5.7 Asphyxia Neonatorum - Incidence in Cape Town. c.d. Molteno, A.f. Malan and h. de v. Heese

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26 Oktober 1974

S A

M I S TY SKR IF

2183

sphyxia Neonatorum Incidence

•

Cape Town

C

D. MOLTENO, A. F. MALAN, H. DE v. HEESE

SUMMARY

The

over-al l incidence

of asphyxia neonatorum as well as

that

fo r the

var ious complications

of pregnancy and

modes

of

delivery

are reported

fo r

the non-Whites

in Cape

Town. The

increased incidence

in this

populat ion group

can

be par tly accounted

fo r by

the f requency of certain

complications

of

pregnancy

and

abnormal modes

of de

livery.

Of

additional significance is the associat ion between

both increasing maternal age and asphyxia neonatorum.

The

high inc idence of i nfan ts with l ow bir thweight al so con

t ri bu tes conside rably towards the preva lence of the con

dition.

Afr Med l

48, 2183

1974).

Failure to

establish

regular respiration after birth

remains

a

major cause

of

newborn mortality and morbidity.

The long-term ,equelae of such

failure of

adaptat ion to

extra-uterine life

can

be very serious indeed. Prevention

and

prompt

management

of

asphyxia neonatorum

is

the

task

of all concerned with the process of

human

repro

duction.

In

order to

ach ieve this , a study

of the incidence

and r isk factors of asphyxia

neonatorum

was

undertaken

in the Groote Schuur

Maternity

Hospital.

TABLE

I. INCIDENCE OF ASPHYXIA NEONATORUM

Source of Hospital

Apgar

score

0

3

information

deliveries

Period

1 min 5 min

Groot Schuur

Hospital

3167

1971 -

1972

6,1

1,4

Mowbray Mater-

nity Hospi ta l 1383

1971

2,7

Barcelona 20933

1966

-

1968

1,5

Sloan Hospital

fo r Women 15384 1952

-

1956

7,9

Collaborative

study 17221 1958

-

1964

6,7

1,8

The

associa tion between increasing

maternal

age

and

asphyxia

neonatorum

is shown in Fig. 1

becoming

significant

over

25 years of age. Increase in parity is

also assoc ia ted wi th an increased incidence

of

asphyxia

(Fig. 2). No correlation was

found

between maternal age

and birthweight.

DISTRIBUTION

Y

MATERNAL AGE

Fig. 1. Distribution

of

asphyxia neonatorum by maternal

age.

PATIENTS AND METHODS

A

prospective study

was

carried out on

all

infants

deliver ed in the Groote

Schuur Maternity Hospital from

1

April

1971

to 31 March

1972. All

mothers

in this

maternity hospital

were

non-White, and

full detai ls of

their

pregnancies and deliveries were

recorded.

Asphyxia

neonatorum

(syn.

birth

asphyxia) was diagnosed if

the

I-minute Apgar

score

l

was 0 - 3 or if

the

infant needed

artificial ventilation in the f irst 10 minutes of life.

RESULTS

Table

I gives the

comparative

incidence

of asphyxia

neona to rum in the pr es ent s tudy

in

the Mowbray Mater

nity

Hospital

White

mothers),

and

in

3 series

reported

in the literature. There is a substantially lower incidence

among Cape Town

White

infants, and in the recent

figures

from Barcelona.

Department of Paediatrics and

Child

Health,

University

of

Cape Town

C

D. MOLTENO, F.C.P.

S.A.),

- 1.MED. PAED.) , D .C .H .

A

F. MALAN,

M.MED.

PAED.),

M.D., DIP.MID. C.O.G.

d.

DE

V

HEESE,

B .SC. , M .D ., F .R .C .P ., D.C.H.

Date received:

10

July 1974.

40

30

Q)

Cl

o

20

u

Q)

Cl

10

•

total

l ive births

o

asphyxia

neonatorum

0

0-

0-

N

N N

)

M

0

V

I I I

I

0

I t )

0

I t )

N

N

M

M

maternal

age

In years



2184

S A M E D IC AL JO U R N A L

26 October 1974

40

DISTRIBUTION BY PARITY

• total l ive births

o asphyxia neonatorum

The

influence of maternal diseases and complications of

pregnancy on

the

frequency of asphyxia

neonatorum are

l is ted in Tab le I ll . The hypertensive conditions

of

preg

nancy are significantly associated with asphyxia

neonatorum.

TABLE Ill . INCIDENCE - DISEASES AND

COMPLICATIONS

OF PREGNANCY

30

IV

Cl

C

20

u

a.

o

4

parity

5

6 7

8+

Maternal condition

P,re-eclamptic toxaemia

Eclampsia

Hypertension

Cardiac

disease

Anaemia

Diabetes

Placenta praevia

Abruptio placentae

APH unclassif ied

Clinical fetal distress

Percentage of

pregnancies

9,0

0,3

3 2

3,1

12,7

2,3

2 1

2,0

4 5

9 1

Percentage

asphyxiated

17 6

20,0

23 8

3,1

6 3

16 4

20 0

17,7

7 6

18,3

Maternal cardiac disease was associated with a remark

ably low birth asphyxia rate, whereas

maternal anaemia

(diagnosed by

recording

a haemoglobin concentration of

less than 10 gjlOO

ml

during pregnancy was complicated

by

asphyxia neonatorum in 6,3 of cases. Diabetes mel

titus, diagnosed in

mothers with an

abnormal

oral

glucose

tolerance test, was associated with a moderately increased

rate.

Placenta

praevia referred

to

vaginal haemorrhage after

28

weeks gestation,

where

a

placenta

was fe lt at vaginal

examination or

was seen to be in

the

lower segment at

Fig.

2.

Distribution of asphyxia

neonatorum

by parity.

Table I I gives the incidence

of

asphyxia neonatorum as

found

in the various types of delivery. The incidence of

3,2

0

0

in

spontaneous

vertex deliveries increases to

8.8 10

in low birthweight

infants

(less than 2,5 kg). Both medical

and surgical inductions are associated with an increased

incidence. All other types of delivery were

found

to be

associated with an increased incidence

of

asphyxia neona

torum being particularly high in Caesarean section

and

breech deliveries.

The

figure

rapidly

increases in

the

very

small infants. Surprisingly, when vacuum extraction was

used,

the

incidence

of

asphyxia was only slightly h igher

than

in

spontaneous vertex deliveries. Of

the

66

pairs

of twins, 116 were born alive in hospital (in one case, a

retained twin was born in hospital, the other having

been delivered

in

the district).

There

were 5 stillbirths.

Of

the

18 with asphyxia neonatorum 7 were f irst-born

and 11 second-born twins. In one case both were asphy

xiated,

and

in ano th er the

f ir st was

asphyxiated and the

other stillborn.

TABLE INCIDENCE - METHOD OF DELIVERY

40

30

DISTRIBUTION

BY

BIRTH

MASS

• total

live

births

o

asphyxia neonatorum

Delivery

Spontaneous

vertex

Low bir thweight

Medical inductions

Surgical inductions

e s r ~ n section

Low birthweight

Forceps

Vacuum extraction

Breech

Low birthweight

Twin

Percentage of total

deliveries

74,3

15,6

7,0

5,0

12,2

7,2

2,6

3,7

3,7

Percentage

asphyxiated

3,2

8,8

7,8

16,5

20,8

35 0

12,1

4,7

30 0

40,9

15,5

0

0 .

Of

+

N

N M

M

1

V

I

,

I

,

Of

0

0

1

0

1

N

N M

M

birth

mass

kg

Fig.

3. Distribution

of asphyxia

neona to rum by b ir th

weight.



26

Oktober 1974

S A M E D 1 E S E

T Y D S K R I F

2185

DISTRIBUTION BY GESTATIONAL GE

Fig . 4.

Distribution of

asphyxia

neonatorum

by gestational

age.

.40-

G)

g

:

30-

)

v

20-

10-

Caesarean

section.

Abruptio

placentae was d iagnosed by

finding significant r et roplacen ta l haemorrhage . Vaginal

haemorrhage after 28 weeks ' gestational age, not classified

as p lacenta praevia or abruptio placentae, was termed

unclassified antepartum haemorrhage.

Clinical fetal distress was diagnosej if there was

meconium-stained liquor in a cephalic presentat ion,

or

if

the fe ta l

heart r at e

was

more

than

160/minute.

l e ~ s

thiln

l20/minute or was grossly irregular . Although this is a

notoriously

inaccurate

measure of intra-uterine hypoxia,

in this group 18,300 of cases resulted in b ir th asphyxia.

Figs 3 and 4 demonstrate the increased incidence of

asphyxia

neonatorum

at the extremes of birthweight

and

gestational age. This applies particularly to low birthweight

and

preterm infants. There was a male preponderance

of

birth-asphyxiated infants of 5 7 , 2 ° ~ .

DISCUSSIO

The trend t o w ~ r d s a d e r e ~ e in the incidence of asphyxia

neonatorum apparent in Western countries is reflected in

our White infants. The situation among the non-Whites.

however,

is

similar to

that

in the USA

in

the 1950s and

early 1960s.

3

There is a high rate

of

low bir thweight in

fants

in

the non-White populat ion,

and

this agrees with

Yerushalmy s figures for the

USA

( 6 , 7 ° ~ in Whites and

1 3 , 7 ° ~

in non-Whites):

and

with those

in

the collaborative

perinatal study (7, I

°v

in Whites and 13.4

v

in non-Whites)

The number of asphyxiated

infants

increases markedly in

low birthweight

Caesarean

sections

and

breech deliveries.

Labour was induced in 12°0

of

pregnancies, which is a

comparable figure with that given in the perinatal mor

tality survey in Britain.' When considering the increased

frequency

of

bir th asphyxia, par t:cularly

in

surgically

induced infan ts, one must t ake in to account the indication

for the procedure .

Caesarean sections were performed in 12.2 of preg

nancies. In a ~ t u d y

in

New South Wa es reported in

1967, the incidence was 4,5°0

of

all deliveries, r ising

to

7, I in teaching hospitals .' Factors contributing to asphy

xia

neonatorum

in

Caesarean

sections include the indi

cation

for

the operation as well as the effect of the

anaesthetic

on

the infant.

In

the present series m o ~ t

of

the Caesarean sections were

performed

under general

anaes thes ia with nit rous oxide.

Whereas forceps deliveries were associated with' an

increased rate

of

asphyxia neonatorum, this was not the

case with vacuum extraction.

Vacuum

extraction, there

fore, as ca rried out in

the

Groo te Schuur

Maternity

Hospital, is a safe procedure when judged by the incidence

of asphyxia

neonatorum.

The

incidence

of

breech deliveries compares with that

reported in the literature.

The

high rate

of

asphyxia

neonatorum

stresses the

danger

of this

method

of delivery.

and the fact that the incidence rises dramatically in low

birthweight in fants emphasises the importance of the

asphyxial aspects in addition to the purely traumatic ones.

The

incidence

of

hypertensive disorders

of

pregnancy is

difficult to a ~ s e s s . The figure quoted in the col labora tive

perinatal study in the

USA

for non-Whites was 1 2 , 7 ° ~ . o

In our series 1 2 , 2 ° ~ of the mothers had pregnancies

complicated by hypertension, with a high incidence

of

asphyxia neonatorum.

The incidence of both ma te rnal c ard ia c disease and

diabetes mel li tus recorded here is higher than usual

because such cases are

concentrated

in this hospital.

Of

interest

is

the low

rate of

asphyxia

neonatorum

in

infants o f mothers with cardiac d i ~ e a s e compared with

those of diabetic mothers.

The incidence of antepartum haemorrhage was slightly

higher

t han that

reported

by Niswander

al

for non

Whites in the USA (accidental haemorrhage 1,17 and

placenta praevia 0 , 5 4 8 ~ ~ ) . Abruptio placentae is associated

with an exceptionally high perinatal mortali ty , mainly

resulting

from

tillbirths. The incidence of asphyxia neo

natorum is only

moderately

increased.

Th e

high rate

of depressed infants in

placenta

praevia is

accounted

for

• total live births

o

asphyxia

neonatorum

l

.,

0

M

-

M

M

M

M

N

I

I

I

I

<t

v

0

CX

0

M

M

M

gestcitional age in weeks

50-

60-



2186

S

M E D I C L

J O U R N L

26

Oct ober

1974

partly

by t he u nd er ly in g

condition

a nd p artly by their

d el iv er y b y Caesarean section

an d

th e increased frequency

of

l ow b ir th we ig ht i nf an ts in

this group.

Since there

wa s

no significant

correlation

be twe en m a te r

na l

a ge a n d b ir th we ig ht

in

th e

series,

two groups of

patients

emerge. Firstly, th e

infants born to

elderly

multiparas,

an d secondly, the low

birthweight

infants.

These

groups

probably

contribute significantly

to the

increased incidence

o f

asphyxia

neonatorum

in th e

non-Whites

of th e Western

Cape. I mpr oving birth c on tr ol w ou ld u nd ou b te dl y

reduce

th e numbers in th e first group.

Th e

second group, which

ha s

been studied by Moodie et al. requires

to

be

approached

on

a

broader

front, since

nutritional

an d socio

e co nom ic fa ct or s p la y a large part in t he ir occ urrenc e.

C as es w hi ch must

be

considered

of high

ris k, t here fore,

ar e those with a maternal

age

g re at er t ha n 25 years, a

fetus

of lo w

weight or gestational age, breech deliveries an d

inductions,

an d forceps

or Caesarean section del iveries

fo r complications of pregnancy.

Boeke Ontvang :

Anaerobic Bacteria: Role in Disease. Ed. by A Balows, Ph.D.,

R. M. de Haan, M.D.,

V

R. Dowell, jnr, Ph.D. and

L

B

Guze, M.D. Pp. xxi 655. TIlustrated. 27,50. Springfield,

Illinois: Charles

C

Thomas. 1974.

Gasrrointestinal Pan-Endoscopy. Oesophagoscopy, gastroscopy,

bulbar

a nd p os tb ul ba r duodenoscopy procto-sigmoido

scopy, colonoscopy and peritoneoscopy. By

L

H. Berry,

M.S., M.D. Pp. xxiv 632. TIlustrated. 32,50. Spring

field, TIlinois: Charles

C

Thomas. 1974.

Childhood Disorder. A psychosomatic approach. By P.

Pinkerton, M.D., F.R.C.Psych., D.P .M. Pp. x ii

192

£3,75. London: Granada. 1974.

Th e Genetics

of

Locomotor Disorders. By C.

O

Carter,

M.A,

D.M., F.R.c.P. and T.

J

Fairbank, M.A., M.B., B.Chir.,

F.R.C.S. Pp. xii

17

£5,00. London and Cape Town:

Oxford University Press. 1974.

REFERENCES

1.

Apgar, V. (1953): A n ae s th . A na lg . Curr. Res.,

32,

260.

2.

Bal1abriga,

A ., M or ag as , A .,

Gal1art-Cata1a,

A. and B ar at , N . (1970):

A c ta p a ed ia t. s ca n d. , 59, 497.

3.

Apgar,

V ., D un ca n, A ., H ol ad ay , A ., J am es , L S ., W e is br ot ,

M.

an d Berrien,

C. 1958) :

J. A me r. M ed. Asso c., 168 , 1985 .

4. Drage, J. S. , Kennedy,

C.

an d Schwartz, B. K. (1964): O bs te t. a nd

Gynec.,

24,

222.

5. Yerushalmy, J. ,

Va n

del Berg,

B.

J ., E rh ar dt , C. L an d Jacobziner,

H. (1965): Amer. J. D is . C hi ld ., 109 , 43 .

6.

Niswander, K. R.

a nd G or do n,

M.

(1972):

he omen and

cheir

Pregnancies

C ol la b or at iv e P e ri na t al S tu dy

of

t he N at io na l

Institute

of Neurological

Disease and Stroke), p. 55.

PhJadeJphia:

W.

B.

Saunders.

7

Butler,

M.

R.

and Bonham, D.

G.

(1963):

Perinacal Morcalicy

First

Report of the

1958

British

Perinatal

Mortality Survey),

p. 183. Edin

b urg h: E .

&

S. Livingstone.

8. Caesarean

section in Ne w

S ou th Wa le s, 1966 - 1967: a mortal. ly

an d

m or bi di ty s tu dy .

D ep ar tm en t o f

P ub li c H ea lt h,

Ne w

South

Wales

(1969):

Med.

J.

Aust., I,

319.

9. H all, J. E., Kohl, S., O B rien,

F. an d

Ginsberg,

M.

(1965): Amer.

J . O bs te t. G yn ec .,

91,

665.

10. Niswander,

K

R. an d

G or do n, M .

(1972):

p

cir.

5

, p. 393.

L1 iswander,

K.

R ., F ri ed ma n.

E.

A.,

H oo ve r, D .

B ., P ie rr ow sk i.

H.

a nd We st pha l, M .

C.

(1966): A me r. J . O bst et . G yn ec ., 95, 838 .

12. Moodie,

A.

D. ,

Hansen,

J. D. L Jordaan,

H.

V.

F. , Malan,

A. F.

an d

Davey, D.

1970):

S. Afr. Med. J. , 44, 1400.

Books Received

Clinical Chemical Pathology. 7t h ed. By

C

H Gray, D.Sc.,

M.D., F.R.c.P., M.R.C.S., F.R.I.C., F.R.C.Path. Pp. vi

247. £4,50 Boards; £2,25 Paperback . London: Edward

Amold. 1974.

Lifespan an d Factors Affecting

I t

Aging theor ies in geron

tology. By D. Hershey, Ph.D.

Pp .

xiii

158

9,75.

Springfield, TIlinois: Charles C. Thomas. 1974.

The Alpha Syllabus. A handbook

of

human EE G Alpha acti

vity. Ed. by Barbara

B

Brown, Ph.D. an d J.

W

Klug,

AB. Pp. xvii 347. Cloth 17,50; Paperback 12,95.

Springfield, TIlinois: Charles C. Thomas. 1974.

Annals

of

the New

York

Academy

of

Sciences. Vol. 232.

Third

Conference on Cooley 's Anemia. Ed. by E. C. Zaino.

Pp. 380. TIlustrated. 33,00. New York: New York Aca

demy

of

Sciences. 1974.

5.7 Asphyxia Neonatorum - Incidence in Cape Town. c.d. Molteno, A.f. Malan and h. de v. Heese

Documents

Transcript of 5.7 Asphyxia Neonatorum - Incidence in Cape Town. c.d. Molteno, A.f. Malan and h. de v. Heese