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Practice Essentials:
Perinatal asphyxia, more appropriately known as hypoxic-ischemic encephalopathy (HIE), is characterized by clinical and laboratory evidence of acute or subacute brain damage due to hypoxia-ischemia. The primary causes of this condition are systemic hypoxemia and/or reduced cerebral blood flow (see image below). Birth asphyxia causes 840,000 or 23% of all neonatal deaths worldwide.
Signs and SymptomsMild hypoxic-ischemic encephalopathy:Signs of mild hypoxic-ischemic encephalopathy include:Muscle tone may be slightly increased and deep tendon reflexes may be brisk during the first few daysTransient behavioral abnormalities may be observed, such as poor feeding, irritability or excessive crying, or drowsiness (typically in an alternating pattern)It usually resolves within 24 hours.
Moderately severe hypoxic ischemic encephalopathy:Signs of moderately severe hypoxic ischemic encephalopathy include:The infant is lethargic, with significant hypotonia and decreased deep tendon reflexesGrasp, Moro, and sucking reflexes may be slow or absentThe infant may experience occasional periods of apneaSeizures typically occur early within the first 24 hours after birthComplete recovery is possible within 1 to 2 weeks, associated with a better long-term outcome.Severe hypoxic ischemic encephalopathy:Seizures may be delayed and severe and may initially be resistant to conventional treatments. Seizures are usually generalized and may increase in frequency during the first 24 to 48 hours after onset, correlating with the phase of reperfusion injury.As the lesion progresses, seizures become less severe and the EEG becomes isoelectric or shows a burst suppression pattern. Wakefulness may then worsen further and the fontanelle may bulge, suggesting increased cerebral edema. Other symptoms include:Typically, stupor or coma is typical; the infant may not respond to any physical stimuli except the most noxious ones.Respiration may be irregular and the infant often requires ventilatory supportGeneralized hypotonia and depressed deep tendon reflexes are commonNeonatal reflexes (e.g., sucking, swallowing, grasping, Moro) are absentOcular movement disorders, such as oblique deviation of the eyes, nystagmus, swaying, and loss of "doll's eye" (i.e., conjugate) movements may be revealed by cranial nerve examinationPupils may be dilated, fixed, or poorly responsive to lightIrregularities of heart rate and blood pressure are common during the period of reperfusion injury, as is death from cardiorespiratory failure.An initial period of well-being or mild hypoxic-ischemic encephalopathy may be followed by sudden deterioration, suggesting ongoing brain cell dysfunction, injury, and death; during this period, seizure intensity may increase.Diagnosis:The American Academy of Pediatrics (AAP) and American College of Obstetrics and Gynecology (ACOG) guidelines for hyperactive ischemic stroke (HIE) indicate that all of the following must be present for the designation of perinatal asphyxia severe enough to cause acute neurologic injuryrofound or mixed metabolic acidemia (pH < 7) in an umbilical artery blood sample, if obtainedPersistence of an Apgar score of 0-3 for more than 5 minutesNeonatal neurologic sequelae (e.g., seizures, coma, hypotonia)Multiple organ involvement (e.g., kidneys, lungs, liver, heart, intestines).Laboratory studies include:Serum electrolyte levelsRenal function studies.
Cardiac and liver enzymes: These values are an adjunct to assess the degree of hypoxic-ischemic damage to the heart and liverCoagulation system: Includes prothrombin time, partial thromboplastin time, and fibrinogen levelsArterial blood gases: Blood gas monitoring is used to assess acid-base status and to avoid hyperoxia and hypoxia, as well as hypercapnia and hypocapnia.Imaging studies include:Brain magnetic resonance imagingCranial ultrasoundEchocardiographyAdditional studies may include:EEG: Standard and amplitude-integrated EEGHearing tests: There has been an increased incidence of deafness among infants with hypoxic-ischemic encephalopathy who require assisted ventilation.Retinal and ophthalmic examination. Management:
After initial resuscitation and stabilization, treatment of acute ischemic stroke (HIE) is largely supportive and should focus on the following:Adequate ventilationPerfusion and blood pressure management: Studies indicate that a mean BP greater than 35-40 mm Hg is necessary to avoid decreased cerebral perfusionCareful fluid managementAvoid hypoglycemia and hyperglycemiaAvoid hyperthermia: Hyperthermia has been shown to be associated with an increased risk of adverse outcomes in neonates with moderate to severe hypoxic-ischemic encephalopathy.Treatment of seizuresTherapeutic hypothermia (33-33.5ºC for 72 hours) followed by slow, controlled rewarming for neonates with moderate to severe HIE.Of note, there is growing interest in determining the effectiveness of therapeutic hypothermia for neonates with mild hypoxic-ischemic encephalopathy.