|Year : 2017 | Volume
| Issue : 2 | Page : 161-165
Prevalence and outcome of perinatal asphyxia: Our experience in a semi-urban setting
Ibrahim Aliyu1, Teslim O Lawal2, Ben Onankpa3
1 Department of Paediatrics, Aminu Kano Teaching Hospital, Bayero University Kano, Kano, Nigeria
2 Department of Paediatrics, Federal Medical Centre, Birnin Kebbi, Nigeria
3 Department of Paediatrics, Usmanu Danfodiyo University, Sokoto, Nigeria
|Date of Web Publication||14-Nov-2017|
Department of Paediatrics, Aminu Kano Teaching Hospital, Bayero University Kano, Kano
Introduction: Perinatal asphyxia is a significant cause of infant morbidity and mortality globally. Although considerable achievement has been made in reducing the impact of infectious diseases, much is yet to be seen in reducing the menace of perinatal asphyxia especially in semi-urban and rural areas. Materials and Methods: Data from medical records of all cases of perinatal asphyxia admitted over the study period of 30 months were retrieved and documented for the study. Results: Total admission to the special care baby unit was 1040, with 257 reported cases of perinatal asphyxia hence a prevalence of 24.7%. There were 149 (60.3%) males and 98 (39.7%) females; male:female ratio of 1.52:1. The gestation ages at delivery of the cases ranged from 35 to 44 weeks with mean of 38.02 ± 1.95; while the weight on admission ranged between 1.16 and 4.70 kg; mean weight of 2.97 ± 0.60. One hundred and eighty (72.9%) of the mothers were unbooked. About 73.3% of the deliveries occurred in the study center; vaginal deliveries accounted for 142 (57.5%) of the cases. Labor lasted between 18 and 24 h in 129 (52.2%) of the cases; however, eclampsia was the most common illness documented in these mothers. Two hundred and sixteen (87.4%) cases were discharged without documented complication, while seven deaths (2.8%) were recorded. Conclusion: Perinatal asphyxia is still prevalent in our setting; preventive measures should be adopted to reduce the disease burden by improving accessibility to health care, and also providing and increasing the acceptance of maternal antenatal care.
Keywords: Outcome, perinatal asphyxia, prevalence, semi-urban
|How to cite this article:|
Aliyu I, Lawal TO, Onankpa B. Prevalence and outcome of perinatal asphyxia: Our experience in a semi-urban setting. Trop J Med Res 2017;20:161-5
| Introduction|| |
Perinatal asphyxia is a major cause of morbidity and mortality globally. Despite the reduction in under-five mortality in recent decades attributable to the tackling of infectious diseases such as measles, malaria, pneumonia, and diarrhea in postneonatal infants and children, there has been little reduction in deaths in the neonatal period., Indeed, mortality in the 1st week after birth has shown no measurable change in global level in the last decade. In the year 2000, 37% of under-five deaths were neonatal deaths; this has risen to over 41%, a total of 3.6 million deaths. Prenatal asphyxia associated deaths are the fifth most common cause of under-five deaths, accounting for an estimated 814,000 deaths annually. Perinatal asphyxia is associated with long-term sequelae, resulting in a burden of 42 million disability adjusted life years., If progress toward effective health care is to be achieved then attention has to be directed at reducing neonatal deaths of which perinatal asphyxia is a significant contributor.
The study site; Federal Medical Centre, Birnin Kebbi is the only hospital in the state with a neonatal unit. It thus serves as a referral center for the whole state. This study, therefore, seeks to determine the prevalence and short-term (neonatal) outcomes, as well as the neonatal and maternal factors associated with perinatal asphyxia in Birnin Kebbi. This will assist in health-care planning.
| Materials and Methods|| |
The special care baby unit (SCBU) consists of the inborn and the outborn sections. All babies delivered in our hospital from both booked and unbooked pregnancies requiring admission are received in the inborn section, while babies received from health facilities outside the hospital are admitted in the outborn section. The hospital receives a referral from government hospitals of all local government areas of the state and also from private hospitals.
Full application of criteria for defining perinatal asphyxia by the American Academy of Pediatrics and American College of Obstetrics, such as: “(a) umbilical cord arterial pH <7” are difficult to fulfill in resource constraint countries-absence of blood gas analysis which is a common scenario in most resource limited setting makes umbilical cord pH analysis non-practicable. Therefore, definition-based predominantly on Apgar scoring at 5-min of <7; or absence of baby crying immediately after birth was used. The severity of perinatal asphyxia was classified as mild if the Apgar score is 6 or a history that the baby required only suctioning/stimulation to establish a strong cry. Moderate perinatal asphyxia is Apgar score of 4–5, or a history that the baby required the baby requires stimulation and oxygen administration before a strong cry. A score of 0–3 or a history that the baby required major intervention such as Ambu bagging, or presented with convulsion, loss of consciousness, central cyanosis, or floppiness was defined as severe birth asphyxia.,,
This was a retrospective study. The medical records of neonates admitted into the SCBU of Federal Medical Centre Birnin Kebbi with a diagnosis of perinatal asphyxia from August 1, 2011, to February 28, 2014, were reviewed. Information on bio-data including age at presentation, sex, birth weight/weight at admission, gestational age, and information on Apgar score, pregnancy and delivery history as well as the outcome at discharge were extracted and entered into the study pro forma. Files with gross incomplete records affecting the predominant variables in this study were excluded in the relevant data analysis. Babies <34 weeks gestational age were also excluded from the analysis because the Apgar scoring system is inapplicable in newborns <34 weeks gestational age. Prolonged labor was defined as labor lasting for more than 24 h. the individuals were classified based on the duration of hospital stay as 1–7 days, 8–14 days, and more than 14 days; these durations corresponds to the time taken for resolution of most complications of the various forms of hypoxic ischemic encephalopathy (HIE).
Data generated were analyzed using Statistical Package for Social Sciences version 20 (IBM Corp. Armonk, New York) and results were presented as means, standard deviation, and percentages. Comparison of categorical variables such as duration, outcome of hospital stay, and their relationship with HIE staging was done using Chi-squared test; and P < 0.05 was adjudged statistically significant.
| Results|| |
There were 257 cases of perinatal asphyxia out of 1040 admissions over the study period with a prevalence of 24.7%; however, 10 (3.9%) case files were excluded from further relevant analysis due to incomplete data. Therefore, 247 cases were analyzed: 149 (60.3%) males and 98 (39.7%) females with male:female ratio of 1.52:1.
As shown in [Table 1], the gestational age of the cases ranged from 35 to 44 weeks with mean of 38.02 ± 1.95; the 37–40 weeks gestational age group constituted the largest population in this study. Forty-two (17.0%) of the individuals had no record of their birth weight. However, among those with recorded birth weight; the weight ranged between 1.16 and 4.70 kg with a mean weight of 2.97 ± 0.60, the majority of the cases were within the normal birth weight of 2.5–4 kg.
As shown in [Table 2], maternal age ranged between 16 and 48 years with a mean age of 26.06 + 5.18. One hundred and eighty (72.9%) of the mothers were unbooked while only 67 (27.1%) were booked for antenatal care in FMC and General Hospital, both in Birnin Kebbi. Most of the mothers were delivered of their babies in our tertiary hospital (73.3%). Delivery was through vaginal delivery in 142 (57.5%) of the cases while cesarean section was done in 105 (42.5%). Labor lasted <24 h in 188 (76.1%) and more than 24 h in 59 (23.9%) of the cases, respectively. Most of these mothers had no documented antecedent medical illness; however, eclampsia was the most common illness associated with mothers with babies with birth asphyxia.
Apgar scoring and its relationship with hypoxemic ischemic encephalopathy staging
As shown in [Table 3], eighty-four (34.0%) of the cases had no record of their Apgar scores. However, among those with documented Apgar scores, moderate birth asphyxia was most common and using the Sarnat-Sarnat classification, Stage 2 HIE was the most common form of encephalopathy.
|Table 3: Apgar scoring and its relationship with hypoxemic ischemic encephalopathy staging|
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Outcome of perinatal asphyxia and its relationship with the hypoxic ischemic encephalopathy staging
As shown in [Table 4], two hundred and sixteen cases were discharged without documented sequelae, while seven deaths were recorded. Majority of cases with stage 2 HIE were successfully discharged without neurologic sequelae; however, five deaths were recorded in the group with HIE 3 (#χ2 = 39.864, df = 8, P = 0.00).
|Table 4: Outcome of perinatal asphyxia and its relationship with the hypoxemic ischemic encephalopathy staging (n=247)|
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Duration of hospital stay and its relationship with the hypoxic ischemic encephalopathy staging
As shown in [Table 5], the duration of hospital stay ranged from 1 to 39 days with a mean of 6.75 + 4.91.
|Table 5: Duration of hospital stay and its relationship with hypoxemic ischemic encephalopathy staging (n=247)|
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One hundred and fifty-four (62.3%) of the cases spent shorter time on admission; of these majority of them had stage 1 HIE (#χ2 = 41.051, df = 4, P = 0.00).
| Discussion|| |
Perinatal asphyxia contributes significantly to neonatal morbidity and mortality., This study recorded a prevalence of 24.7% which slightly higher than the 21.1% reported by IIah et al., but slightly lower than the 27% reported by Mukhtar-Yola and Iliyasu in Kano, 29.4% reported by West and Opara in Port Harcourt. However, our prevalence rate for severe birth asphyxia was significantly higher than what was obtained by Okechukwu and Achonwa (12.7%) in Abuja, and 2.6% by Kinoti in East, central and Southern Africa. Maldistribution of health facilities are issues of great concern in most developing countries. In Nigeria, big cities such as Abuja are better equipped with modern, state of the art health facilities when compared to the poorly equipped state hospitals. Little wonder in the disparity between the prevalence reported in Kano, Birnin Kebbi, Zamfara, and Rivers state who receive referrals from rural hospitals; and Abuja. Therefore, most mothers in rural settings lacked proper antenatal care; therefore, early detection of adverse events during labor such as fetal distress would have been missed. However, our prevalence was lower than what Ugwu et al. obtained in Warri which is also a resource limited setting as ours. This disparity may be attributed to the lower cost of health care in most Northern states; therefore, higher patronage is expected with its attendant better outcome.
aMore males than females were affected with perinatal asphyxia in this study, this finding compared favorably with previous studies by Onyiruka, West and Opara, Ugwu et al. but contrasted with the report by IIah et al.; the reason for this difference is not completely understood but in most African society, males are often given preference even in health care-related issues; therefore, a sick male child is most likely to be taken to the hospital earlier, especially in the face of the current economic hardship. Term babies with appropriate sized weight were mostly affected by perinatal asphyxia in this study which is similar to reports from previous studies.,,,, This was attributable to possible poor antenatal services because most of the mothers in this study were unbooked (72%) which is higher than the 39% reported by West et al., therefore, there is the need to improve on the public enlightenment on the importance on antenatal care while ensuring that these services are made readily available to mothers.
Common maternal risk factors identified were; prolonged labor and eclampsia which explained the high cesarean section rate of 46% recorded which is similar to findings in previous Nigerian studies., Similarly, pregnancy-induced hypertension (PIH) was a rarity in our study as was also reported in Zamfara study; we also agree with their explanation on the possible reason which is applicable to our observation that majority of the pregnant mothers were unbooked therefore early detection of PIH could have been missed hence most of them presenting as eclampsia. This means, there is the urgent need to determine the immediate and possible remote causes of the poor acceptance of antenatal care with the goal of mitigating its furtherance.
Majority of the patients (87.4%) were successfully discharged without complications; and only 2.8% death was recorded; this is a commendable result considering the fact that majority of the mothers were unbooked; however, the low mortality recorded in this study may be attributable to the lower prevalence of stage 3 HIE cases; furthermore, contributions from timely intervention by obstetricians and better care in the SCBU are remarkable. Our result showed a better outcome when compared to reports from Zamfara, and Port Harcourt.
The relationship between Apgar score and the severity of birth asphyxia has been established; this was substantiated by comparing the Apgar scoring system with umbilical artery pH in determining the predictability of outcome especially in high-risk pregnancies. Therefore, Apgar scoring still remains a viable, valuable and reliable tool in not only assessing the need for resuscitation of the newborn but also in predicting possible neurologic outcome in perinatal asphyxia; this is important in resource constrained settings where umbilical blood pH testing maybe difficult to accomplish. Our study showed that 3.9% of the cases had no documentation of their Apgar score in their files which is lower when compared to 7.6% reported by West et al., and 10.6% reported by IIah et al. This may be due to the fact that majority of the deliveries were in the hospital setting.
Majority of our cases had Apgar scores of 4–5 indicative of moderate birth asphyxia; little wonder the successful outcome recorded in this study.
| Conclusion|| |
Perinatal asphyxia still remains a major concern among neonatal morbidities. Poor antenatal care is still a major contributory factor; therefore, there is the urgent need to determine the immediate cause of this poor acceptance of antenatal care.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]