVES

To identify biomarkers for neuronal injury and outcome in perinatal asphyxia.

METHODS

This prospective cohort study was done in authors' level III NICU involving 80 neonates - 40 babies with perinatal asphyxia and 40 weight and gender matched normal neonates. Levels of cytokines IL-6, IL -1β, IL-2 and TNF -α in cord blood of these neonates were estimated and correlated with the severity of asphyxia and developmental outcome at 6 mo using Baroda Developmental Score.

RESULTS

The baseline parameters revealed that there was no statistically significant difference between the two groups in terms of maternal age, parity, gestational age, gender and birth weight. The levels of cytokines IL-6 (p < 0.001) and IL-1beta (p < 0.03) were significantly higher in babies with perinatal asphyxia and correlated with the severity of asphyxia. The levels of IL-6 and IL-1β had significant negative correlation with developmental score at 6 mo. A cut off level of 14.18 pg/ml for IL-6 had 92.3 % sensitivity and 57.7 % specificity [Area under the curve = 0.80 (0.62-0.84)] for adverse neuro-developmental outcome while it was 11.17 pg/ml for IL-1β with a sensitivity of 69.2 % and specificity of 71.2 % [Area under the curve = 0.67 (0.57-0.80)].

CONCLUSIONS

IL-6 and IL-1 β are good predictive markers of severity of asphyxia and adverse neurological outcome.

Serum cortisol concentrations during induced hypothermia for perinatal asphyxia are associated with neurological outcome in human infants

Birth asphyxia is a cause of neonatal death or adverse neurological sequelae. Biomarkers can be useful to clinicians in order to optimize intensive care management and communication of prognosis to parents. During perinatal adverse events, increased cortisol secretion is due to hypothalamo-pituitary-adrenal axis activation. We aimed to investigate if cortisol variations during therapeutic hypothermia are associated with neurodevelopmental outcome. We compared 18 cases (neonates with birth asphyxia) with 18 controls (healthy term newborns) and confirmed increased serum cortisol concentrations following the peri-partum adverse event. Among cases, we stratified patients according to neurological outcome at 18 months (group A - good; group B - adverse) and found that after 24 h of therapeutic hypothermia serum cortisol concentration was significantly lower in group A vs group B (28.7 ng/mL vs 344 ng/mL, *p = 0.01). In group B serum, cortisol concentration decreased more gradually during therapeutic hypothermia. We conclude that monitoring serum cortisol concentration during neonatal therapeutic hypothermia can add information to clinical evaluation of neonates with birth asphyxia; cortisol values after the first 24 h of hypothermia can be a biomarker associated with neurodevelopmental outcome at 18 months of age.

Prevalence and outcomes of acute kidney injury in term neonates with perinatal asphyxia

BACKGROUND

The kidney is the most damaged organ in asphyxiated full-term infants. The severity of its damage is correlated with the severity of neurological damage. We determined the prevalence of perinatal asphyxia-associated acute kidney injury (AKI).

METHODS

We conducted a prospective cohort study including 60 full-term neonates admitted at the Kenyatta National Hospital newborn unit (NBU) in Nairobi with hypoxic ischaemic encephalopathy (HIE) from June 2012 to November 2012. Renal function was assessed by measuring serum creatinine on day 3 of life. AKI was defined by a level of creatinine above 133 µmol/l. The degree of neurological impairment was determined daily until patient discharge, death or day 7 of life.

RESULTS

Of the 60 infants 36.6% had HIE I, 51.6% HIE II and 11.8% HIE III. The prevalence of AKI was 11.7 %. There was a 15 fold increase risk of developing AKI in HIE III versus HIE I, p=0.034. Mortality rate in perinatal asphyxia associated AKI was 71.4 % with a 24 fold increase risk of death in neonates with AKI, p=0.001.

CONCLUSIONS

AKI is common and associated with poorer outcomes in perinatal asphyxia. Larger studies need to be done to correlate maternal factors and perinatal asphyxia-associated AKI.

The diagnostic value of both troponin T and creatinine kinase isoenzyme (CK-MB) in detecting combined renal and myocardial injuries in asphyxiated infants

Background

Troponin T (cTnT) and Creatinine Kinase Isoenzyme (CK-MB) are both markers of myocardial injuries. However, CK-MB is also elevated in acute kidney injury.

Objective

The diagnostic value of both cTnT and cardiac CK-MB in combined myocardial and acute kidney injuries (AKI) in asphyxiated neonates was evaluated.

Method

40 asphyxiated infants and 40 non-asphyxiated controls were consecutively recruited. Serum levels of cTnT, CK-MB and creatinine were measured. Myocardial injury and AKI were defined as cTnT >95^th percentile of the control and serum creatinine >1.0 mg/dl respectively.

Results

Of the 40 subjects, 9 (22.50%), 8 (20.00%) and 4 (10.00%) had myocardial injury, AKI and combined AKI and myocardial injuries respectively. The mean cTnT and CK-MB values were highest in infants with combined AKI and myocardial injuries. The Mean cTnT in infants with AKI, myocardial injury and combined AKI and myocardial injuries were 0.010±0.0007 ng/ml, 0.067±0.040 ng/ml and 0.084±0.067 ng/ml respectively, p = 0.006. The mean CK-MB in infants with AKI, myocardial injury and combined AKI and myocardial injuries were 2.78±0.22 ng/ml, 1.28±0.11 ng/ml and 4.58±0.52 ng/ml respectively, p = <0.0001.

Conclusion

In severe perinatal asphyxia, renal and myocardial injuries could co-exist. Elevated cTnT signifies the presence of myocardial injury. Elevated CK-MB indicates either myocardial injury, AKI or both. Therefore renal injury should be excluded in asphyxiated infants with elevated CK-MB.

[Blood lactate measurments as a diagnostic and prognostic tool after birth asphyxia in newborn infants with gestational age > or = 34 gestational weeks]

Blood lactate at birth as result of activated anaerobic glycolysis is a marker of perinatal asphyxia.

AIM

To evaluate the dynamics of blood lactate, pH and base excess (BE) as a tool for assessing the severity of fetal hypoxia and predicting neonatal outcome.

METHODS

79 neonates (> or = 34 gestational weeks) were included and followed up until discharge: 43 with pathologic fetal hearth rate patterns and/or 1-minute Apgar score < 7 ("asphyxia group"); 36 without obstetric or clinical signs of asphyxia (control group). Samples from umbilical artery (u.a.), capillary blood at 2h and 12-24 h after birth were analyzed for blood lactate, pH and BE.

RESULTS

Lactate value (u.a.) was significantly higher (5.3 +/- 3.4 mmol/l), pH and BE were lower (7.29 +/- 0.05 and -14.1 +/- 5.9 mmol/l) in the "asphyxia group" compared to the control group (2.7 +/- 1.2 mmol/l, 7.29 +/- 0.05 and -5.9 +/- 3.3 respectively). The 2 h lactate-values increased significantly in infants with asphyxia (6,.7 +/- 4.7) compared to the controls (3.2 +/- 1.1), the 12-24 h values were reduced in the main group (4.6 +/- 1.5) and without changes in the controls (3.2 +/- 0.88). Values of pH and BE at 2 h and 12-24 h increased progressively in both groups without significant differences between them. Hypoxic-ischemic encephalopathy (HIE) stage II-III was observed in infants with u.a. pH < 7.05, BE < -15 if u.a. lactate was high and progressively increased in next 2 h.

CONCLUSIONS

High u.a. lactate values correlate with low pH and BE and is a reliable tool for assessing the severity of fetal asphyxia. Increasing lactate concentration after birth is better predictor of severe HIE.

The influence of clinical and anthropometric parameters on the serum levels of the endothelin-1 in pregnant women and their newborns

Pregnancy induced hypertension (PIH) is major contributor to maternal death in developing countries. Endothelin-1 (ET-1) is the most potent vasoconstriction agent known and its serum levels are increased in PIH. Therefore it is important to elucidate maternal and neonatal factors which influence endothelin-1 serum levels. 100 pathological pregnancies and 88 controls were analyzed for blood endothelin-1 and their anthropometric and clinical data were collected. In maternal blood ET-1 levels were strongly predicted by diagnosis, therapy and BMI, while umbilical cord ET-1 levels were strongly predicted by gestational age, therapy and delivery termination. Positive correlation between BMI and ET-1 levels suggest that obese pregnant women have increased risk for cardiovascular diseases. Inverse relationship between Apgar and umbilical ET-1 indicates that ET-1 could be considered as a prognostic marker in cases of neonatal asphyxia.

Serum S100B and neuron-specific enolase levels in normothermic and hypothermic infants after perinatal asphyxia

AIM

Serum S100B and neuron-specific enolase (NSE) levels are elevated after perinatal asphyxia, but the influence of hypothermia on these proteins has not been previously reported. The aim of this study was to evaluate the effect of systemic hypothermia on these protein levels after perinatal asphyxia, time course, and association with perinatal factors and neurodevelopmental outcome at 2 years of age.

METHODS

Serum S100B and NSE levels were measured at fixed time points in asphyxiated infants treated with standard intensive care on hypothermia (HT: n = 13) or normothermia (NT: n = 11).

RESULTS

Serum S100B and NSE levels were grossly elevated in both HT and NT groups. Compared with the values at 6 h of age, S100B values decreased over time in both groups (NT: p = 0.002, HT: p = 0.04). Serum S100B values were lower in HT infants compared with those in NT infants (p = 0.047 at 48 h). Serum S100B and NSE values were significantly higher in infants who died or developed severe neurological impairment (S100B, p < 0.05 at all time points; NSE, p = 0.036 at 24 h of age).

CONCLUSION

Both NSE and S100B levels are highly elevated following asphyxia. Serum S100B levels were lower in the HT group and strongly correlated with the neurodevelopmental outcome.

Cardiac troponin I concentrations in neonates with hypoxic-ischaemic encephalopathy

AIM

Myocardial dysfunction is a frequent sequel of perinatal asphyxia. Cardiac troponin I (cTnI) is a marker of myocardial injury and a surrogate marker of myocardial dysfunction in adults, but there are few data in neonates. Our aim was to compare serum cTnI concentrations with clinical severity of encephalopathy and with duration of inotropic support in asphyxiated neonates.

METHODS

Retrospective study of 60 neonates admitted with hypoxic-ischaemic encephalopathy (HIE). cTnI concentrations measured within 36 h of birth were compared with clinical grade of HIE (Sarnat-Sarnat classification) and with duration of inotropic support.

RESULTS

Serum cTnI concentrations and duration of inotropic support were significantly greater with increasing severity of HIE. Median (95% CI) cTnI concentrations were 0.04 μg/L (0.02-0.07 μg/L) in grade 1 HIE, 0.12 μg/L (0.08-0.20 μg/L) in grade 2 HIE and 0.67 μg/L (0.41-1.35 μg/L) in grade 3 HIE. Median (95% CI) duration of inotropic support required was 0 h (0-24 h) in grade 1 HIE, 28 h (0-118 h) in grade 2 HIE and 48 h (0-140 h) in grade 3 HIE.

CONCLUSION

In asphyxiated neonates, cTnI concentrations within 36 h of birth correlate strongly with clinical grade of HIE and with duration of inotropic support. Early cTnI concentrations may provide a useful proxy marker for the anticipated severity of myocardial dysfunction.

Hemostasis and platelet dysfunction in asphyxiated neonates

Hemostasis is the balance between bleeding and clotting and includes coagulation and fibrinolysis with platelet interactions. Despite developmental hemostasis that describes the major differences between neonates and older children and adults, neonates do not have increased bleeding or clotting unless clinical situations disturb the "balance." Perinatal asphyxia alters the balance of hemostasis, resulting in abnormalities that may result in bleeding and thrombosis. The following discussion will describe normal hemostasis, laboratory measures of hemostasis, developmental hemostasis, and the effects of asphyxia on hemostasis.

Collaborative Study Group of Neonatal Umbilical Cord Blood Gas Parameters. [Multicenter clinical study on umbilical cord arterial blood gas parameters for diagnosis of neonatal asphyxia]

OBJECTIVE

To obtain the normal range of statistics of umbilical artery blood gas parameters of the newborns for diagnosis of neonatal asphyxia.

METHODS

From March 2008 through September 2009, 17 978 singleton term appropriate for gestational age (AGA) or larger than gestational age (LGA) newborns in six hospitals of five provinces/autonomous regions were consecutively enrolled in this prospective study. The normal ranges of umbilical artery blood gas parameters were obtained from 17 645 newborns with 1 min Apgar score ≥ 8. The correlations between umbilical artery blood pH, BE and prenatal high-risk factors, Apgar scores, and organ damage were analyzed. The diagnostic criteria for asphyxia included the following: (1) Having high-risk factors that might cause asphyxia; (2) 1 min Apgar score ≤ 7 (the respiratory depression must be present); (3) At least one organ showed evidence of hypoxic damage; (4) Other causes of low Apgar score were excluded. The study focused on the distributive characteristics of umbilical artery blood pH (clinically corrected by Eisenberg formula) and BE values of the asphyxiated and non-asphyxiated cases in low Apgar score group, as well as the sensitivity and specificity of different selected pH and BE threshold spots within their distributing ranges.

RESULTS

Among the 17 978 singleton term AGA or LGA newborns, the statistically normal range of umbilical artery blood pH, BE for the 17 645 cases with 1 min Apgar scores ≥ 8 were 7.20 ± 0.20 (x(-) ± 1.96 s) and -7.64 ± 10.02 (x(-) ± 1.96 s), respectively. The pH well correlated positively with BE (r = 0.734, P < 0.01). The umbilical artery blood pH and BE values correlated positively with the Apgar scores. The umbilical artery blood pH and BE values correlated negatively with organ damage (r = 1, the P values = 0.000 for both). Among the 333 low Apgar score cases, the umbilical artery blood pH corrected values and BE values of the asphyxiated group (163 cases) were 7.011 ± 0.09 (x(-) ± s) and -14.98 ± 2.99 (x(-) ± s), being lower than 7.18 ± 0.07 (x(-) ± s) and -8.56 ± 4.68 (x(-) ± s) of the non-asphyxiated group (170 cases) respectively (t = 14.3, 8.79, P values < 0.001). The distributing ranges of the umbilical artery blood pH corrected values and BE values of the asphyxiated group were < 7.00- < 7.20 and < -10- < -18, respectively. Within the above ranges, none of selected spots with both high sensitivity and high specificity was found.

CONCLUSIONS

The statistically normal range of the umbilical artery blood pH and BE for the newborns was 7.20 ± 0.20 (x(-) ± 1.96 s) and -7.64 ± 10.02 (x(-) ± 1.96 s) respectively. Owing to individual differences and the measured blood pH should be clinically corrected, the statistical threshold was not fully equal to the clinicopathological threshold. The pathological threshold of pH or BE for neonatal asphyxia is a range rather than a fixed point. The distributing range of the umbilical artery blood pH clinically corrected values and BE values for neonatal asphyxia were < 7.00- < 7.20 and < -8- < -18, respectively. In the presence of the other four indexes for diagnosing neonatal asphyxia, the blood gas index should be used flexibly in the above ranges.

[Effect of Astragalus injection on the signal conduction of neonatal postasphyxial-serum induced human renal tubular cell injury]

OBJECTIVE

To investigate, from cytoprotein and molecular levels, the action mechanism of astragalus injection (ASI) on the signal conduction of human renal tubular cells (HK-2) injury induced by neonatal postasphyxial-serum (NPS), whether it is through activating the nuclear factor kappaB (NF-kappaB) signaling pathway.

METHODS

Taking HK-2 as the target cell and the 20% NPS as the attacking factor, the experiment was conducted by dividing the target cells into two groups before attacking, the blank control group and the ASI pretreated group. The nuclear translocation of NF-kappaB was detected by confocal microscopy with indirect immunofluorescence stain, and the amount of NF-kappaB inhibitor subunit (I-kappaBalpha) was detected by Western blot before attacking. The detections were repeated at various time points in the experiment, i.e., 15 min, 1 h and 2 h after attacking, respectively.

RESULTS

Before attacking, the nuclear translocation of NF-kappaB and the amount of I-kappaBalpha were not different in the two groups. But the former increased and the latter decreased significantly in the ASI group at all the time points after attacking with the topmost changes presented at 1 h after attacking, and significantly different to those in the control group at corresponding time

CONCLUSION

ASI pretreatment could inhibit the activation of NF-kappaB induced by postasphyxial-serum.

[Influence of diazoxide on mitochondrial apoptosis in human renal tubular cells induced by serum obtained from neonates with asphyxia]

OBJECTIVE

To study the influence of diazoxide on mitochondrial apoptosis pathway of human renal proximal tubular cells (HK-2 cells).

METHODS

Cultured HK-2 cells were inoculated on 6-well plates, according to stochastic tables law, and they were divided into normal serum-treated group (NSTG) , post-asphyxial serum treatment group (PSTG), and post-asphyxial serum and diazoxide treatment group (PSDTG). The serum from neonates 24 hours after asphyxia in a dilution of 20% (volume fraction) was used for challenge. Diazoxide in a final concentration of 100 mol/L, was used for intervention. The expression of caspase-3 was detected by immunohistochemical method. The translocation rate of Omi/HtrA2 and mitochondria membrane potential were determined by indirect immunofluorescence and confocal microscopy.

RESULTS

Compared with that of NSTG, the expression of caspase-3 absorbance (A) value of HK-2 cells in PSTG was significantly increased (25.19 + or - 3.33 vs. 13.63 + or - 1.89, P<0.01), the translocation rate of Omi/HtrA2 of HK-2 cells in PSTG was significantly increased [(56.01 + or - 5.30)% vs.(37.59 + or - 5.60)%, P<0.01], mitochondrial membrane red/green fluorescence intensity ratio was decreased significantly (0.79 + or - 1.42 vs. 1.82 + or - 0.23, P<0.01). Compared with the PSTG, the expression value of caspase-3 of HK-2 cells in PSDTG was significantly decreased (20.17 + or - 2.19), the translocation rate of Omi/HtrA2 of HK-2 cells in PSDTG was significantly decreased [(46.91 + or - 2.70)%], and mitochondrial membrane red/green fluorescence intensity ratio increased significantly (1.47 + or - 0.14), but did not recover to the same degree as that of the NSTG (all P<0.01).

CONCLUSION

The diazoxide may reduce the expression of caspase-3, intracellular translocation of Omi/HtrA2, and stability of mitochondrial membrane potential, thereby significantly alleviates HK-2 cells injury induced by post-asphyxial-serum of neonate.

[Plasma levels of N-terminal pro-brain natriuretic peptide and glycogen phosphorylase isoenzyme BB in neonates with asphyxia complicated by myocardial injury]

OBJECTIVE

To investigate the changes and the clinical significance of N-terminal pro-brain natriuretic peptide (NT-proBNP) and glycogen phosphorylase isoenzyme BB (GPBB) levels in neonates with asphyxia complicated by myocardial injury.

METHODS

Sixty-four neonates with asphyxia (39 mild, 25 severe) were enrolled. Of the 64 neonates, 30 had myocardial injury and 34 did not develop myocardial injury. Twenty-five healthy neonates served as a control group. Plasma levels of NT-proBNP and GPBB were measured using ELISA. Myocardial enzymes and cardiac troponin I were stimultaneously measured, and electrocardiography and chest radiographs were obtained.

RESULTS

The plasma levels of NT-proBNP and GPBB in neonates with myocardial injury were significantly higher than those in neonates without myocardial injury and in the control group (P<0.01). The neonates with severe asphyxia had significantly increased plasma NT-proBNP and GPBB concentrations compared to those with mild asphyxia and the control group (P<0.01). Spearman rank correlation analysis showed that plasma NT-proBNP level was positively correlated with plasma GPBB level in neonates with asphyxia. Plasma levels of NT-proBNP and GPBB were also positively correlated with plasma levels of CK-MB, CK and LDH (P<0.01).

CONCLUSIONS

Both NT-proBNP and GPBB can be used as biomarkers of myocardial injury in neonates with asphyxia. The measurement of plasma NT-proBNP and GPBB levels was useful in early identification of myocardial injury and severity evaluation in neonates with asphyxia.

Electrolyte status in birth asphyxia

OBJECTIVE

To study electrolyte status in asphyxiated newborns of different severity in early neonatal period and compare with controls.

METHODS

Sodium, potassium and total calcium levels were estimated in the serum samples of asphyxiated newborns of different severity and control group immediately after birth.

RESULTS

Mean serum sodium level was significantly lower (122.1 +/- 6.0 mEq/L vs 138.8 +/- 2.7 mEq/L; P < 0.001), mean serum potassium was higher (5.05 +/- 0.63 mEq/L vs 4.19 +/- 0.40 mEq/L; P < 0.001) and mean serum calcium level was found lower (6.85 +/- 0.95 mg/dl vs 9.50 +/- 0.51 mg/dl; P < 0.001) in cases than controls. Among cases, a strong positive linear correlation was found between the serum sodium, serum calcium levels and their Apgar scores, between sodium levels and total calcium levels and significant negative linear correlation between Apgar scores and serum potassium level.

CONCLUSION

Among cases, hyponatremia and hypocalcemia developed early and simultaneously and the decrease in their serum levels was directly proportional to each other and to the degree of asphyxia. Though, mean potassium level was within the normal limit, the value was higher among cases than controls and directly proportional to asphyxia.

Cord blood brain derived neurotrophic factor: diagnostic and prognostic marker in fullterm newborns with perinatal asphyxia

This prospective case control study was designed to evaluate cord blood brain derived neurotrophic factor level in full term newborns with perinatal asphyxia as a marker of central nervous system insult and predictor of severity of hypoxic ischemic encephalopathy, with follow up of its level during the reperfusion phase. The study included twenty fullterm neonates with perinatal asphyxia (cases) and twenty controls. Cord blood samples were obtained at birth and peripheral blood samples at 72 h postnatal from cases only. Plasma brain derived neurotrophic factor level was measured using enzyme linked immunosorbent assay. The clinical severity of encephalopathy was graded based on Sarnat and Sarnat staging. Cord Plasma brain derived neurotrophic factor level was significantly increased among cases compared to controls. Among cases, brain derived neurotrophic factor level at delivery and after 72 h significantly correlated with the severity of encephalopathy according to Sarnat staging being higher as severity increases. Brain derived neurotrophic factor level significantly increased after 72 h of life compared to its level at delivery among cases. Brain derived neurotrophic factor levels at delivery and at 72 h postnatal were predictors of severe Sarnat stage and poor outcome. We concluded that brain derived neurotrophic factor level as a marker of central nervous system insult is increased in full term newborns with perinatal asphyxia. It can serve as an indicator for the severity of encephalopathy and adverse outcomes.

Activated protein C resistance in cord blood from healthy and complicated newborns

OBJECTIVES

Newborns are susceptible to thrombosis secondary to the immature hemostatic system and maternal and fetal complications. The contribution of activated protein C resistance (APCR) to thrombosis tendency has not yet been established. This study was conducted to investigate the effects of maternal and fetal complications on APCR levels.

METHODS

APCR levels were determined in cord blood from healthy term infants and compared with those in healthy preterm and complicated neonates as well as that in adult venous blood.

RESULTS

The mean value of APCR in cord blood from healthy term infants (166 +/- 40 s) was not significantly different from that in adult venous blood (173 +/- 40 s). No significant differences in the mean cord blood APCR values were observed between healthy term and preterm infants, infants with vaginal and cesarean delivery, infants from preeclamptic and non-eclamptic mothers, and infants with or without perinatal asphyxia. The activity levels of protein C, protein S, and antithrombin III were not significantly different between these groups except for lower levels in preterm babies.

CONCLUSIONS

The level of APCR in cord blood is comparable to that in adults and not influenced by maternal and fetal complications. It appears that APCR does not contribute to the thrombotic tendency in newborns.

Nucleated red blood cell and platelet counts in asphyxiated neonates sufficient to result in permanent neurologic impairment

OBJECTIVE

Recent research has suggested that a nucleated red blood cell (NRBC) count >or=26 per 100 white blood cells (%) or the development of a platelet count <or=100,000 per mm(3) within five days of birth is characteristic of neonates who have experienced acute birth asphyxia.

STUDY DESIGN

Study cases were from the population defined in a prior publication (Prenat Neonat Med 1997;2:286). The impaired neonates were separated into three groups: group 1, persistent non-reactive fetal heart rate (FHR) pattern from admission until delivery; group 2, reactive FHR pattern on admission followed by a tachycardia, non-reactivity, repetitive variable or late decelerations, and usually a loss of variability; group 3, cases with a reactive FHR pattern on admission followed by a sudden, rapid and sustained deterioration of the FHR usually in response to a hypoxic sentinel event that lasted until delivery or a bradycardia on admission. The FHR pattern in group 3 is considered most consistent with acute birth asphyxia. We then examined these FHR groups with respect to the presence of hematologic injury. Chi-square testing was used to describe differences among the study populations.

RESULTS

Of the original 52 cases, sufficient hematologic data were available for 47. Of these, the proportion of cases with NRBC >or=26% was: group 1, 10/21 (47.6%); group 2, 0/14 (0%); group 3, 0/12 (0%). Those with a platelet count <or=100,000 per mm(3): group 1, 11/21 (52.4%); group 2, 2/14 (14.3%); group 3, 0/12 (0%). Group 1 was significantly more likely to have an NRBC count >or=26% than group 3 (p = 0.0135). A platelet count <or=100,000 per mm(3) within five days of birth was also significantly more likely to be encountered in group 1 as compared with group 3 (p = 0.0072).

CONCLUSION

In cases of acute birth asphyxia, hematologic injury was infrequently encountered. Our findings suggest that a neonatal NRBC count >or=26% and/or a platelet count <or=100,000 per mm(3) within five days of birth is inconsistent with acute birth asphyxia.

[Disorders of the acid-basic balance in the post-hypoxic suffering at newborn babies]

The study aims to asses the acid-basic disorders and the blood gasses in the blood of the umbilical cord and their correlation with the evolution of the newborn baby in the maternity hospital.

MATERIAL AND METHOD

157 newborns with perinatal asphyxia hospitalized (2002-2005) in the Maternity of "Sf. Apostol Andrei" Clinical Emergency Hospital of Galaţi, following-up the gestation age, the Apgar score, the risk factors of perinatal asphyxia, the pH in the cord and the evolution of the blood gasses in the cord, the start and evolution of neurologic disorders.

RESULTS

The main risk factors for the asphyxia production: prematurity (64% of the cases and 25% of the cases with gestation age below 30 weeks), HTA induced in pregnancy, IUGR 39.4%. The Apgar score at one minute: values between 0-3 (40.8% cases), progressively decreasing to 20 minutes in 1.3%. 50% of the new born babies showed severe acidosis in the cord: pH > 6, 9, hypoxia in the cord blood was of 75%. The neurologic disorders started from the birth in all cases, with evolution to decease in 25.5% of the cases, higher incidence in prematures and a significant correlation with the pH in the cord.

[Role of pH value of umbilical artery blood in neonatal asphyxia]

OBJECTIVE

To study the role of pH value of umbilical artery blood in the diagnosis and the assessment of prognosis of neonatal asphyxia.

METHODS

A total of 140 single term newborn infants who were found abnormal by the fetal electrocardiogram monitoring were enrolled. The pH value of umbilical artery blood was measured immediately after birth. The Apgar score was performed 1 minute and 5 minutes after birth. The infants with the Apgar score<or=7 (n=62) were transferred to the pediatric ward for further management after resuscitation. Serum CTnI content was determined 24 hrs after birth.

RESULTS

pH value of umbilical artery blood was positively correlated to 1 min and 5 min Apgar scores (r=0.513 and 0.478 respectively; p<0.01). There were significant differences for the umbilical pH value in infants with different Apgar scores (p<0.01). Serum CTnI content was negatively correlated to 1 min and 5 min Apgar scores (r=-0.614 and -0.569 respectively; p<0.01). The infants with umbilical artery pH value of more than 7.2, 7.0-7.2 and less than 7.0 had serum CTnI contents of 31.82+/-8.63, 53.24+/-11.18 and 79.36+/-18.51 ng/L, respectively (p<0.01). There was a negative correlation between umbilical artery pH value and serum CTnI content (r=-0.578, p<0.01). The incidence of organ injuries increased significantly with decreasing Apgar scores (p<0.05) and showed a negative correlation with 1 min and 5 min Apgar scores (r=-0.548 and -0.496 respectively; p<0.01). The infants with umbilical artery pH value of more than 7.2, 7.0-7.2 and less than 7.0 had the incidence of organ injuries of 36.4%, 60.0% and 83.3%, respectively (p<0.05). There was a negative correlation between umbilical artery pH value and the incidence of organ injuries (r=-0.578, p<0.05).

CONCLUSIONS

Umbilical pH value correlates with Apgar score and may serve as sensitive indexes together with Apgar score for the diagnosis of neonatal asphyxia. Umbilical pH value is useful in the assessment of severity and prognosis of neonatal asphyxia.

[Activin A as a possible marker for hypoxia and intraventricular haemorrhage in newborns]

The article presents general information about activin A, a glycoprotein that belongs to the transforming growth factor beta superfamily. Structure, mechanism and role of activin as a possible marker of hypoxia and intraventricular haemorrhage were described.

[Relationship between brainstem auditory evoked potential and serum neuron-specific enolase in neonates with asphyxia]

OBJECTIVE

To study the correlation between brainstem auditory evoked potential (BAEP) and serum neuron-specific enolase (NSE) in neonates with asphyxia and explore the role of NSE in the evaluation of hearing impairment following asphyxia.

METHODS

Fifty-two term neonates with asphyxia, including 38 cases of simple asphyxia (mild: 23 cases; severe: 15 cases) and 14 cases of asphyxia complicated by hypoxic-ischemic encephalopathy (HIE), were enrolled. In the double-blind trial, BAEP and NSE were simultaneously detected 7 days after birth. The patients who did not pass BAEP test received another BAEP and NSE examinations 3 months after birth. Thirty healthy term neonates served as normal control group.

RESULTS

Of the 52 neonates with asphyxia, 50.0% and 21.2% of patients failed the initial and the second BAEP tests, respectively. The detection rates of BAEP anomalies in the simple severe asphyxia group in the initial and the second tests (63.3% and 26.3%, respectively) were significantly higher than those in the simple mild asphyxia group (36.9% and 5.9%, respectively)(P<0.05). The neonates with asphyxia complicated by HIE showed a higher detection rate of BAEP anomalies in the second test compared with the asphyxiated neonates without HIE (31.3% vs 16.7%; P<0.05). Mean serum NSE levels in asphyxiated neonates were significantly higher than those in normal controls (<0.01). There were significant differences in serum NSE levels between the neonates with mild and severe asphyxia (26.70+/-2.34 microg/L vs 17.18+/-3.16 microg/L; P<0.01). The asphyxiated neonates with HIE had serum NSE levels similar to the simple severely asphyxiated neonates. Serum NSE levels in patients who failed the initial BAEP test were significantly higher than those who passed the test (25.69+/-4.12 microg/L vs 17.15+/-3.09 microg/L; <0.01). Serum NSE levels had a positive correlation with wave V reaction threshold detected in the BAFP test (<0.05).

CONCLUSIONS

The serum level of NSE is closely correlated with BAEP, and it may be useful to the evaluation of the hearing impairment and the outcome in neonates with asphyxia.

[Role of serum from asphyxiated neonates in the inducement of human renal tubular cell adhesion to neutrophils]

OBJECTIVE

To study the role of serum from asphyxiated neonates in the inducement of human renal proximal tubular epithelial cells (HK-2) adhesion to neutrophils and possible mechanisms.

METHODS

HK-2 cells were cultured randomly with 20% serum from neonates (1, 3, and 7 days after asphyxia), pyrrolidine dithiocarbamate (PDTC) or placebo. The activity of myeloperoxidase (MPO), an indicator of adhesion ability of HK-2 cells to neutrophils in suspensions, was detected by the biochemistry assay. Intercellular adhesion molecule-1 (ICAM-1) and nuclear factor-kappaB (NF-kappaB) of HK-2 cells were examined with the immunohistochemical staining.

RESULTS

The expression of MPO in the post-asphyxial 1-day serum treatment group were significantly higher than that in the PDTC treatment and the control groups as well as the post-asphyxial 3 and 7-day serum treatment groups (P<0.01). The expression of ICAM-1 and NF-kappaB in the post-asphyxial 1-day serum treatment group was also significantly higher than that in the other groups (P<0.01).

CONCLUSIONS

Serum from asphyxiated neonates can induce HK-2 cell adhesion to neutrophils, possibly through activating NF-kappaB and increasing the synthesis and expression of ICAM-1 on the surface of renal tubular epithelial cells.

Consequences of neonatal resuscitation with supplemental oxygen

There has been considerable controversy surrounding the optimal inspired oxygen concentration for resuscitation of term and preterm infants. We have developed a rat pup model to quantify both physiologic and biochemical parameters associated with normoxic vs. hyperoxic resuscitation. We have confirmed existing human data that hyperoxic resuscitation of rat pups is associated with a significant delay in onset of spontaneous respiratory efforts. Both 40% and 100% inspired oxygen delayed onset of respiratory activity when compared to 21% oxygen. We have also documented, in the rat pup model, that hyperoxic resuscitation is associated with reduced levels of glutathione at 24 hours post resuscitation. The implications of these and other findings for human infants are that term asphyxiated babies can be safely resuscitated in 21% oxygen and that supplementary oxygen can be reserved for non-responders. In contrast, resuscitation of extremely low gestational age infants does appear to require an initial low inspired oxygen concentration (eg, 30%) with subsequent pulse oximetry titration to optimize oxygenation status.

Fetal electrocardiographic monitoring during labor in relation to cord blood levels of the brain-injury marker protein S-100

BACKGROUND

Cord artery protein S-100 levels at birth are potential markers of brain damage after asphyxia. Our aim was to investigate if S-100 levels were elevated in neonates with indirect signs of asphyxia during birth. S-100 levels in cord blood were studied in relation to cardiotocography (CTG) and fetal electrocardiography (FECG) changes during birth and to acidemia in umbilical blood.

MATERIAL AND METHODS

This case-control study was performed in parallel to a large randomized controlled trial (RCT) studying FECG at birth. Protein S-100 samples were collected from 103 neonates at birth and related to the CTG and ECG changes during labor and to pH in umbilical blood.

RESULTS

Protein S-100 was significantly higher in neonates with umbilical artery blood pH<or=7.05, compared to neonates with pH>7.05. Furthermore, neonates with preterminal CTG patterns showed increased S-100 levels compared to neonates with normal CTG. Neonates having significant CTG and ECG changes, leading to intervention according to clinical guidelines, showed significantly higher S-100 levels compared to neonates without such indication of intervention.

CONCLUSION

A relation exists between S-100 in umbilical blood at birth, acidosis and pathological patterns in CTG and FECG during labor.

[Serum levels of homocysteine and folate in neonates with asphyxia]

OBJECTIVE

To determine whether serum homocysteine and folate levels are correlated with the occurrence of neonatal asphyxia and to study the effects of gender and gestational age on serum homocysteine and folate levels.

METHODS

Thirty-five neonates with mild asphyxia (19 males and 16 females) and 40 normal neonates (control group,18 males and 22 females) were enrolled in this study. The asphyxia and the control groups consisted of 10 and 11 cases of preterm infants respectively. Serum homocysteine levels were measured using ELASA. Serum folate levels were measured using radioimmunity assay.

RESULTS

Serum homocysteine level (14.66+/-2.61 micromol/L vs 7.55+/-0.50 mumol/L; P<0.05) was significantly higher and serum folate level (2.47+/-0.24 ng/mL vs 3.28+/-0.28 ng/mL; P<0.05) was significantly lower in the asphyxia group than that in the control group. There were no significant differences in serum levels of homocysteine and folate between males and females either in the asphyxia group or the control group. The asphyxiated neonates born at premature showed increased serum homocysteine level compared with the full-term neonates with asphyxia (21.25+/-5.01 micromol/L vs 12.34+/-2. 01 micromol/L; P<0.05).

CONCLUSIONS

The increased serum homocysteine level and decreased serum folate level are correlated with the occurrence of neonatal asphyxia. Serum homocysteine and folate levels are not associated with the gender. A more significantly increased serum homocysteine level may be found in asphyxiated neonates born at premature.

Evaluation of lactate dehydrogenase, creatine kinase and hepatic enzymes for the retrospective diagnosis of perinatal asphyxia among sick neonates

It is difficult to make a retrospective diagnosis of perinatal asphyxia in symptomatic neonates delivered non-institutionally. We studied serum creatine kinase muscle-brain fraction (CK-MB), lactate dehydrogenase (LDH), glutamic oxaloacetic transaminase (SGOT) and glutamic pyruvate transaminase (SGPT) for differentiating asphyxiated (n=25) from non-asphyxiated (n=20) neonates who present with non-specific signs of sickness. CK-MB was assayed at 8 and 24 h; and LDH, SGOT and SGPT at 72 h of life. On comparing cases and controls, median 8-hr CK-MB [80 U/L vs. 26 U/L respectively, P< 0.001], median 24-hr CK-MB [33.5 U/L vs. 21.5 U/L respectively, P=0.009] and median LDH [965 U/L vs. 168 U/L respectively, P< 0.001] were higher in asphyxiated neonates. Raised LDH had 100% sensitivity, while CK-MB had 100% specificity for asphyxia. LDH had the highest area under ROC curve (0.998). We conclude that LDH at 72 hr of life is most accurate at differentiating asphyxiated from non-asphyxiated symptomatic neonates.

[Birth asphyxia, neonatal risk factors for hypoxic ischemic encephalopathy]

OBJECTIVE

Neonates suffering from severe birth asphyxia may develop hypoxic ischemic encephalopathy (HIE), some of which develop permanent neurological damage. As the incidence of asphyxia and HIE in Iceland is unknown, this study was conducted. Furthermore, we evaluated the association between some neonatal risk factors and the development of HIE.

MATERIAL AND METHODS

All term infants born at LSH from 1997-2001 with birth asphyxia, defined as 5 minute Apgar score or=<6, were included in the study. Clinical information, length and weight, Apgar scores at 1, 5 and 10 minutes normoblasts count, initial pH and hemoglobin levels were retrospectively collected.

RESULTS

The incidence of HIE after birth asphyxia was 1.4/1000. The infants who developed HIE had significantly lower birth weight and Apgar scores at one, five and ten minutes. They also had lower umbilical artery pH, had more base deficit and lower serum bicarbonate concentrations than the infants who did not develop HIE.

CONCLUSION

The incidence of HIE was low compared to other studies. Birth asphyxia resulting in HIE is associated with lower birth weight, Apgar scores, pH and neonatal hemoglobin levels at birth. We conclude that neonates with low hemoglobin level are at increased risk for developing HIE and that low pH and Apgar scores may predict worse outcomes after birth asphyxia.

Changes in laboratory parameters indicating cell necrosis and organ dysfunction in asphyxiated neonates on moderate systemic hypothermia

AIM

Asphyxia is a major cause of morbidity and mortality in term infants. In addition to cerebral injury other organs are also distressed due to hypoxic-ischaemic insult. Systemic hypothermia has a beneficial effect on brain injury. We tested the impact of hypothermia on hypoxic damage of other internal organs.

METHODS

Asphyxiated term neonates (n = 21) were randomised to groups treated with hypothermia (n = 12) and normothermia (n = 9). Hypothermia (33-34 degrees C) was initiated within 6 h of life, and maintained for 72 h. We determined serum transaminase, lactate dehydrogenase, creatine kinase, uric acid, creatinine levels and diuresis during 6, 24, 48 and 72 postnatal hours.

RESULTS

Area under curve values of aspartate aminotransferase (ASAT), lactate dehydrogenase (LDH), uric acid and creatinine during the investigated period and alanine aminotransferase (ALAT) value at 72 h were lower in neonates on hypothermia than in those on normothermia. Renal failure and liver impairment affected less hypothermic than normothermic neonates (3/12 vs. 7/9, p = 0.03, 3/12 vs. 6/9 p = 0.08, respectively). Four of the 12 hypothermic and 6 of the 9 normothermic neonates developed multiorgan failure.

CONCLUSIONS

These results suggest that systemic hypothermia may protect against cell necrosis and tissue dysfunction of internal organs after neonatal asphyxia.

Elevated total peripheral leukocyte count may identify risk for neurological disability in asphyxiated term neonates

OBJECTIVE

The present study investigated the relationship between neurologic outcome and total circulating white blood cell (WBC) and absolute neutrophil counts (ANCs) in the first week of life in term infants with hypoxic-ischemic encephalopathy (HIE).

STUDY DESIGN

Long-term neurologic outcome at 18 months was measured retrospectively in 30 term neonates with HIE using the Pediatric Cerebral Performance Category Scale (PCPCS) score with outcomes dichotomized as either good or poor. We then compared white blood cell and ANC levels during the first 4 days of life and magnetic resonance imaging (MRI) obtained within the first month life between the two PCPCS groups. MRI was quantified using a validated scoring system.

RESULTS

Neonates with good long-term outcomes had significantly lower MRI scores (indicating lesser injury) than neonates with poor outcomes. More importantly, neonates with poor outcomes had significantly higher WBC and ANC levels as early as12 h after birth and up to 96 h after birth compared to those with good outcomes. These data suggest that elevated peripheral neutrophil counts in the first 96 h of life may signal or predict adverse long-term outcome.

CONCLUSIONS

Our findings suggest that elevated peripheral neutrophil counts in the first 96 h of life in term infants with HIE may contribute to abnormal neurodevelopmental outcome.

Is serum troponin T a useful marker of myocardial damage in newborn infants with perinatal asphyxia?

AIM

To assess the correlation of echocardiographic signs of myocardial damage to serum cardiac troponin T (cTnT) concentrations in newborn infants with perinatal asphyxia.

METHODS

Electocardiograms (ECG) and echocardiograms (Echo) were obtained during the first 24 h of life from 29 asphyxiated and 30 control infants and correlated with cTnT concentrations. The echocardiographic parameters included systolic ventricular performance, preload, afterload, diastolic function, stroke volume (SV), left ventricular output (LVO), hyperechogenity of the papillary muscles and insufficiency of the atrioventricular valves.

RESULTS

LVO and SV were lower but CTnT were significantly higher in asphyxiated than in control infants: 0.15 (010-0.23) vs. 0.05 (0.02-0.13), p < 0.001). Asphyxiated infants with signs of myocardial damage were associated with significantly higher cTnT than those without, 0.20 (0.11-0.28) and 0.11 (0.05-0.14 ug/L), p = 0.04.

CONCLUSION

Cardiac troponin may prove to be valuable in evaluating myocardial damage in birth asphyxia. However, the degree of prematurity may complicate the assessment.