Effect of Hypothermia and Severity of Hypoxic-Ischemic Encephalopathy in the Levels of C-Reactive Protein during the First 120 Hours of Life.

OBJECTIVE: This study aimed to describe normal C-reactive protein (CRP) levels of newborns diagnosed with hypoxic-ischemic encephalopathy (HIE) and assess the influence of therapeutic hypothermia (TH) and the severity of HIE. STUDY DESIGN: We prospectively recruited infants ≥35 weeks of gestational age diagnosed with HIE from 2000 to 2013 and compared CRP levels in the first 120 hours of life according to the severity of HIE and the use of TH, which was introduced in 2009. RESULTS: Moderate HIE was diagnosed in 115 newborns, severe HIE in 90 (hypothermia was performed in 151 cases), and mild HIE in 20. Cooled newborns showed lower levels of CRP in the first 34 hours, but reached higher median maximum CRP levels (15.4 vs. 8.5 mg/L), and at a significantly older age (53 vs. 17 hours). Levels of CRP in mild HIE were lower than those of moderate-severe forms. Moderate and severe HIE had similar CRP levels, but time to maximum CRP was significantly less in moderate cases. CONCLUSION: CRP levels of mild HIE are similar to healthy newborns, while CRP elevations can be expected in newborns with moderate-severe HIE. TH produced a slower rise, with a higher and late maximum CRP peak level.

Types of intrapartum hypoxia on the cardiotocograph (CTG): do they have any relationship with the type of brain injury in the MRI scan in term babies?

Electronic foetal monitoring using cardiotocography is aimed at the timely recognition and management of foetal hypoxia. The primary objective of this study was to examine whether a relationship exists between the types of foetal hypoxia (acute, subacute, evolving, chronic), as identified on cardiotocography and the nature of hypoxic ischaemic encephalopathy, as observed on MRI scans after birth. We conducted a retrospective study of 16 babies born (out of 52,187 births) at St George's Hospital in London during 2006-2017 with a postnatal diagnosis of HIE. Of the 16 babies, only 11 had both MRI scans and CTG traces available. Of those, 9 showed evidence of intrapartum hypoxia on CTG, but only 6 demonstrated evidence of HIE on MRI. Those with acute hypoxia showed abnormalities in the basal ganglia and thalami. A gradually evolving hypoxia or subacute hypoxia was associated with lesions in myelination and cerebral cortex.Impact StatementWhat is already known on this subject? It has been reported that inter-observer agreement for CTG interpretation is low (30%) when pattern recognition based guidelines are used (Rhöse et al. 2014; Reif et al. 2016), even amongst 'experts' (Hruban et al. 2015). Furthermore, it has been shown that CTG traces do not reliably predict neonatal encephalopathy (Spencer et al. 1997).What do the results of this study add? Our study indicates that if 'types of intrapartum hypoxia' are used for interpretation, then inter-observer agreement increases to 81%, from the reported 30% when traces are classified into 'normal, suspicious and pathological' using guidelines based on 'pattern recognition'. Furthermore, our study shows a good correlation between the type of intrapartum hypoxia observed on CTG trace and the nature of injury observed on the MRI.What are the implications of these findings for clinical practise and/or further research? Improving inter-observer agreement of CTGs with the use of pattern recognition in combination with the good correlation to MRI scan findings ultimately leads to better management and post-natal outcomes. This is evidenced by the fact that after the introduction of physiology-based CTG interpretation and mandatory competency testing on CTG interpretation for all staff in 2010, St. George's Maternity Unit has half the nationally reported rate of cerebral palsy.

Suitability of an inter-burst detection method for grading hypoxic-ischemic encephalopathy in newborn EEG.

Electroencephalography (EEG) is an important clinical tool for grading injury caused by lack of oxygen or blood to the brain during birth. Characteristics of low-voltage waveforms, known as inter-bursts, are related to different grades of injury. This study assesses the suitability of an existing inter-burst detection method, developed from preterm infants born <; 30 weeks of gestational age, to detect inter-bursts in term infants. Different features from the temporal organisation of the inter-bursts are combined using a multi-layer perceptron (MLP) machine learning algorithm to classify four grades of injury in the EEG. We find that the best performing feature, percentage of inter-bursts, has an accuracy of 59.3%. Combining this with the maximum duration of inter-bursts in the MLP produces a testing accuracy of 77.8%, with similar performance to existing multi-feature methods. These results validate the use of the preterm detection method in term EEG and show how simple measures of the inter-burst interval can be used to classify different grades of injury.

Outcomes following neonatal cardiopulmonary resuscitation. / Utfallet etter hjerte-lunge-redning av nyfødte.

BAKGRUNN: Hjerte-lunge-redning av et kritisk sykt barn ved fødsel kan føre til overlevelse eller død. De som overlever kan utvikle komplikasjoner direkte etter fødsel eller senere i småbarns- og skolealder. Hypoksisk iskemisk encefalopati er en tilstand med nevrologiske symptomer hos den nyfødte etter hypoksi ved fødsel. Tilstanden klassifiseres som mild, moderat eller alvorlig. Vi ønsket å gi en oversikt over kort- og langtidsutfall etter hjerte-lunge-redning ved fødsel. KUNNSKAPSGRUNNLAG: Vi søkte i databasen Medline for utfall etter hjerte-lunge-redning ved fødsel. RESULTATER: Vi identifiserte 15 indekserte, fagfellevurderte originalartikler og to metaanalyser om utfall etter hjerte-lunge-redning ved fødsel eller fødselsasfyksi. Hypoksisk iskemisk encefalopati rammer generelt 38 % av pasientene i mild til moderat grad og 23 % i alvorlig grad. Dødeligheten varierte fra 10 % i høy- til 28 % i lavinntektsland. Overlevende utvikler ofte motoriske, kognitive og sensoriske utviklingshemninger. I noen tilfeller blir det først avdekket ved skolestart når mer komplekse ferdigheter kreves. FORTOLKNING: Funksjonshemning ved skolealder er sterkt korrelert til tilstanden i småbarnsalder. Endringer i algoritmene ved hjerte-lunge-redning og rutinebehandling med hypotermi har redusert risikoen for alvorlige følgetilstander etter hypoksisk iskemisk encefalopati.

High-Dose Erythropoietin and Hypothermia for Hypoxic-Ischemic Encephalopathy: A Phase II Trial.

OBJECTIVE: To determine if multiple doses of erythropoietin (Epo) administered with hypothermia improve neuroradiographic and short-term outcomes of newborns with hypoxic-ischemic encephalopathy. METHODS: In a phase II double-blinded, placebo-controlled trial, we randomized newborns to receive Epo (1000 U/kg intravenously; n = 24) or placebo (n = 26) at 1, 2, 3, 5, and 7 days of age. All infants had moderate/severe encephalopathy; perinatal depression (10 minute Apgar <5, pH <7.00 or base deficit ≥15, or resuscitation at 10 minutes); and received hypothermia. Primary outcome was neurodevelopment at 12 months assessed by the Alberta Infant Motor Scale and Warner Initial Developmental Evaluation. Two independent observers rated MRI brain injury severity by using an established scoring system. RESULTS: The mean age at first study drug was 16.5 hours (SD, 5.9). Neonatal deaths did not significantly differ between Epo and placebo groups (8% vs 19%, P = .42). Brain MRI at mean 5.1 days (SD, 2.3) showed a lower global brain injury score in Epo-treated infants (median, 2 vs 11, P = .01). Moderate/severe brain injury (4% vs 44%, P = .002), subcortical (30% vs 68%, P = .02), and cerebellar injury (0% vs 20%, P = .05) were less frequent in the Epo than placebo group. At mean age 12.7 months (SD, 0.9), motor performance in Epo-treated (n = 21) versus placebo-treated (n = 20) infants were as follows: Alberta Infant Motor Scale (53.2 vs 42.8, P = .03); Warner Initial Developmental Evaluation (28.6 vs 23.8, P = .05). CONCLUSIONS: High doses of Epo given with hypothermia for hypoxic-ischemic encephalopathy may result in less MRI brain injury and improved 1-year motor function.

Grading hypoxic-ischemic encephalopathy severity in neonatal EEG using GMM supervectors and the support vector machine.

OBJECTIVE: This work presents a novel automated system to classify the severity of hypoxic-ischemic encephalopathy (HIE) in neonates using EEG. METHODS: A cross disciplinary method is applied that uses the sequences of short-term features of EEG to grade an hour long recording. Novel post-processing techniques are proposed based on majority voting and probabilistic methods. The proposed system is validated with one-hour-long EEG recordings from 54 full term neonates. RESULTS: An overall accuracy of 87% is achieved. The developed grading system has improved both the accuracy and the confidence/quality of the produced decision. With a new label 'unknown' assigned to the recordings with lower confidence levels an accuracy of 96% is attained. CONCLUSION: The statistical long-term model based features extracted from the sequences of short-term features has improved the overall accuracy of grading the HIE injury in neonatal EEG. SIGNIFICANCE: The proposed automated HIE grading system can provide significant assistance to healthcare professionals in assessing the severity of HIE. This represents a practical and user friendly implementation which acts as a decision support system in the clinical environment. Its integration with other EEG analysis algorithms may improve neonatal neurocritical care.

Classification of hypoxic-ischemic encephalopathy using long term heart rate variability based features.

Hypoxic-ischemic HI injury at the time of birth could lead to severe neurological dysfunction at an older age. Therapeutic hypothermia can be used to treat HI if severity of injury is determined within 6 hours of birth. EEG is generally used to assess the brain injury but it is neither widely recorded after birth nor is the expertise to interpret it commonly available. This study presents a novel system to classify HI injury using heart rate variability. The system makes decisions based on long-term statistical features extracted from the short-term HRV features. The preliminary results show the promising performance and robustness of the proposed method given a poor quality dataset. This tool can serve as decision support system in remote maternity units to help clinical staff to initiate hypothermia.

A new electroencephalogram classification with reduced recording time in asphyxiated term infants.

BACKGROUND AND OBJECTIVES: Conventional electroencephalogram (cEEG) is a reliable predictor of outcome in term infants with hypoxic ischemic encephalopathy (HIE). Early therapeutic hypothermia initiated within 6h after birth is a beneficial treatment in these infants. However, a classification system with reduced cEEG recording time to determine early intervention has not been reported. The aim of this study is to propose a new classification of depression on cEEG with reduced recording time in infants with HIE and to examine the correlation between the classification and short-term outcome. PATIENTS AND METHODS: We retrospectively investigated 20 term infants with HIE in whom cEEG was performed within 12h after birth, and deaths or outcomes at 18months of age were assessed. We determined grades 0-3 EEG depression in each 10-min epoch based on the most common EEG patterns of each 20s epoch defined by our criteria. RESULTS: Eighteen infants could be assessed by depression grade. The Spearman's rank correlation coefficient Rs between the maximum depression grade in 10-min epochs and three-grade outcomes was 0.68 (P=0.002), and that between the minimum one and outcomes was 0.66 (P=0.003). The area under the receiver operating characteristic curve of the maximum and minimum depression grades for predicting abnormal outcome were 0.885 and 0.869, respectively. CONCLUSIONS: We demonstrated a new cEEG depression classification with a recording time of at least 10min in term infants with HIE and a good correlation with short-term outcome.

[The contribution of the clinical examination, electroencephalogram, and brain MRI in assessing the prognosis in term newborns with neonatal encephalopathy. A cohort of 30 newborns before the introduction of treatment with hypothermia]. / Évaluation du pronostic de l'encéphalopathie précoce du nouveau-né à terme avant l'avènement de l'hypothermie.

OBJECTIVES: Perinatal asphyxia complicated by hypoxic ischemic brain injury remains a source of neurological lesions. A major aim of neonatologists is to evaluate the severity of neonatal encephalopathy (NE) and to evaluate prognosis. The purpose of this study was to determine the contribution of brain MRI compared to electroencephalogram (EEG) and clinical data in assessing patients' prognosis. MATERIALS AND METHODS: Thirty newborns from the pediatric resuscitation unit at Rouen university hospital were enrolled in a retrospective study between January 2006 and December 2008, prior to introduction of hypothermia treatment. All 30 newborns had at least two anamnestic criteria of perinatal asphyxia, one brain MRI in the first 5 days of life and another after 7 days of life as well as an early EEG in the first 2 days of life. Then, the infants were seen in consultation to assess neurodevelopment. RESULTS: This study showed a relation between NE stage and prognosis. During stage 1, prognosis was good, whereas stage 3 was associated with poor neurodevelopment outcome. Normal clinical examination before the 8th day of life was a good prognostic factor in this study. There was a relationship between severity of EEG after the 5th day of life and poor outcome. During stage 2, EEG patterns varied in severity, and brain MRI provided a better prognosis. Lesions of the basal ganglia and a decreased or absent signal of the posterior limb of the internal capsule were poor prognostic factors during brain MRI. These lesions were underestimated during standard MRI in the first days of life but were visible with diffusion sequences. Cognitive impairment affected 40% of surviving children, justifying extended pediatric follow-up. CONCLUSION: This study confirms the usefulness of brain MRI as a diagnostic tool in hypoxic ischemic encephalopathy in association with clinical data and EEG tracings.

Evolution of the Thompson score during the first 6 h in infants with perinatal asphyxia.

AIM: This study aimed to determine the evolution of the Thompson score, which provides composite grading of encephalopathy signs, during the first 6 h of birth in neonates with perinatal asphyxia. METHODS: Twenty term infants with perinatal asphyxia were prospectively studied from the University Hospital of Kinshasa during a 12-month period. The Thompson score was performed after 1 h, then hourly until 6 h of birth. RESULTS: Fourteen infants had a Thompson score ≥7 and six had a score <7 after 1 h of birth. The Thompson score remained higher than 7 after 3 h in nine infants (64.3%) and in four infants (25.6%) after 6 h. After 3 h of birth, four infants moved from a score ≥7 to a score below 7. After 6 h, five infants had a score below 7. Seventy per cent of patients had a Thompson score higher than 7 after 1 h, 45% after 3 h and 20% after 6 h. CONCLUSION: The Thompson score changes over the time during the first 6 h of birth, and this should be taken into account when it is being used as an entry criterion for cooling.

Hipoxia perinatal y su impacto en el neurodesarrollo / Perinatal hypoxia and its impact on neurodevelopment

Durante el periodo perinatal el cerebro puede quedar privado de oxígeno por dos mecanismos importantes: la hipoxemia y la isquemia. El primero consiste en una disminución de la concentración de oxígeno en sangre y el segundo en la cantidad de sangre que riega al cerebro. Clínicamente se le conoce como encefalopatía hipoxia-isquémica al síndrome caracterizado por la suspensión o grave disminución del intercambio gaseoso a nivel de la placenta o de los pulmones, que resulta en hipoxemia, hipercapnia e hipoxia tisular con acidosis metabólica. Los cambios metabólicos resultantes provocan a corto plazo daño necrótico y a largo plazo daño apoptótico. Las principales lesiones neurológicas que se presentan son la necrosis neuronal selectiva, la lesión cerebral parasagital y la leucomalacia periventricular, provocando secuelas como la parálisis cerebral, epilepsia, problemas en el habla y el lenguaje, auditivos y neuropsicológicos, siendo los procesos, atencionales, mnémicos, y visuoespaciales los más representativos en este rubro. En México se reporta una incidencia de 14.6 por cada 1,000 recién nacidos vivos, con una letalidad del 8.5 por ciento y un índice de secuelas de 3.6 por ciento. A pesar de la gran cantidad de estos estudios sobre secuelas de la hipoxia perinatal aún son pocos los programas a nivel institucional enfocados en el diagnóstico y tratamiento temprano.

During the perinatal period the brain can be deprived of oxygen by two major mechanisms, hypoxemia and ischemia. The first consists in a decrease in blood oxygen concentration and the second in the amount of blood that irrigates the brain. Clinically, it is known as hypoxic-ischemic encephalopathy; a syndrome characterized by severe suspension or decreased gas exchange in the placenta or lungs, resulting in hypoxemia, hypercapnia and tissue hypoxia with metabolic acidosis. A metabolic short-term change causes necrotic damage and long-term change causes apoptotic damage. The main neurological injuries that occur are selective neuronal necrosis, parasagittal brain injury and periventricular leukomalacia, causing sequelae such as cerebral palsy, epilepsy, speech and language disorders, lost hearing and neuropsychological deficits, especially in attentional, mnemonic, and visuospatial proceses. In our country, an incidence of 14.6 per 1,000 live births, with a mortality rate of 8.5 percent and 3.6 sequels index percent are reported. Despite the large number of studies about consequences of perinatal hipoxia are still few institutional level programs focused on early diagnosis and treatment.

A case-control study of hypoxic-ischemic encephalopathy in newborn infants at >36 weeks gestation.

OBJECTIVE: The purpose of this study was to determine risk factors that are associated with hypoxic ischemic encephalopathy (HIE). STUDY DESIGN: This was a case-control study that included newborn infants with HIE who were admitted to the hospital between January 2001 and December 2008. Two control newborn infants were chosen for each case. Logistic regression and classification and regression tree (CART) analysis that compared control infants and cases with grade 1 HIE and control infants and cases with grades 2 and 3 HIE was performed. RESULTS: Two hundred thirty-seven cases (newborn infants with grade 1 encephalopathy, 155; newborn infants with grade 2 encephalopathy, 61; newborn infants with grade 3 encephalopathy, 21) and 489 control infants were included. Variables that were associated independently with HIE included higher grade meconium, growth restriction, large head circumference, oligohydramnios, male sex, fetal bradycardia, maternal pyrexia and increased uterine contractility. CART analysis ranked high-grade meconium, oligohydramnios, and the presence of obstetric complications as the most discriminating variables and defined distinct risk groups with HIE rates that ranged from 0-86%. CONCLUSION: CART analysis provides information to help identify the time at which intervention in labor may be of benefit.

Defining hypoxic ischemic encephalopathy in newborn infants: benchmarking in a South African population.

OBJECTIVES: There are few population-based studies of hypoxic ischemic encephalopathy (HIE) in sub-Saharan Africa, and the published criteria that are used to define and grade HIE are too variable for meaningful comparisons between studies and populations. Our objectives were (1) to investigate how the incidence of HIE in our region varies with different criteria for intrapartum hypoxia and (2) to determine how encephalopathy severity varies with different grading systems. METHOD: We reviewed the records of infants with a diagnosis of HIE born between September 2008 and March 2009 in public facilities in the Southern Cape Peninsula, South Africa.The incidence of HIE was calculated according to four definitions of intrapartum hypoxia and graded according to three methods. RESULTS: Depending on which defining criteria were applied,the incidence of HIE varied from 2.3 to 4.3 per 1000 live births, of mild HIE ranged from 0.4 to 1.3 per 1000 live births, and of moderate-severe HIE ranged from 1.5 to 3.7 per 1000 livebirths. Ninety-seven of the 110 (88%) infants reviewed had at least one intrapartum-related abnormality. Only 62 (56%) infants had a blood gas performed in the fi rst hour of life. CONCLUSION: The incidence and grade of HIE can vary more than 2-fold in the same population, depending on which defining criteria are used. Consensus definitions are needed for benchmarking.

Is myocardial performance index useful in differential diagnosis of moderate and severe hypoxic-ischaemic encephalopathy? A serial Doppler echocardiographic evaluation.

INTRODUCTION: The aim of this study was to investigate the importance of myocardial performance index as an additive criterion to Sarnat criteria in differential diagnosis of newborn babies with moderate and severe hypoxic-ischaemic encephalopathy. METHODS: Our study group included 50 healthy term newborn babies and 20 newborn babies with hypoxic-ischaemic encephalopathy. The 20 newborn babies with hypoxic-ischaemic encephalopathy were scored using Sarnat grades. Left and right ventricular functions were determined on the first day and thereafter in the 1, 3-4, 6-7, and 11-12 months of life by M-Mode and pulsed Doppler. RESULTS: Myocardial performance indexes of the left ventricle were significantly higher in the severe hypoxic-ischaemic encephalopathy group than in the control group during the first, second, and third analyses (p = 0.01, p = 0.02, p = 0.02, respectively) and only during the first analysis (p = 0.01) in the moderate hypoxic-ischaemic encephalopathy group. In addition, the myocardial performance indexes of the right ventricle were significantly higher during the first, second, and third analyses in both severe and moderate hypoxic-ischaemic encephalopathy groups than in the control group (p = 0.01, all). Hypoxia-induced alterations last longer in the right ventricle than in the left ventricle in the moderate group, as during the second and third analyses myocardial performance index continues to be higher than the control group. CONCLUSION: Myocardial performance indexes for the left and right ventricles were significantly higher in both severe and moderate hypoxic-ischaemic encephalopathy groups than in the control group during the first analysis, and myocardial performance index greater than or equal to 0.5 can be used in order to distinguish moderate and severe hypoxic-ischaemic encephalopathy babies according to Sarnat grades as a discriminative additive criterion.

Acute renal failure: nephrosonographic findings in asphyxiated neonates.

To determine the incidence of acute renal failure (ARF) and nephrosonographic findings among asphyxiated neonates, and to correlate this with uric acid levels and the severity of hypoxic encephalopathy, we studied 80 full-term appropriate-for-date singleton neonates with perinatal asphyxia, and 30 healthy full-term neonates as controls from March 2006 to February 2007. A detailed history, thorough clinical examination along with investigations, including urine examination, 24-h urine collection, ultrasonography of abdomen and cranium, serum electrolytes, blood urea nitrogen, serum creatinine, and serum uric acid were obtained. ARF developed in 45% (36/80) of the asphyxiated neonates. Forty-eight (60%) neonates showed significant elevation of blood urea and 41 (51.3%) neonates had significant elevation of serum creatinine than the control group (P < 0.001). Sixty-two (77.5%) neonates developed significant elevation of serum uric acid levels, and nephrosonography revealed hyperechogenicity in all of them, while only two among the healthy neonates showed the raised uric acid levels (P < 0.001). Nonoliguric renal failure was seen 28/36 (77.8%) of the neonates with ARF, whereas eight (22.2%) neonates had oliguric renal failure. Eight (27.8%) patients among ARF patients maintained abnormal biochemical parameters after 2 weeks, and of whom four patients died after variable lengths of time with a mortality rate of 11.11%. Kidneys are the most common organs involved in perinatal asphyxia, and uric acid might be a causative factor for failure in addition to hypoxic insult. Routine use of kidney function test, along with abdominal ultrasonography form an important screening tool to detect any additional morbidity in these patients.

Predictors of outcome of neonates with hypoxic ischaemic encephalopathy admitted to the neonatal unit of the University Hospital of the West Indies.

This was a retrospective review to determine predictors of outcome in term infants with hypoxic ischaemic encephalopathy (HIE) at the University Hospital of the West Indies. Ninety-five neonates fulfilled criteria for entry into the study of these 34 (36%) had a poor outcome. The stage of encephalopathy, seizures on admission, the need for more than one antiepileptic for seizure control and an abnormal neurological examination at hospital discharge were found to be associated with poor outcome. Multiple logistic regression analyses showed that an abnormal neurological examination at discharge was the only independent predictor of poor outcome. Babies who had an abnormal neurological examination at hospital discharge were more likely to have a poor outcome (odds ratio 2.6, confidence interval 0.03-0.4). An abnormal neurological examination at discharge had a positive predictive value of 88% and a negative predictive value of 84% for poor outcome, with a sensitivity and specificity of 60 and 96%, respectively. We recommend that if post-HIE, an infant has an abnormal neurological examination at the time of discharge from hospital, that infant should be followed up and monitored in a specialist neurology clinic and parents counselled about the guarded prognosis for normal neurodevelopmental outcome.

Does the International Classification of Disease (ICD-9) code accurately identify neonates who clinically have hypoxic-ischemic encephalopathy?

BACKGROUND/AIMS: Hypoxic-ischemic encephalopathy (HIE) refers to neonatal neurological signs and symptoms of hypoxia and/or ischemia. Our aim was to determine the accuracy of ICD-9 codes to identify newborns with HIE confirmed by umbilical cord blood analysis. METHODS: ICD-9 codes in the newborn chart for birth trauma, birth asphyxia, intrauterine hypoxia, and fetal distress were used to identify newborns with suspected HIE by neonatal personnel. Maternal charts were reviewed for umbilical cord gases meeting the HIE clinical criteria. RESULTS: There were 21,008 deliveries at center I and 17,540 at center II. ICD-9 codes identified 172 neonates, 49 infants (2.3‰ births) at center I and 123 neonates (7‰) at center II. Only 3 neonates (6%) were ≥34 weeks and none met ACOG criteria [umbilical artery pH <7.00 or base excess (BE) ≥12 mmol/l at center I]. At center II, 80 infants were ≥34 weeks but only 5/123 (4%) met the ACOG clinical criteria for HIE (pH <7.00, BE ≥12 mmol/l, and Apgar ≤3 at 5 min). CONCLUSIONS: ICD-9 codes are unreliable in identifying birth asphyxia and cannot identify newborns meeting the clinical criteria for intrapartum HIE.

Comparison of computer tomography and magnetic resonance imaging scans on the third day of life in term newborns with neonatal encephalopathy.

OBJECTIVE: Our goal was to compare the patterns of brain injury detected by computed tomography, conventional MRI (T1- and T2-weighted sequences), and diffusion-weighted MRI in a cohort of term newborns with neonatal encephalopathy studied uniformly with all 3 modalities on the third day of life. METHODS: Term newborns (> or =36 weeks' gestation) admitted to our center with neonatal encephalopathy were scanned with computed tomography, MRI, and diffusion-weighted MRI at 72 (+/-12) hours of life (n = 48). Each modality was scored independently of the other with previously validated scoring systems. The predominant pattern of brain injury was classified as: normal, watershed, basal nuclei, total (maximal basal nuclei and watershed), and focal-multifocal (presence of strokes and/or white matter injury alone). RESULTS: The agreement for the predominant pattern of injury was excellent between MRI and diffusion-weighted MRI (77% agreement). The agreement for the pattern of injury was also good for computed tomography and diffusion-weighted MRI (67% agreement). The extent of cortical injury and focal-multifocal lesions, such as strokes and white matter injury, were less apparent on computed tomography than diffusion-weighted MRI. In 19 newborns with a repeat MRI in the second week of life, the predominant pattern seen on the day 3 diffusion-weighted MRI was confirmed. CONCLUSIONS: Diffusion-weighted MRI is the most sensitive technique with which to assess brain injury on day 3 of life in term newborns with neonatal encephalopathy, particularly for cortical injury and focal-multifocal lesions such as stroke and white matter injury. All 3 modalities identify the most serious patterns of brain injury similarly.

Post-resuscitation management of asphyxiated neonates.

Inspite of major advances in monitoring technology and knowledge of fetal and perinatal medicine, perinatal asphyxia is one of the significant causes of mortality and long term morbidity. Data from National Neonatal Perinatal Database suggests that perinatal asphyxia contributes to almost 20% of neonatal deaths in India. "Failure to initiate or sustain respiration after birth" has been defined as criteria for the diagnosis of asphyxia by WHO. Perinatal asphyxia results in hypoxic injury to various organs including kidneys, lungs and liver but the most serious effects are seen on the central nervous system. Levene's classification is a useful clinical tool for grading the severity of hypoxic ischemic encephalopathy. Good supportive care is essential in the first 48 hours after asphyxia to prevent ongoing brain injury in the penumbra region. Strict monitoring and prompt correction is needed for common problems including temperature maintenance, blood sugars, blood pressure and oxygenation. Phenobarbitone is the drug of choice for the treatment of convulsions.