Neonatal Complications in Newborns With an Umbilical Artery pH 7.00

8/13/2019 Neonatal Complications in Newborns With an Umbilical Artery pH 7.00

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Neonatal complicationspH


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Volume 175, Number 5 van den Berg et al 1153AmJ Obstet Gynecol

T a b l e I . M a t e r n a l a n d f e ta l d e m o g r a p h i c a n d i n t r a p a r t u m c h a r a c t e r i s t i c s

Totalpopulat ionn = 14, 025)

Matched cases

tudygroupn =84)

Controlgroupn = 84)

Unmatchedacidoticcases

n = 33)Age (yr) (m ea n _+ SD) 29.6 + 4.6 29.1 -+ 4.5 29.1 -+ 3.6 30.6 -+ 5.1Nullip arous (%) 51] 64 64 72Ge sta tio na l age (days) (m ea n + SD) 270 -+ 26 270 --- 21 270 -4- 20 235 -+ 31 +Im mat ure (%) 3 0 0 13+Pr em atu re (%) 13 18 18 66++Te rm (%) 78 81 81 19+Postm ature (%) 6 1 1 3Presenting part (caput/br eech) (%) 89.6/10.4]- 81/19 81/19 52/48Delivery metho dNot oper ative (%) 67]- 48 48 27 +Vacuum extraction (%) 9]- 16 16 0 +Force ps (%) 6 10 10 9Elective cesa rean (%) 11 14 14 425Eme rgency cesarean (%) 8]- 13 13 21Bir th weigh t (gin) (m ea n + SD ) 3049 -+ 845 2935 -+ 772 2909 - 717 1926 :t: 765 +9 0p m o l /L a f t e r 3 d a y s o f l if e , a n d (6) g a s t ro in t e s t i n a l c o m-p l i c a ti o n s ( a l a n i n e a m i n o t r a n s f e r a s e > 2 5 U / L , a s p a r ta t ea m i n o t r a n s f e r a s e > 3 3 U / L , n e c r o t i z i n g e n t e r oc o l it i s ) .Se ps i s, a d miss io n to t h e n e o n a ta l i n t e n s iv e c a re u n i t , a n dd e a th w e re a l so n o te d .

D i f f e r e n c e s i n n e o n a t a l c o m p l i c a t i o n s b e t w e e n t h es t u d y g r o u p ( p H < 7 . 00 ) a n d t h e c o n t r o l g r o u p ( p H>7 .24 ) w e re a n a ly z e d a c c o rd in g to t h e se p a ra me te r s . Tod e sc r ib e t h e s tu d y g ro u p , me ta b o l i c a c id o s i s w a s d e f in e da c c o rd in g to G o o d w in e t a l . s as Pc o u _ 6 5 m m H g a n d b a s e d e fi c it < 1 0 m m o l / L . M i x e da c ido s i s w a s d e f in e d a s Pc o 9 >6 5 mm H g a n d b a se d e f i c i t> 1 0 m m o l / L .

S ta ti s t ic a l s i g n i f i c a n c e w a s d e t e rm in e d b y 2 x 2 c o n t in -g e n c y t a b l e s a n d F i sh e r ' s e x a c t t e s t s . D i f f e re n c e s i n mo r -b id i ty b e tw e e n th e tw o g ro u p s w e re t e s t e d fo r s ig n i f i c a n c e


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1154 van den Berg e t a l . November 1996Am J Obs tet GToaecol

E

6o=

160

140

120

1 O0

80

60

40

20

0

o

DD~B

5 10 15 20 25 30base deficit m molll)

Fig. 1 , Base deficit v e r s u s P c o i n u m b i l i c a l a rt e r y w i t h s u b d i v is i o n f o r g e s t a ti o n a l a g e a n d n e u r o l o g i cdysfunc t ion , l so -p H l ines were d rawn a t pH 7 .00 , 6 .90 , 6 .80 and 6 .70 . Sol id square , P r e t e r m i n f a nt s w i thn e u r o l o g i c c o m p l i c a t i o n s ; open square, p r e t e r m i n f a n t s w i t h o u t n e u r o l o g i c c o m p l i c a t i o n s ; solid triangle,t e r m i n f a n ts w i t h n e u r o l o g i c c o m p l i c a t io n s ; open triangle, t e r m i n f a n ts w i t h o u t n e u r o l o g i c c o m p l i c a t i o n s .

T a b l e I I . U m b i l i c a l c o r d a c id - b a s e p a r a m e t e r s

Totalp o p u l a t i o n *N = 1 4 , 0 2 5 )

Matched cases

S t udyg r o u pn = 84)

Controlg r o u pn = 84)

U nm at c he dacidotic

casesn = 3 3 )

A r t e r i a lpH (m ean _+ SD)P c o u ( m m H g ) ( m e a n + S D )B a se d e f i c i t ( m m o l / L ) ( m e a n + S D )V e n o u spH (m ean --_ SD)Pco 2 (mm Hg) (m ean +_ SD)B a se d e f i c i t ( m m o l / L ) ( m e a n + S D )

7.24 +- 0.08 ( N = 14,025) 6,91 + 0.09 (81)12.0 + 3.3 (80)18.2 + 4.3 (81)

7.02 + 0.12 (84)9.5+- 3.1 (81)15.5__+ 4.3 (82 )

7.29 + 0.03 (84)6.6 +-+- .2 (77 )3.6 + 2.4 (78)7.35__+ 0.04 (84 )5.2 + 0.9 (78)3.8__+ 2.0 (79 )

6.87 + 0.13 (31)

Values in pa ren theses ind ica te number .* T o t a l i n v e s ti g a t e d p o p u l a t i o n d e l i v e r e d i n U n i v e r s i t y H o s p i t a l N i j m e g e n i n b e t w e e n 1 9 86 a n d 1 9 93 .

w i t h t h e M c N e m a r t e st . A p v a lu e < 0 .0 5 w a s c o n s i d e r e ds i g n i f i c a n t .

R e s u l t sT h e d e m o g r a p h i c a n d i n t r a p a r t u m c h a r ac t e ri s ti c s o f

t h e 8 4 p r e g n a n c i e s ( 70 t e r m a n d 1 4 p r e t e r m n e o n a t e s ) i nt h e a c i d o ti c a n d c o n t r o l g r o u p s a r e s u m m a r i z e d i n T a b l eI a n d c o m p a r e d w i t h t h e g e n e r a l o b s t e t ri c p o p u l a t i o n o ft h e U n i v e r s i ty H o s p i t a l o f N i j m e g e n o v e r t h e s a m e t i m ei n t e r v a l ( 1 9 8 6 t o 1 9 93 ) a n d w i t h t h e n e o n a t e s i n t h ea c i d o ti c g r o u p t h a t c o u l d n o t b e m a t c h e d . I n t h e s t u dyg r o u p t h e p e r c e n t a g e o f n u l l i p a r o u s p a t ie n t s , b r e e c h p r e -s e n t a t i o n s , v a g i n a l o p e r a t i v e d e l i v e ri e s , m u l t i p l e g e s t a-t i o n s, a n d m a l e n e o n a t e s w a s s i g n i f ic a n t l y h i g h e r t h a n i nt h e t o t a l p o p u l a t i o n . I n t h e g r o u p o f a ci d o t ic n e o n a t e st h a t c o u l d n o t b e m a t c h e d , t h e g e s t a ti o n a l a g e a n d b i r t hw e i g h t w e r e s i g n i fi c a nt l y l o w e r ; th e r e w e r e m o r e p r e m a -t u r e a n d i m m a t u r e i n fa n ts , a n d m u l t i p l e p r e g n a n c i e sw e r e m o r e c o m m o n . A l s o , s i g ni f ic a n tl y m o r e o p e r a t iv ed e l iv e r i es w e r e p e r f o r m e d . I n T a b l e I I t h e p o s t p a r t u ma c i d - b a s e p a r a m e t e r s i n t h e u m b i l i c a l a r t e r y o f t h e t o t a l

p o p u l a t i o n , t h e u n m a t c h e d c a se s, a n d t h e a c id o t i c a n dc o n t r o l g r o u p s a r e s h o w n .

N e o n a t a l c o m p l i c a t i o n s f o r t h e m a t c h e d a c i d o t i c a n dt h e n o n a c i d o t i c g r o u p s a r e s u m m a r i z e d i n T a b l e II 1. N e o -n a t a l m o r b i d i t y ( p o o r c o n d i t i o n a f t e r d e li v e ry , n e u r o -l o g i c , p u l m o n a r y , g a s t r o i n t e s t i n a l , a n d c a r d i o v a s c u l a rc o m p l i c a t i o n s ) w a s s ig n i f i c a n tl y h i g h e r i n t h e a c i d o t i cg r o u p t h a n i n t h e n o n a c i d o t i c g r o u p , w i t h th e e x c e p t i o no f r en a l c o m p l i c a ti o n s . N e o n a t a l i n t e n si v e c a r e u n i t a d -m i s s i o n s w e r e a l s o s ig n i f i c a n tl y h i g h e r . T w o n e o n a t e s i nt h e a c i d o t i c g r o u p d i e d . C o n v e r s e ly , 2 3 ( 2 7 ) a c i d o t i cn e o n a t e s w i t h a p H b e t w e e n 6 .8 0 a n d 7 .0 0 d i d n o t s h o wa n y s i g ns o f n e o n a t a l m o r b i d i t y .

O f t h e a c i d o t i c n e w b o r n s , 8 7 . 5 h a d a m i x e d , 2 . 5 ar e s p i r a t o r y , a n d 1 0 a m e t a b o l i c a c i d o s i s ( F i g. 1 , n = 8 0 ;i n t h r e e c a s e s n o a r t e r i a l b l o o d s a m p l e w a s a v a i l a b l e , i no n e c a se P c o 2 w a s n o t m e a s u r e d ) . R e g a r d i n g t h e n e u r o -l o g i c c o m p l i c a t i o n s , a l l w e r e s e e n i n t h e g r o u p w i t hm i x e d a c i d o si s a n d n o n e i n t h e m e t a b o l i c a c i d o s is g r o u p .A l m o s t a l l ( 1 5 / 1 6 ) n e u r o l o g i c c o m p l i c a t i o n s w e r e f o u n di n a c i d o t i c n e o n a t e s w i t h a b a s e d e f i c i t >__15 m m o l / L . A l l


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Volume 175, Number 5 van den Bet 9 et al. 1155Am J Obstet Gynecol

T a b l e I I I . N e o n a t a l c o m p l i c a t i o n s i n n e w b o r n s w i t h u m b i l i c a l a r t e r y p H < 7 . 00 ve r s us u m b i l i c a l a rt e r y p H > 7 .2 4Study cohort McN ema r test Control groupComplication n = 84) significance) n = 84)

Poo r cond itio n after delive ry 63 (75) p < 0.001 10 (12)Resuscitatio n 51 p < 0.001 6Intu bati on 24 p < 0.001 2Ap gar score


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1156 van den Berg et al. November 1996AmJ Obstet Gynecol

1098

61 6

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6 6

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umbilical artery p

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a a

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n m a ~a

a aa

~an

a a

~

D m a

6 . 9 6 . 9 5

Fig. 2. Umbilical artery pH versus 1-minute Apgar score withsubdivision for gestational age and neurologic dysfunction. Solidsquare Preterm infants with neurologic complications; opensquare preterm infants without neurologic complications; solidtriangle term infants with neurologic complications; open triangleterm infants without neurologic complications.

l9el

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6 . 6

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m ao n n a n ~

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ai - i [ i ~ J I I

6 . 6 5 6 . 7 6 . 7 5 6 . 8 6 8 5 6 9 6 9 5 7umbilic l artery p

Fig. 3. Umbilical .artery pH versus 5-minute Apgar score withsubdivision for gestational age and neurologic dysfunction. Solidsquare Preterm infants with neurologic complications; opensquare preterm infants without neurologic complications; solidtriangle term infants with neurologic complications; open triangleterm infants without neurologic complications.

that only newborns (term and preterm) with metabolicacidosis (base deficit >16 mmol /L ) showed an increase inneona tal complications. The respiratory comp one nt (hy-percarbia) was considered unim por tan t in their analysis.Pure respirat ory acidosis, defined as umbilica l artery car-bon dioxide tension >75 mm Hg, was not associated witheither an increase in frequency or severity of newborncomplications compared with nonacidotic controls.Goodwin et al., ~ and the curr ent results showed that neo-natal complications are predominantly found when thebase deficit is >15 mmol/L. They found that extremehypercarbia (>100 mm Hg) was present in all neonateswith major neurologic deficits, whereas no infants withpure metabolic acidosis had seizures. We found that ne o-nates in the acidotic group who had neurol ogic problemsall revealed a Pco 2 >_65 mm Hg. Fetuses with pro lon gedintrapartum hypoxia (causing anaerobic metabolism tostart) where plac ental gas exchange c ontinue s to be dis-rupted appear to be at the highest risk for neonatalmorbidity. The abs ence of neurologic dysfunction in fe-tuses with pure metabolic acidosis (Fig. 1) may be ex-plained by the restoring of oxygen supply (and placentalcarbon dioxide diffusion) at a time before tissue damagehas occurred.

Twenty-seven perce nt of neonate s born with a pH be-tween 6.80 and 7.00 had no neona tal problems. Neonatalmorbidity may not only depend on the duration anddegree of exposure to hypoxia but also on the differencein fetal vulnerabilitydet ermi ned by adequacy of adaptiveresponses (i.e., redistribution of blood flow to the vitalorgans), genetic factors, and maturity of the central ner-vous system] ~

In this study the predictive value of a 1-minute Apgar


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Neonatal Complications in Newborns With an Umbilical Artery pH 7.00